“Designing for Health" is a monthly, Web-exclusive series from healthcare
interior design leaders at Perkins+Will that focuses on the issues, trends,
challenges, and research involved in crafting today's healing environments. This
month's article focuses on safety in behavioral health
Mental disorders are more common than you may think. According to the National
Institute for Mental Health, more than one-quarter of all Americans over the age
of 18 suffer from a diagnosable mental disorder every year.(1) Six percent
suffer from the most serious disorders(2)—those which often require
Diagnosing and treating these conditions require
healthy, healing environments, yet our existing building stock is not up to the
task. Conventional perceptions of psychiatric hospitals conjure up imagery of
massive, gothic institutions from the early 20th century. This was the State
Hospital—the first model for psychiatric care. That model began to shift in the
mid 20th century toward smaller, community-based hospitals. Yet the heavy,
institutional character survived. Thick walls, few windows, heavy doors, and an
oppressive atmosphere still endure. Visually, they are a sibling to jails or
other correctional facilities.
Patients and staff want a healthier
environment than these existing buildings afford—one that is lighter, brighter,
more compassionate and more human. An incredible design opportunity awaits.
However, all these goals must balance against one critical consideration:
safety. The safety of patients and staff is cited as the number one concern in
the design of behavioral health facilities.(3)
has been resolved by designers using a correctional system approach: Contain
the patient. Remove items that may be used as weapons. And build it strong.
It has been used to excuse an institutional character. But rather than allow
safety to diminish the quality of a space, we have an opportunity to craft
sensitive spaces that use safety to positively inform the design and support
patient outcomes. To achieve this, we need to understand safety from a holistic
sense. What type of patient population is using the space? What are the
functional requirements of the treatment program? What at-risk events is the
owner trying to control? The design team must advocate a process to engage the
user group and understand the unique requirements for a behavioral health
Safety is achieved at all levels of design, from a global
perspective to finer levels of detail. If designed well, a space can be safe and
provide other qualitative benefits for occupants. Safety begins at the perimeter
of a building or unit. In many cases a nurse station will serve as a control
point for access or egress. Traditionally, staff are stationed behind protective
walls and windows, physically isolated from the patients. However, this approach
can create an “us” versus “them” environment that may undermine the
effectiveness of treatment programs.
This was one legacy at Adventist
Behavioral Health, a behavioral health facility located in Rockville, Maryland.
In November of 2009, the hospital completed renovations to a 27-bed unit for
adolescent girls, which stands as a model for rethinking how we achieve safety
and how the physical environment supports treatment programs.
onset, the owner identified the existing nurse station as an impediment to
facilitating a healthy environment. “It was put there for the safety of staff,
but it can create a hostile environment that says ‘you are scary. We need to
separate ourselves because you might hurt us’,” says program director Simone
Bramble, MSW, LSCW-C. “It was not therapeutic. Instead, we want to encourage
spending time with the kids to minimize those relationship fractures when you
create such an environment.”
The design solution eliminated these
physical and psychological barriers. The nurse station was “opened” and treated
as a sculptural element within the traditional patient area. Separate spaces
became one, replacing a confrontational environment with one that encourages
patient and staff interaction.
“It was important for us to create an
environment that gives residents and their families hope," says Sako Maki,
president of Adventist Behavioral Health. “Our design team helped us achieve
this by incorporating natural light into the residential treatment center,
creating softer architectural lines such as archways that lead to larger group
therapy areas, and a modern, centrally located nurse station that allows for
more resident and staff interaction. These changes helped us provide better care
by creating a welcoming environment that is more conducive to successful
Safety is also achieved via visibility. Empirical
evidence suggests patients are most prone to harm themselves when they are
alone. Visibility is achieved in two ways. First, the unit should be organized
such that obscured areas are eliminated. Interior glazing can provide a visual
connection to adjoining spaces, such as a corridor, which will serve as a
psychological impediment to at-risk behavior. A visual connection always must be
maintained between staff and patients. This requires careful evaluation of
sightlines in plan and elevation. The less compartmentalized the plan, the
easier this is to achieve.
Second, visibility is facilitated through
thoughtful provision of light. Lighting is most successful when artificial
sources are balanced with natural light. Daylighitng has been shown to support
our circadian rhythms and physical and emotional well-being, and exterior
glazing may offer a positive distraction with views to nature. Minimum light
levels allow staff to see all areas and are a disincentive to at-risk behavior.
But they may also be manipulated, by providing increased light levels in areas
that may be perceived as trouble spots, such as toilet rooms, laundry rooms, or
other less public areas. The perception of a space can modify
Safety is also realized by removing any materials, products, or
assemblies that may be used as a weapon. They must be durable and of sound
construction. This will govern the detailing of millwork assemblies,
specification of plumbing/mechanical/electrical fixtures, and selection of
hardware and furniture. Historically, designers have been very limited in the
range of products available, often looking to the correctional industry for
products. But in recent years, manufacturers have broadened their offerings and
offered levels of customization previously unseen. This affords the opportunity
for a more tailored design to the client’s needs.
The success of these
selections will require special attention by the design team. The design process
will require greater engagement with the owner and less assumptions than other
project typologies may allow. Conventional construction methods and details will
not suffice without some adjustment. Custom detailing and specifications are
required for behavioral health projects. As the design team selects materials,
samples should be provided to the owner for field testing.
Only in a
healthy environment can behavioral health treatment programs thrive. Safety can
complement, rather than impede, spaces that are warm, bright, and sensitive to
Click here for a chart of a survey using PACI Method,
developed by Dr. Christine Timko. Research and chart by Jamie Huffcut, LEED AP,
Jordan Thompson, AIA, NCARB, LEED AP, is a
project architect with the Washington, D.C. office of Perkins+Will. He can be
reached at firstname.lastname@example.org.
December 2, 2009.
2 Kessler RC, Chiu WT, Demler O, Walters EE.
Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the
National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry,
2005 Jun; 62(6):617-27.
3 “Implementation of Evidence Based Design
in Adolescent Behavioral Health Facilities.” Jamie Huffcut, Marymount
University, Spring 2008. Survey based upon PACI methodology developed by Dr.
Christine Timko, Stanford University, 1996.
Past installments of
"Designing for Health" include (click on title to access the full article):
• A Harmonious Companionship-- Rejuvenating
• Leading by Design – A Place to Flourish
• Expanding the Definition of Sustainability to Include Chemical
• 10 Strategies to Move Your Client Toward Sustainability
• The Age Factor--Energizing the Healthcare Workplace
• Medical Teaming Centers
• Integrating Security in Hospital Emergency Departments
• We Eat What We Build
• Evidence-Based Healthcare Design Forum