Psychological Design

A review of mental health facility design: The case for person-centred care.

There’s a growing schism in mental health services around the world. There is a broad call for person-centered 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 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 though all the available evidence suggests that this approach is at the expense of the patient’s wellbeing and even best chances for recovery.

The current models for mental health service design appear to reflect societies main concerns about mentally ill patients: that is, 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 (Figure 1). These ‘sight-lines’ 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 cup of tea, change the station of the TV, they have to rap on the glass and ingratiate themselves. While this is widely understood to be a non-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. This is evidence that coercive environments cause clients to behave contrary to the intent of the threat, in other words, behavior management leads to misbehavior and a controlling environment leads to loss of self-control. But it’s not only behavior that’s affected. Bad environments appear to have a powerful causal influence in mental illnesses (Golembiewski, 2013). Effectively the current mental health facility is the ‘wrong vehicle’ for the job at hand, and that these must change, along with the 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 not passive nor a merely a minor factor. Several studies suggest that it is perhaps the largest and most consistent
factor in the psychotic illness (Golembiewski, 2013). The psychotropic potency of the environment was also unequivocally demonstrated by (Ellett et al., 2008), who exposed 30 persecutory psychotic patients and matched controls to a ‘dose’ of only 10 minutes of walking through a relatively normal, albeit slightly run-down urban environment (Camberwell High Street in South London). This ‘dose’ was sufficient to significantly increase key indicators of psychosis – anxiety and paranoia. Before and after the walk, the subjects were given a battery of psychological 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 behavior in the facility radically improves for both clients and staff (Tyson et al., 2002; Golembiewski, 2013). The question about what the alternative – a person-centered 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- centered 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 real functional requirement of a mental health facility isn’t to perform staff routines, control clients behavior, to observe their every move or to make sure clients are medicated. It’s to prepare clients to tackle the realities of the outside world; to keep them engaged in positive and rewarding activity during their stay. 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, this makes them 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. tests. These revealed very significant decreases in health indicators due to anxiety, t (14) = −3.57, p = 0.003, and paranoia, t = −2.69, p = 0.017. Another study that also confirms the hypothesis that psychotic patients are many times more susceptible to environmental stimuli, goes further by finding that the differences are magnified by affect. 20 Post-acute psychiatric patients and ten matched healthy controls a series of positive and negative images while scanning their frontal lobes with fMRI. The psychiatric patients were divided into two groups; one catatonic, the other with more typical presentations. These groups were matched for medication, gender, age and diagnoses (n = 3; akinetic type I bipolar disorder, n = 7; paranoid schizophrenia, n = 3; and type I bipolar, n = 7). The data was reanalyzed by Golembiewski (2012), who subtracted total inhibitory responses from total excitatory ones, to revel that paranoid/manic patients showed a 6495% (p = 5) surplus of excitatory activations against healthy controls and that catatonic patients showed 5671% (p = 5) more excitation than controls when exposed to negative stimuli. In the positive stimuli condition, healthy controls greater disinhibition than the psychiatric cohort – 100% greater than the paranoid/manic patients and 47% more than catatonic patients. A hypothesis was proposed that excitatory surpluses generated by negative experiences manifest as symptoms – that is undesirable thoughts and actions, whereas the excitatory deficits generated by positive experiences appear as ‘negative signs’. tests. These revealed very significant decreases in health indicators due to anxiety, t (14) = −3.57, p = 0.003, and paranoia, t = −2.69, p = 0.017. Another study that also confirms the hypothesis that psychotic patients are many times more susceptible to environmental stimuli, goes further by finding that the differences are magnified by affect. 20 Post-acute psychiatric patients and ten matched healthy controls a series of positive and negative images while scanning their frontal lobes with fMRI. The psychiatric patients were divided into two groups; one catatonic, the other with more typical presentations. These groups were matched for medication, gender, age and diagnoses (n = 3; akinetic type I bipolar disorder, n = 7; paranoid schizophrenia, n = 3; and type I bipolar, n = 7). The data was reanalyzed by Golembiewski (2012), who subtracted total inhibitory responses from total excitatory ones, to revel that paranoid/manic patients showed a 6495% (p = 5) surplus of excitatory activations against healthy controls and that catatonic patients showed 5671% (p = 5) more excitation than controls when exposed to negative stimuli. In the positive stimuli condition, healthy controls greater disinhibition than the psychiatric cohort – 100% greater than the paranoid/manic patients and 47% more than catatonic patients. A hypothesis was proposed that excitatory surpluses generated by negative experiences manifest as symptoms – that is undesirable thoughts and actions, whereas the excitatory deficits generated by positive experiences appear as ‘negative signs ‘tests. These revealed very significant decreases in health indicators due to anxiety, t (14) = −3.57, p = 0.003, and paranoia, t = −2.69, p = 0.017.
Another study that also confirms the hypothesis that psychotic patients are many times more susceptible to
environmental stimuli, goes further by finding that the differences are magnified by affect. 20 Post-acute psychiatric patients and ten matched healthy controls a series of positive and negative images while scanning their frontal lobes with fMRI. The psychiatric patients were divided into two groups; one catatonic, the other with more typical presentations. These groups were matched for medication, gender, age and diagnoses (n = 3; akinetic type I bipolar disorder, n = 7; paranoid schizophrenia, n = 3; and type I bipolar, n = 7). The data was reanalyzed by Golembiewski (2012), who subtracted total inhibitory responses from total excitatory ones, to revel that paranoid/manic patients showed a 6495% (p = 5) surplus of excitatory activations against healthy controls and that catatonic patients showed 5671% (p = 5) more excitation than controls when exposed to negative stimuli. In the positive stimuli condition, healthy controls greater disinhibition than the psychiatric cohort – 100% greater than the paranoid/manic patients and 47% more than catatonic patients. A hypothesis was proposed that excitatory surpluses generated by negative experiences manifest as symptoms – that is undesirable thoughts and actions, whereas the excitatory deficits generated by positive experiences appear as ‘negative signs’.

 

Figure 1: A generic staff-centered facility entrenches the inequality between
staff and clients, by establishing the locus of control at a central staff station,
from which ‘sight-lines’ 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 behavior and
best outcomes.

Figure 2: A patient-centered 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 (‘back-stage’), 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 behavior.

Declaration of Conflicting Interests

The author is a director of MAAP, a firm that has specialized 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.

Ellett L, Freeman D and Garety P.
(2008) The psychological effect
of an urban environment on
individuals with persecutory
delusions: the Camberwell
walk study. Schizophrenia
Research 99: 77-84.
Golembiewski J. (2012) All common
psychotic symptoms can be
explained by the theory of
ecological perception. Medical
Hypotheses 78: 7-10.
Golembiewski J. (2013) Lost in Space:
the role of the environment in
the aetiology of schizophrenia.
Facilities 31: 427-448.

Acknowledgements
Special thanks to the staff at MAAP
for your help in this work, especially to
Alison Huynh and Shuang Wu for
providing illustrations.

Higgs WJ. (1970) The effects of gross
environmental change upon
behavior of schizophrenics: a
cautionary note. Journal of
Abnormal Psychology 76: 421-
422.

Tyson GA, Lambert G and Beattie L.
(2002) The Impact of Ward
Design on the Behaviour,
Occupational Satisfaction and
Well-Being of Psychiatric
Nurses. International Journal
of Mental Health Nursing 11:
94-102.

 

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