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The
mental health care system has flaws. The flaws faced, stem from
historical stigmas and modern criticisms and interpretations, such as
the ideas of what mental illness actually is. The improper follow
through with programs and outdated facilities adds to the fear of
patients in the outside world. One step to fixing these problems is
starting with the basics. As designers one of the thing we can do is
give patients a facility that is conducive to their healing process.

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Mental
health is defined as a person’s condition with regard to their
psychological and emotional well-being, many people use this
interchangeably with behavioral health(1). Behavioral Health is
defined as any change in behavior that can effect ones health.

Examples of behavioral health can include but are not limited to
substance abuse, bipolar, anxiety and others that can fall under
mental health. In essence behavioral health is an umbrella that
covers not only mental health but genetic problems and also healthy
living.(2) Adolescents can have serious mental health issues that
can hit them at anytime. Many are already so lost and confused with
who they are and how they are supposed to act, that sometimes a
mental health problem can go untreated for years. The reasoning for
this is best summed up in the definition of the adolescent, “the
ambiguity of the phase between childhood and adulthood that
challenges the adolescent to define themselves while society places
them, changes in identity, biological development and peer
interaction result in behaviors mistrusted by adults”.

When
thinking of a Behavioral Healthcare Facility, most people’s mind will
immediately jump to horror stories they have heard. Some parts of
history would prove them right, however, it is important to look back
to see how far treatment has come in a relativley short time span. In
ancient cultures it was popular belief that “madness” was caused
by evil spirits and divine punishment,(Malcolm, 2016) The ancient
Greeks associated mental illness with physical illness and in
medieval times the belief was that saints, martyrs and relics were
the only things that could cure the followers of jesus.(Malcolm,
2016) During the age of enlightenment, doctors admitted that some
forms of madness belonged to the divine, but others belonged to
science; however, the problem with this was that no one knew where
the line was drawn.(Malcolm, 2016) The 18th century brought about the
general conclusion that mental illness was rooted in the general
study of illness.(Malcolm, 2016) About a hundred years later the
first Insane Asylum was erected with the thought that changing the
environment the patients are immersed in, to a more forgiving place,
could help restore their sanity.(Malcolm, 2016) However, with this
safe environment came experimental techniques to restore sanity
faster. These techniques included near death experiences consisting
of putting patients in cages and submerging them completely into
water until they stopped breathing at which point they would be
yanked out.(Malcolm, 2016) It was also believed that patients could
be “shocked” to sane by tying them to chairs and spinning them
until they puked and emptied their bowels.(Malcolm, 2016) Another
method consisted of the “tranquilizer”,

which
was a restraining chair that had padding that went over the eyes and
ears, essentially cutting off all senses and reducing blood flow.

(Malcolm, 2016) At which point cold water was poured on the head of
the patient and hot water was poured on the feet in order to “draw
the insanity out”.(Malcolm, 2016) In the 20th century following the
thought the mental illness derived from a psychological problem,
lobotomies and electroshock therapy was made possible and implemented
on patients.(Malcolm, 2016) This was because the general consensus
throughout society was that the mad were seen as the walking dead and
they had lost all their human rights(Malcolm, 2016). While most would
say that the patients are being treated better than in the past,
there are still modern day horror stories.

In
2014, a hospital in Guatemala was called “the worlds most dangerous
hospital”, according to Chris Rogers. On his trip there he had seen
patients left out to burn in the sun while heavily sedated, dressed
in rags with shaved heads(Rogers, 2014). Some were completely naked
covered in feces and urine(Rogers, 2014). While touring through the
hospital, patients begged him to take them out of the hospital and
others reported being raped by staff, either while sedated, sleeping
or wide awake(Rogers, 2014). While being secretly filmed, the
director of the hospital admits that patients are being raped by the
male staff(Rogers, 2014). When Rogers asked about staffing, he was
told that two or three nurses are left to look after 60 to 70
patients(Rogers, 2014). The Guatemalan government’s response to the
investigation was that they follow all of the rules set forth by
World Health Organization(Rogers, 2014). A legal case was brought
forward in 2015, but no account of what happened can be found(Rogers,
2014).

It
came to light in July of 2016 that in the 60’s and 70’s a doctor
named Kenneth Milner was using truth serum on his
patients(Kemp,2016). This took place at Ashton Hall Hospital in
Derbyshire, and was brought to light by the posting of pictures of
the old hospital before its demolition(Kemp,2016). Former patients
started telling of their experiences and unanswered questions they
had about their treatments(Kemp,2016). One patient had mentioned that
she was told to strip for an internal examination and then asked a
series of questions while the serum was administered(Kemp,2016). 60
years after the fact an investigation is being launched into a man
who has been dead for almost 25 years(Kemp,2016).

With
the more research conducted one just finds more areas to place blame.

For instance, there are five very different stories from the family
members of patients who ended up dying after leaving a facility. One
story tells of a mother who lost her insurance and had to pay over
$40,000 in bills for her daughter’s mental health treatment. After
watching her mother stress about payments and feeling all of the
guilt, the daughter had killed herself (Spencer,2014). Another tells
of a girl who died at the age of 14, after being told she would have
to stay at a facility for 12 weeks. When the girl had reached a
“healthy” weight, the insurance company stopped paying at six
weeks and the girl had to go home even though she was not mentally
ready. Two days after being home and purging she had died from heart
failure(Pelley,2014). The fact is that even though there are laws and
organizations in place to better the care of mental patients the
mental health system is still broken. As the practices of psychiatry
have been forced to change in the face of low health insurance
reimbursements, hospital bed have been disappearing.(Abbott, 2004)
When looking at facilities most of the time the blame can not be put
solely on one area. A facility has to not only have a staff that is
well equiped but a building that can accommodate the needs of the
patients.

According
to the W.H.O depression is predicted to be the second leading global
burden disease by 2020(Gender differences). Many people are afraid to
come forward and admit that their is something wrong because of the
stigmas set by society. In 2006 an Australian study found that one in
four people thought depression was a sign of weakness and that 42%
thought people with depression were unpredictable.(4)  Many of
these stigmas can be found in the media which is just spreading the
misconceptions instead of fighting them.(5) The media should be
telling facts like depression is reported to be twice as common in
women than men across diverse societies and social contexts(Gendder
differences). More than 350 million people of all ages have
depression and there are interrelationships between depression and
physical health.(7) Some other health conditions and life style
factors associated with depression include obesity, hypertension, and
smoking.(gender differences) There are certain signs that will help
someone tell if a person may be depressed. Some signs include
significant weight loss or gain, lack of interest in things they used
to enjoy, insomnia or excessive sleeping, highs and lows in emotions
and the inability to concentrate.(9) There are many steps to take if
one might have depression and depending on the severity of the
problem, it may be suggested by a professional that someone should go
to a behavioral health care facility. When someone is first admitted
they have a Patient suicide risk assessment done; however, the tools
currently available for this are unreliable(Hunt,2015). With this in
mind, designers and architects should proceed as if there is no way
of knowing a patients true intentions(inser).

The
first step in trying to figure out how to build a Behavioral health
care facility is to make sure you’re aware of the differences between
psychiatric hospitals when compared to medical hospitals. While in
medical hospitals, patient treatment takes place in patient rooms; in
psychiatric treatment centers patients are encouraged to leave their
room and join group therapy and spend time in social areas. Family
visitation, while strict at a medical hospital, is more encouraged at
a behavioral healthcare facility and it is preferred that they meet
in semi public areas. Other differences include, infection control,
where isolation is rarely used in behavioral facilities because of
the nomadic nature of the patient population.

A
valuable way of figuring out how to build facilities that work is by
looking at ones that don’t and figure out why. Some of the reasons
for facilities not working consist of problematic design,
technological failure and evolution. Problematic design comes from
the fact that many architectural design awards are based on the way
they look and not how they function in context.(Sine, 2009) Often
times when a facility, is built the form is forever playing catch up
with the technological advancements and treatment theories that are
constantly changing.(Sine, 2009) Along with the change in theories
and the way of clinicians’ thinking, building and health codes are
changing while the building of new facilities are happening(Sine,
2009). While all this is happening, the buildings themselves need to
be more adaptable to all the changes. For all of these reasons, many
of the existing facilities have become too costly to maintain, are
not energy efficient, technologically outdated, and do not provide an
environment that can keep pace with the current standard of care for
a safe environment. (Sine, 2009) With older facilities, the
institutional environments did not offer enough flexibility for
adapting spaces to patient demographics (deinstitutionalizing
design).

After
looking at what does not work, one should look at facilities that do.

Two example of facilities that work are Brentwood Meadow, and
Sheppard Pratt’s. Brentwood Meadow is in the tri-state area of
Indiana, Kentucky, and Illinois. This facility utilizes both indoor
and outdoor spaces for recovery(Hammer, 2010). The exterior is a mix
of stone and brick work to make the facade look more
residential(Hammer, 2010). The outdoor amenities contain three
separate veranda style courtyards that include a patio, rocking
chairs, ceiling fans, and a fenced in area for privacy. As of 2009
they were planning on expanding and adding a horticultural therapy
area that contains a walking trail, a reflection pond, rock garden
and different landscape designs. The interior is done in a color
scheme similar to what one would find in a bed and breakfast:
greens, oranges and other natural colors balanced with a wood
floor(Hammer, 2010). Interior amenities include a theater style
classroom and spirituality center, fitness center, nutrition station,
cafe, computer labs, and lounge and study areas (Hammer, 2010).

Sheppard
Pratt’s hospital, located in Townsend Maryland, is a hospital
complex along with the new mental treatment facility that totals in
240,000 square feet. The design objective was to provide quality care
for behavioral health patients. This is the first hospital in the US
to have all private bedrooms. The accessibility for patients and
staff is separate from that of the visitors, giving patients a
greater sense of privacy and confidentiality. Using a dual corridor
system also allows for the staff and patients to circulate without
interfering with public traffic creating an extra layer of safety.

The sight lines from nurses stations cover all areas including
bedroom doors and common areas. The flexibility of the new unit
allows for the change in room sizes as per the patients needs. The
design of the behavioral health care unit is for the patients
ultimate goal of a shorter stay with effective treatment.(Abbott,
2004)

When
building a new space, it is of the upmost importance to keep in mind
the patients safety, self harm and escape remain the two events that
drive most of the safety related design choices in a behavioral
health unit(Sine, 2009). 75% of inpatients suicides are by “Hanging”
or anoxia. Anoxia is the lack of blood flow to the brain caused by
tying something around the neck tightly enough to cut off blood flow
(Hunt, 2014). 86% of those take place in a patients bedroom or
bathroom(Hunt, 2014). 20% of patient deaths were from jumping from
the building(Sine, 2009). A study done in 2008 found that doors and
wardrobes counted for 41% of the anchor points for hanging.(Sine,
2009) Opportunities for self harm can be reduced by limiting ligature
attachment points or anchors,(Hunt, 2015) such as privacy curtain
attachments, shower heads and drapes(Hammer, 2010). In order to avoid
escapes the ability to lock the doors and choices of good security
systems comes in handy. Door locks fall into two categories,
Fail-safe and Fail-secure. Fail-safe locks provide automatic
unlocking exits when the fire alarms are activated and Fail-secure
locks have to be unlocked by a staff when alarms are activated.(Hunt,
2015)A full security system should be included in the design, this
entails having a digital recording system with cameras throughout the
facility.(Hammer, 2010) However, while keeping safety in mind it is
easy to fall into making a facility that feels and looks like a
prison(Hunt, 2015). The way for a designer to avoid this is to have
the facility feel more like a home than a treatment center.

Another
way to increase safety is to eliminate recesses, blind corners and
dead ends in the walls. By doing so, one eliminates hiding spaces for
staff and patients. In order to do this, the designer can plan out a
wall to fill in the recess. This will allow for improved observation,
safety and security and expand the reach of natural light as well as
nourishing and open feeling throughout the space.

To
avoid the feeling of entrapment, it is important to get the
perspective of the healthcare providers to create a therapeutic
environment.(Mourshed, 2012) A questionnaire given to healthcare
providers showed that the principle components identified were
spatial maintenance and environmental design(Mourshed, 2012).It is
also valuable to ask the patients what they do and do not like.

Interviews with adolescents led to the conclusion that they disliked
primary colors, children toys, and small scale furniture.

(Huffcut,2010)) they also said that they would like to improve the
daylighting in the facility and they enjoyed cool colors of blue and
purple.(Huffcut, 2010)

Behavioral
healthcare facilities include:
diagnostic and treatment areas, dietic areas, supply, housekeeping,
administrative, out patient and inpatient areas.(Carr, 2011)
Clinical and administrative leaders, along with patients prefer a
more residential design(deinstitutionalizing design). While no one
can agree what type of design is better(Sine, 2009), most people
agree that the best approach considers the risk zones public areas,
supervised patient treatments and activity rooms, and patient
solitude zones.(deinstitutionalizing design) When designing, one
wants to first figure out the designated private areas, the seating
options, and how to increase daylight.(Huffcut,
2010)) The design of the facility should also be chosen
between a campus design or consolidated design. A campus design, or
pod design, is multiple areas with a main “street”, while a
consolidated design has everything in one area.(Sine, 2009)

Circulation
can be either a three corridor circulation, or central circulation.

They have to be carefully studied to have the correct width to length
ratios and give staff easy sight lines (deinstitutional design). A
three corridor circulation system is often used in a consolidated
design. It separates staff patients and visitors. The staff is then
available to circulate between patients and support spaces, while
having easy access to “Offstage” areas (deinstitutionalizing
design). The “offstage areas allow for breaks and paperwork
(deinstitutionalizing design). Central Circulation connects
classrooms, treatment areas, dinning and social experiences for the
entire Facility community.(deinstitutionalizing design)

The
biggest design challenge that accompanies pod design is to achieve a
unit that is open and has good sight lines for
staff.(deinstitutionalizing design) The good thing about pod design
is that it provides flexibility for changes in patient demographics,
and each area can be designed to meet physical, psychological and
social needs for several patient populations.(deinstituyinalizing
design) For this reason, pod design has become more desirable and has
been used more frequently with modern institutions. Essentially
central circulation is a spine that leads throughout the space. Some
facilities that use central circulation have what they call “facility
malls”, these house banks markets and salons. (deinstitutionalizing
design) The malls encourage patient interaction and help with the
transition from a facility to the real world. (deinstitutionalizing
design) In both consolidated and campus design, nurses stations
should be decentralized, and without barriers, allowing for better
observation of the patients. Removing the glass or using frame free
nurses station encourages interaction between patients and staff.

However this will also require the staff to be comfortable working in
a more open setting.

In
seclusion spaces, such as bedrooms, it is essential to remember that
it remain a refuge for the patients. The problem faced with the
bedroom is keeping the feeling residential while safety and security
measures a properly set up. Outward swinging room doors helps keep
sight lines open when staff is looking in on patients. Having sensors
placed on top of the patients bedroom and bathroom doors will also
help with safety measures, as they can alert staff if pressure is
applied to the top should a patient attempt suicide. In secluded
zones there is a higher risk of self harm. Keeping this in mind
furnishings and finishes should be carefully selected. The furniture
should be free of any sharp edges and be securely fastened to the
walls. It is also suggested that there be no doors or drawers on any
furniture pieces. The use of damage resistant material will also help
avoid potential hazards, such as shatter proof non glass mirrors. The
ceiling should be monolithic while seamlessly integrating sprinklers,
heating and cooling, and security lighting. The colors patterns and
textures should be similar to those used in residential spaces.

Keeping
quiet rooms and living rooms apart from seclusion spaces allows
patients to interact with each other or take a step away from the
group if they feel overwhelmed. This also gives the patient an area
to cool down and gain a grasp on what they feel(darcy). Using built
in seating in these areas help create safe levels of seclusion and
allow for the impression of having a more private nook within the
space. However, using sound absorbing materials proves to be
difficult. This is because they tend to be more porous and softer
creating a greater risk for infection.

Large
open areas such as social and group treatment areas are replacing the
older enclosed day rooms. When designing these spaces should be
thought of as multipurpose spaces. Doing this allows for greater
flexibility for what is needed. Curtains in this area should be
removed and replaced by blinds placed within the windows. Placing
the blinds between the glass denies access to the controls creating a
safer environment. Finishes and furnishings for these areas should be
durable and safe, even though supervision and visibility of these
areas generally reduce patient risk. Public zones, such as the
entrance or out-patient areas, can be furnished with similar things
found in a hospitality setting. The only caveat to this is to make
sure the bathrooms are accessible to patients before or during the
admission process.

When
thinking of the finishes and furnishings for a Behavioral healthcare
facility it is critical to keep every surface in mind. One should
always be aware of how the floor is fixed to the walls and floor
coverings should be chosen with the safety of the patient in mind.

This includes the slip resistance texture and how easy it is to
clean. Since the availability of solution dyed yarn and moisture
resistant backing, broadloom carpeting has been widely used. Hardwood
or wood grained flooring will also create more of a residential feel.

Walls are typically more difficult to have sound depletion properties
because they are more susceptible to damage from use. Acoustic
ceiling treatments can be used but not in seclusion rooms bedrooms or
bathrooms. In the open areas or quiet rooms where they are allowed
the acoustic ceiling tiles and not allowed to be the typical lay in
type. This is because while reduced noise levels are very important,
aggressive or disruptive behavior is often the staffs first clue to a
patient’s escalating behavior.

The
lighting in a Behavioral Healthcare facility should be well thought
out. Such as the orientation of the building and how much daylight
certain rooms receive. Bedrooms for example should have a window
allowing for morning sun creating a connection between the time of
day and the seasons for the patient. The natural light also helps
establish an open feeling within the space. Natural light also has
positive effects on patients, some experience shorter stays and more
favorable treatment outcomes. The views provided by windows or
pictures also increase positive feelings while anger and anxiety
decrease.

The
flaws faced in the past should teach designers how to build for the
future. Using what we know and how it correlates to the health of
patients give designers a greater opportunity to help. Having a pod
system a social aspect to the design of a behavioral healthcare
facility design will help teach patients how to deal with different
scenarios and their reactions.