Psychological Design

Blind Spot By Jan Golembiewski

In a brand-new, state-of-the art, high-dependency acute care mental health unit, the nurse beeps in a visitor and pulls on an anti-ligature door handle. The flash front counter sits in a foyer that looks like it could be the corporate headquarters for an international corporation. High, raked timber-clad ceilings and double-height glass windows looking on to untouched garden beds of artfully placed Australian wild grasses. The brief for the new unit was to build a ‘state of the art and future-proof’ facility to replace a 15-year-old ‘deconstruction list-style’ building that was placed opposite the emergency department. The old unit had holes kicked into its plasterboard walls and was plagued by behavioural issues. These, I was told, were because it had a ‘blind spot’, a smoker’s courtyard and dual-occupancy rooms. The new unit has very few blind spots (from the nurses’ station), and these are supported by CCTV surveillance. It has no-smoking, single-occupancy rooms and plenty of parking. The high-dependency units live up to their name – not a door in the unit can be opened without staff assistance, even the bedrooms or courtyard. Thirty years ago, the same hospital (on another site) had a locked psychiatric ward. If you peered in the window, past the safety-glass nurses’ station you could see a Nightingale ward with 20 or so beds on either side: patients were sedated and confined to their beds.
Institutionalisation and deinstitutionalisation
A rise in global concern for psychiatric patients in the 1970s and 1980s had a rare confluence with conservative politics in the US and UK, resulting in policies of deinstitutionalization.

1 In April 1992, the first National Mental Health

Strategy was launched by the Australian federal government. Since then a lot has changed. The problem was complex because psychiatric illness was a black hole that no one wanted to deal with. Mental health wasn’t covered by the universal healthcare system, and as such, the burden of care was carried over many different state government and charity purses, with no one willing to take full responsibility. The result was (and still is to a lesser extent) that mental health was badly underfunded. It also allowed self-serving and hermetic fiefdoms to dominate the sector. At the time, almost 80% of patients in the public system were in long-term care, in stand- alone asylums that were typically located in 19th-century buildings situated within enormous grounds very close to metropolitan centers. There was no evidence that the model worked, but patients and their families did have concerns about their one-way doors, their stigmatizing effect and horrific reputations. A typical example was Callan Park in Sydney, which occupied 43 hectares of waterfront parkland in an inner-city suburb. All the states took different approaches to implementing the first, second and third National Mental Health Strategies – with mixed results. The money for reform largely came from the Labor Party (socialist) controlled Commonwealth (federal) government. But states with Labor administrations failed to implement changes for more than a decade largely due to opposition from nurses’ unions, which feared that nursing jobs might be at risk and that patients might end up on the streets. The first state to fully embrace reform was Victoria, which had a Liberal Party (conservative) administration. It welcomed the funding offered by the Commonwealth and, with bipartisan support, it was able to aggressively push past any opposition and set about replacing the asylums with community-based care. Community-based care is a real improvement on institutional care, but it’s not a magic panacea. How it is implemented varies hugely from state to state and country to country. A worldwide literature review concluded that 12% of homeless populations fit the criteria for a diagnosis of schizophrenia.

2 How this figure relates to deinstitutionalization?

It is unclear because the studies cited are scattered over the period of deinstitutionalisation. In Brazil, for example, formerly institutionalized patients either live in homes with carers, or independently (sometimes homeless) with occasional psychiatric support from day centers. The former model has the disadvantage of replicating some patterns of institutionalization, and the latter can be criticized for entrenching isolation and homelessness. Even so, despite these criticisms, patient consensus is that both alternatives are far better (and cheaper) than total institutionalization, even as models of deinstitutionalized care still need improvement.

3 The Victorian model of deinstitutionalization also attracts criticism, but at least total institutionalization in Victoria was eradicated by 2000: all chronic patients were transferred into ‘villages’, very much like nursing homes, where patients were given rooms in semi independent cottages. Community-based carers, who occupy the gatekeeper houses, care for these patients. Patients who require acute attention are sent to acute mental health centers based within local hospitals. Patients who commit crimes are sent to forensic facilities. More and more, short-term specialist facilities are being constructed to suit local demographics. The next few years saw other states gradually move toward implementing models based on the Victorian success. Most patients throughout Australia are now deinstitutionalized, although only Victoria has completed the process, along with the Australian Capital Territory (ACT) and Northern Territory (NT), which never had asylum-style care. Guidelines inhibit progress
The first Australian attempt to codify the design of acute mental health facilities was in 2007, when CHAA (the Centre for Health Assets Australia – now defunct) released the first edition of the Health Facilities Guidelines (HFG). The guidelines included standards for acute mental facilities. These had very little empirical basis, other than

referring back to relevant statutes and replicating what other countries were doing to provide “solutions to satisfy the
most commonly accepted design requirements”. Nevertheless, they made architectural decision-making easier and
provided a common basis for quoting on new project design and construction. The 2009 edition was officially adopted
to varying degrees in all the states and became the Australasian Health Facilities Guidelines (AusHFG), expanded to
provide guidelines for child and adolescent units, and psychiatric emergency care centres.
Guidelines are probably more suitable for areas of medicine other than psychiatry, where minor changes in the built
environment can be amplified with disastrous results whenever task-oriented surgical procedures are not performed
in highly predictable physical environments.

4 Except for a few specialised procedures (such as electroconvulsive treatment), current models of treatment for mental illness do not demand the same reliability and predictability as a surgical suite. Instead, the built environment is used as a tool to restrict and manage patient unpredictability and other aberrant behaviour. This is reflected in the AusHFG, which somewhat cynically mentions other statutes and guidelines (such as the NSW Department of Health’s Restraint, Seclusion and Transport Guidelines for Patients with Behavioural Disturbance) without drawing any attention to the most salient points: that treatment is compromised by restriction and observation and “that these methods can never be considered a therapeutic intervention”, for instance. Coercive models of care and restrictive environments (including physical and chemical restraint and institutional conditioning) are known to cause emotional damage to patients, and shatter the trust and respect that should be fostered between patients and their carers. Such methods are currently used “at unacceptably high levels in mental health facilities, reflecting prevalence of poor clinical practice and culture”

.5 Rather than address this, the AusHFG
It enshrines such models of care. In crystalizing “the most commonly accepted design requirements” to improve the project management efficiencies, the AusHFG inadvertently draws attention to a bigger problem for all architects: at what point does the architect have a moral responsibility to challenge a flawed brief? The high-dependency unit (HDU) is an environment where the ‘grab and job’ mentality of the institutional wards still persists. It’s also evident that ‘safety’ is a euphemism for an overuse of sedation and an absence of opportunities for suicide: locked doors, separation and the removal of furniture and of objects that may conceivably be used to harm. Yet inpatient suicide is rare, occurring in no more than 0.004% of admissions. Furthermore, there’s no evidence that a restrictive environment alters this figure,

6 Presumably because the loss of a locus of control increases actual risk
While decreasing opportunity. What is alarming about emerging data (as yet unpublished) is the correlation between
restrictive environments and a very significant increase in patient suicide numbers within a week of discharge.
Instead of focusing on what could go wrong, facilities should be declaratively positive, rewarding and empowering
environments to allow recovery

.7 The garden in the new HDU I visited has no plants. The grass is artificial grass laid over rubberised asphalt. Even in the old asylums, the patients enjoyed better than this – real gardens to wander around. In both the gardens and the buildings, there should be variation. Mental illnesses are not all the same and patients may need different environments to recover, just as they may require different psychotropic medications to alleviate symptoms. Some need calming and others stimulation depending on their presentation and time of day.

The Future
The future has always been hazy for mental health facilities, because there’s always been a big question about how mental illnesses can be treated. From here, there are two ways forward. We might stick with the existing paradigms: this position is largely supported by the staff, who still hail from the bygone era of asylum-style models of care, by project managers who don’t consider it their responsibility to interfere, and also by the members of the community who don’t want to know about mental health except that potentially dangerous patients are locked away. Decisions are made on the basis of concerns such as staff convenience rather than best interests for patients. Meanwhile, almost all the available evidence indicates that the current model for mental health facilities is unacceptable and not fit for purpose. There are now hundreds of empirical studies demonstrating that restrictive and coercive practices are part of a dangerous nexus of pathology, clinical practices and social/environmental factors that lead to poor mental health outcomes. Only recently has evidence started to emerge that the environment is a causal factor in mental illness8 and that perception is largely moderated by meso frontal dopamine, the very same neurotransmitter that is implicated in all manic and psychotic illness.9,10 This transmitter is particularly sensitive to perceptions that can be interpreted negatively or are ambiguous in how they should be interpreted.11,12 A mistake that is often repeated is in programming legal facilities (such as magistrates’ rooms in Australia or courts in the US) into mental health facilities. The primary role of these in a facility is to legally impose unwanted restrictions, and the presence of courts and the like makes a mental health facility look and function as an adjunct to the legal system. These lend a negative tone and make instance. The original asylums conceived by TS Kirkbride in the mid-19th century, had animals for patients to milk and care for, vegetable gardens to tend etc. The belief was that meaningful and positive activity was helpful for maintaining a sense of wellbeing. The same principle applies today, but caution should be taken that not all activities should be work-related. (The Kirkbride units had a lot going for them, but within a decade of design, they were universally already becoming overcrowded sweatshops of indentured labourers.) Apart from rewarding work, art, music, reading and writing are important. Some consideration should also be made for tobacco addiction, as taking away this crutch may make life less manageable at a time when that really matters. Sometimes concerns for manageability for staff trump concerns for patients. How often is parking a priority over public transport accessibility? (Understanding that staff will drive cars but patients catch public transport and may get confused if they need to change buses.) Is it better for staff to be cloistered in nurses’ stations or out among the patients? In a brave move, some units in the UK are abandoning nurses’ stations altogether. Meaning is perhaps the most important GRR for mental health patients, especially for affective disorders – those who are depressed, suicidal or violent. Meaning grows with concerns about the world beyond one’s own self. Meaning also spurs action: it makes life worth living. Pets, work, family, friends, other people, religious beliefs, concerns for the environment, nature, politics, art, music and anything that helps to build a sense of identity are all very important for the creation of meaning. In the UK, Medical Architecture regularly designs mental health facilities with provisions for local fauna such as bird and bat houses. Patients appreciate these because they are distinctly positive features that demand an engagement in the world beyond one’s own private concerns. The building of meaning should take precedence over concerns for safety, because meaning is a foundation for sustained wellbeing and therefore safety. In New Zealand, even forensic mental health units such as Ko Awatea encourage Maori (the indigenous people of New Zealand) to carve sacred totems (known as pou). This involves giving forensic patients sharp tools and the space to use them. Reports are that this practice has not resulted in any notable problems. The physical environment either allows meaning to be made or it restricts it. Every design brief must thoroughly consider patients’ frameworks for meaning before they design anything.  What is to happen to a patient’s responsibilities to their pets, children and other important connections when they are admitted? Are pets and children encouraged to stay too? A place that has lots to do and is truly welcoming will encourage more visitors, and that builds a sense of self-worth. Is there amenity for patients to express themselves? Are there provisions for social interaction? Board games and sports can provide social integration. Art and music are also important ways that patients can meaningfully engage with wider society. And is that not ultimately the goal of psychiatric treatment?

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