Abstract
There’s a growing schism in mental health services around the world. There is a broad call for person-centred models of care, a consideration of the whole person, and a focus on recovery on clients’ own terms. Yet these demands are at odds with the current paradigm of design for facilities for psychiatric care. Design paradigms (and the models of care they support) have tried to pay lip-service to person-centred care for decades, but, to this day, they are designed primarily to improve the efficiency of staff routines and patient-management protocols, even although all the available evidence suggests that this approach is at the expense of the patient’s well-being and even best chances for recovery.
The current models for mental health service design appear to reflect society’s main concerns about mentally ill patients: suicide risk and the threat of violence, crime and arson. Reflecting this, current guidance on the design of mental health facilities trace sightlines that emanate from central staff stations and down long corridors of bedrooms and activity rooms. These ‘sightlines’ are not only literally staff-centred, but they also enforce asymmetric relationships by anchoring the locus of control with the staff on duty. Far from empowering patients to develop self-efficacy to better deal with life outside the facility, central staff stations mean that every need and desire is made contingent on the good will and timing of the staff. If clients want to make a telephone call, fix a ‘cuppa’ or change the TV channel, they have to rap on the glass and ingratiate themselves. This attentional focus on the staff station contributes to the ‘honeypot syndrome,’ where patients loiter around the staff stations (Figure 1 shows a typical staff-centred facility). While the staff station is widely understood to be a non-negotiable requirement of a mental health facility, the only evidence on the subject builds a compelling case against the implementation of staff stations altogether – because when staff stations are removed or made more democratic (by removing glazing), the behaviour in the facility radically improves for both clients and staff (Golembiewski, 2013; Tyson et al., 2002) (see Figure 2).
A generic staff-centred facility entrenches the inequality between staff and clients by establishing the locus of control at a central staff station, from which ‘sightlines’ radiate down all the client-accessible corridors. This creates the ‘honeypot syndrome,’ where clients hang around the staff station. It also sets up an oppositional dynamic that is deleterious to behaviour and best outcomes.
A patient-centred model considers all clients and staff as key agents in design of therapeutic environments, like actors in a play. Staff members move between staff and support zones (‘backstage’), while maintaining visual connection with clients in shared spaces. There are discreet key locations where staff members can seat themselves and have excellent observation without bringing attention to the asymmetry of staff vs. client relationships. This shifts and disperses the locus of control, thereby empowering the client and deescalating oppositional behaviour.
The question about what the alternative – a person-centred facility – might look like, is seldom more than that (what the unit will look like) as walls are ‘opened up’ with impervious plate glass into views of pristine gardens that are out of bounds to clients. A poor understanding of what person-centred care means, how it can be implemented with minimal disruption and why it is of clinical importance means that the calls for better mental health facilities fall on deaf ears. It’s all too difficult. The foremost functional requirement of a mental health facility isn’t to perform staff routines, observe and control clients’ behaviour, and so on. It’s to prepare clients to tackle the realities of the outside world. With facilities the way they are, a majority of clients perceive treatment as an incomprehensible and unhelpful process that is out of their control. This is a problem not only for clients and their carers, but also for the health service itself. When treatment has no perceived positive effect on a client’s ability to cope, they may feel that the effort and the sacrifices they’ve made to control their illness is meaningless. And, unsurprisingly, it’s the clients that have those rare empowering client/therapist relationships that benefit most from treatment.
But quite apart from the demands of consumer advocates, there’s a new imperative to change the design of mental health facilities to make them better for care and more person-centric. There’s evidence that coercive environments cause clients to behave contrary to the intent of the threat; in other words, behaviour management leads to misbehaviour and a controlling environment leads to loss of self-control. But it’s not only behaviour that’s affected. Bad environments appear to have a powerful causal influence in mental illnesses (Golembiewski, 2013). Effectively, mental health facilities are the ‘wrongvehicles’ for the job at hand, and they must change along with treatment and management protocols.
Does the environment make a difference?
The ways in which the environment influences mental illness isn’t fully understood. But we know it’s neither passive nor minor. Indeed, several studies suggest that it’s perhaps the largest and most consistent factor contributing to psychotic illnesses (Golembiewski, 2013). The psychotropic potency of the environment was also unequivocally demonstrated by Ellett et al. (2008), who exposed 30 paranoid psychotic patients and matched controls to a ‘dose’ of only 10 min of walking through a relatively normal, albeit slightly rundown urban environment. This ‘dose’ was sufficient to significantly increase key indicators of psychosis. Before and after the walk, subjects completed a battery of psychological tests, which revealed very significant decreases in health indicators due to anxiety [t (14) =
In another study that also supports the hypothesis that psychotic patients are many times more susceptible to environmental stimuli, Golembiewski (2012) goes further by finding that the differences are magnified by affect.
Rx. Environmental psychopharmacology
Since antiquity people have accepted that the environment should make a profound difference to mental health. And led by such ideas, there have been several studies to establish what happens when psychiatric facilities are redecorated in one way or in another. In terms of diagnostic outcomes, these lack the power to establish reliability. To add to this, they follow a repetitive and possibly misguided paradigm: the redecorations aim to make spaces more homely. But is this the best way forward? Is it naïve to suggest homelike touches like domestic furniture and carpet (in an institutional building replete with staff) could cure or prevent mental illness?
Some (quite reasonably) suspect that the dependent variables in environmental-intervention studies in psychiatric facilities are insubstantial. Higgs (1970) tried to prove it: he pointed out that environmental interventions like brighter paintwork, interior decoration such as curtains and divider screens, and rearrangements in seating and of planters shouldn’t affect very serious mental illness, when more fundamental issues such as neurochemistry remained unchanged. But Higgs’ experiment failed to support the null hypothesis, instead uncovering impressive statistical significance, which didn’t attenuate even over months. Despite his intentions, Higgs’ study added to a growing list of the psychiatric facility intervention studies that reliably demonstrate how minor changes exert a disproportionate and sustained influence on the behaviour of psychiatric patients. By just making an environment marginally more homely and less institutional, many of the nonclinical problems that bedevil facilities disappear (or reduce significantly) including violence, isolating, rowdiness and unpleasant staff/patient interactions (Tyson et al., 2002). Lengths of stay in seclusion invariably also fall and ward vandalism appears to cease, and these changes are sustained over the long-term (Golembiewski, 2013).
The data are promising, even though they point to a mysterious aetiology. The intervention studies reinforce the key findings of Golembiewski (2013) and Ellett et al. (2008), that psychiatric patients are much more reactive to the physical milieu than healthy controls, suggesting that the environment may, indeed, be a good target for psychiatric intervention.
The question about the ideal physical environment for recovery from mental illness is still unresolved. We could learn from the interventions and remove nurses’ stations and redecorate facilities. But, by and large, the interventions had low budgets and were faint-hearted. Wouldn’t it be better to have the courage to design something good from the start? The most significant findings of these studies – when seen together, is that the environment is holistic – the aesthetic dynamics of the space affects interpersonal relationships, behaviour and symptoms. There’s no perfect architectural solution yet – but we know that institutional layout, aesthetics and typology is so unhelpful that even superficial changes help considerably. If we went further and provided person-centred facilities, we’d surely get better results still. What’s more, such an approach would be a genuine response to the demands being voiced by clients and patient advocacy groups.
Another recommendation is to design the experience. In mental illness, perception is amplified by affective content, so environments have to strive to be better than simply domestic. The language should make it unambiguous that the milieu is wholesome. Beyond this, the environment should strive to exceed expectations of the client experience with refined aesthetics and by composing a stage-set like environment, where there’s a choice of wholesome things to do, provisions for privacy, dignity, sanctuary, comprehensibility and meaningfulness (Golembiewski, 2013). Conveniently this means person-centricity and experience-orientation are well-aligned goals. But with inadequate health facility guidelines and practice notes, where can we take guidance? Anecdotally, neither staff nor patients know about the aetiological influence of the physical environment. They rarely know what’s possible: both groups often voice fixed opinions and blindly cling to ideas that are not in anyone’s best interests. But, even so, patient questionnaires may be a good place to start. At least in principle they put the client first.
Sympathetic and informed leadership is needed to fearlessly drive new agendas and design, especially as this will encounter resistance from orthodox opinions and established guidance. Good architects, like good physicians, are able to anticipate a client’s needs and feelings. The intensity of psychiatric experience may be different, and psychotic experiences may be eccentric and prone to paranoia, but by acknowledging that mental illness causes too much inhibition of the positive aspects of design, and too little inhibition of the negative, we have a good foundation. Beyond this, the language of affect is relatively universal. The silver bullet won’t be a colour or texture of a wall, but complex combinations of schemata that combine to tell a more complex story. We know that dark walls, dusty portraits and creaking doors arouse fears of the unknown, but the opposite – the chic modernist sterility and silence of a James Bond villain’s villa can be no less ominous, albeit in a completely different way.
Cues to tell an audience that a place is safe and nice are open windows looking out onto water or to beautiful gardens, comfortable (as opposed to austere chic) furnishings, and soft lighting and a passing butterfly or two. The background ‘soundtrack’ of tweeting birds is also desirable. There may be nothing intrinsic about these schemata, but there are few people who are naïve to such semiotic conventions, so these schemata do create a common language.
Opportunities for meaningful action are probably more important still; working gardens, art and sports equipment, musical instruments, activities of daily living kitchens and laundries (that are open and actually work), pens, paper and computers are inexpensive and useful ways of helping people to help themselves – and there’s probably no better therapy for mental illness.
Footnotes
Acknowledgements
Special thanks to the staff at MAAP for help with this work, especially to Alison Huynh and Shuang Wu for providing the illustrations.
Funding
This research was supported by the Schizophrenia Research Institute, which receives funding from NSW Health. The author received no direct funding from any source.
Declaration of interest
The author is a partner and the knowledge and research leader of MAAP, a firm that has specialised in mental health facility design since 1991. Much of research in this article was undertaken during the author’s PhD research, prior to his employment.