Psychological Design

The Architecture of The Psychiatric Milieu

The last time a peer-reviewed volume on the future of mental health facilities was produced was in 1959, following a symposium organised by the American Psychological Association. The consensus was easy enough to follow and still resonates today: the best spaces to treat psychiatric illness will be in smaller, less restrictive units that offer more privacy and allow greater personalisation of space – possibly a converted hotel (Goshen, 1959). In some way, all those ideals have come to pass. An ideal typology was never established, but even so, units have shrunk from thousands of beds to units that typically house no more than 50 patients. Patients are generally more independent and are free to wander (within a unit) as they please. But the trend toward smaller and freer is reversing. This change is not driven by a desire to find the ideal building nor better models of care, but by growing concerns about budgets, self-harm and psychiatric violence. This issue of the Facilities comes at a time when the healthcare design is increasingly dominated by codes, statutes and guidelines. But the articles herein are a call to stop and think. We are not at the point where guidelines can be helpful, because they do not embody any depth of knowledge nor wisdom. These articles are intended to inject some new research on psychiatric/environmental interactions and also to remind planners and managers that guidelines might not tackle a core misunderstanding: fear-management about patient safety and the safety of society is not the purpose of the psychiatric facility. It is purpose is to create spaces that are suitable for improving the well-being of the mentally ill. One problem that reoccurs in each of the
articles in this volume of Facilities (and others that could not be printed because of the caprice of the peer-review process) concerns the locus of control within a unit. All the authors herein find compelling arguments for shifting control incrementally “toward empowerment of the patients”. But the opposite (greater staff control) usually results in better patient behaviour (van der Schaaf etal., 2013) and greater staff control is also  predicted to improve discharge diagnosis. But this is because mental illness is largely diagnosed by unsociable behaviour (American Psychiatric Association, 2000) and not by a consideration of the underlying pathology. Whether this means greater staff control is desirable is anything but clear, because investing responsibility in the patient leads to the ultimate goal of acute mental health care: once patients relearn self-responsibility, they can re-join society.
The model of the ideal patient – one who is well behaved and passive is not necessarily healthier at all (Sloan Devlin and Arneill, 2003) and is better suited to anachronistic models of care. It is conceivable that greater staff control leads to the “revolving door syndrome” – the continual readmission of the very same patients. The last 60 of so years have seen major changes in the way mental health is understood. In the mid-twentieth century, Freudian and Jungian models dominated. Mental illness was the product of bad acculturation, of failed archetypal journeys and of stored images of abuse (Searles, 1965). The relative success of psychotropic medications turned thinking to chemical imbalance models, but psychotropics have only limited applicability (Jones, 2004).

Sometimes they may help, but they do not cure. The sequencing of the human genome over the 1990s offered hope for the millions that
psychotropic medications failed. But genetic studies have so far failed to identify anything more than a predisposition – a “somatic” context for the development of a mental illness. There is no doubt that genetics will prove very significant, if ever we can do
something about the smoking-gun allele and gene mutations that geneticists are
continually discovering. But potential successes in one context are no reason to ignore the other. We remain in contact with
the built environment for almost every minute of our lives, as a context, it is as ubiquitous as our genes – but unlike genetics, the built
environment is “designed”. In this issue of Facilities, the environmental context has been placed in the spotlight: not
only as a site for establishing patterns of best practice in mental facility design through developing outdoor areas that empower patients (Perkins, 2013; Wagenfeld et al., 2013) and identifying problems with current models of care and mental health facility design paradigms (Baltazar et al., 2013; Chrysikou, 2013), but also as the very site for the psychogenesis of mental health problems in the first place (Golembiewski, in review). Side by side with genetic factors, the physical environment moderates and mediates the symptoms of mental health “through moderating and mediating experience itself”. Like genetics, the environment cannot be considered as directly causal, but it does inextricably contribute to the diagnostic symptomatology (Golembiewski, 2012). For every pain-point that this special issue of Facilities touches, there are hundreds that have gone unmentioned. There is still a mountain more research to be done and translated for use in praxis and there will be problems all the way. Not least of all from the normative demands that society places on models of care. But attitudes must shift so the spaces and facilities to treat psychiatric patients can become more humane and more effective places for treatment. It is designers who drive most of the innovations to the design of psychiatric facilities (and even to the models of care they house). Designers and commissioning bodies may despair when they discover that we know how to make established models of care more efficient but seldom think of the effects that these efficiencies have on patient well-being and health. But take heart; this endeavour must start somewhere, and where better than Facilities, one of the few peer-reviewed journals with a scope broad enough to reach out to designers, facility managers and commissioning bodies.
1.American Psychiatric Association (2000), Diagnostic and Statistical Manual (DSM-IV-TR), 4th Text Revision. American Psychiatric Association, Arlington, TX
2.Baltazar, A.P., Kapp, S., de Tugny, A. and Furtado, J.P. (2013), “Spaces for differences: dwelling after deinstitutionalization”, Facilities, Vol. 31 Nos 9/10, pp. 407–417
3.Chrysikou, E. (2013), “Accessibility for mental healthcare”, Facilities, Vol. 31 Nos 9/10, pp. 418–426
4.Golembiewski, J. (2012), “There’s something in my head (but it’s not me): the complex relationship between the built environment and schizophrenia”, PhD thesis, University of Sydney, Sydney
5.Golembiewski, J. (2013), “Lost in space: the place of the architectural milieu in the aetiology and treatment of schizophrenia”, Facilities, Vol. 31 Nos 9/10, pp. 427–448
6.Goshen, C.E. (1959), “A review of psychiatric architecture and the principles of design”, in Goshen, C.E. (Ed.), Psychiatric Architecture; a Review of Contemporary Developments in the Architecture of Mental Hospitals, Schools for the Mentally Retarded and Related Facilities, The American Psychiatric Association, Washington, DC
7.Jones, H.M. (2004), “On biology, phenomenology, and pharmacology in schizophrenia. Commentary on Kapur’s “Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia”, American Journal of Psychiatry, Vol. 161 No. 2, pp. 376–377

8.Perkins, N. (2013), “Including patients, staff and visitors in the design of the psychiatric milieu: notes from the field”, Facilities, Vol. 31 Nos 9/10, pp. 379–3909.Searles, H.F. (1965), Collected Papers on Schizophrenia and Related Subjects, Maresfield Library, London
10.Sloan Devlin, A. and Arneill, A.B. (2003), “Health care environments and patient outcomes: a review of the literature”, Environment & Behavior, Vol. 35 No. 5, pp. 665–694
11.Wagenfeld, A., Roy-Fisher, C. and Mitchell, C. (2013), “Collaborative design: outdoor environments for veterans with PTSD”, Facilities, Vol. 31 Nos 9/10, pp. 391– 406
12.van der Schaaf, P.S., Dusseldorp, E., Keuning, F.M., Janssen, W.A. and Noorthoorn, E.O. (2013), “Impact of the physical environment of psychiatric wards on the use of seclusion”, The British Journal of Psychiatry, Vol. 202 No. 2, pp. 142–149

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