A new era dawns in behavioral health design
Departing from the institutionalized care of the past, architects are designing behavioral health hospitals, clinics, and specialized environments that better reflect the needs of patients and staff.
Erin Sharp Newton has spent years designing buildings in cities around the globe, always with a focus on how her work can better the human condition. After a decade in Italy, she returned to the United States with a desire to tackle projects that go “beyond what looks cool.” At NK Architects in Morristown, New Jersey, she found a design specialty that suited her: Behavioral health.
“Designing behavioral health facilities is a challenge that is unlike any other project type,” she says. “From the windows to the doors, the walls, the ceilings, the lighting, the fixtures; every aspect requires a totally different mode of thinking as compared to a typical design project.”
According to the National Alliance on Mental Illness, every year approximately 1 in 5 American adults experiences mental illness. At the same time, the past year saw only 41 percent of adults with a condition receive mental health services. Location and lack of availability are part of the problem, but the stigma of sealed-off, locked-away care—and the unwelcoming facilities that typically housed patients in the past—remains a pervasive factor as well.
“On a typical project,” Newton says, “you’d ask, ‘What looks nice?’ Maybe you’d envision picture windows, curtain walls, fancy finishes, French doors, seamless walls of glass; all kinds of other wonderful things. Every one of those, you cannot use in a behavioral health facility.”
Instead, this means specialty door hardware, more durable flooring, modified handrails, and safer furniture, fixtures, and equipment. It also means getting granular and understanding the very specific requirements of clients and patients in this field.
“Behavioral health units have been shifting from an observation- and evaluation-based unit to a more healing environment,” notes Christopher Davis, AIA, senior architect at Gresham Smith. “There has traditionally been a hospitality-oriented design approach to the rehabilitation side of behavioral health, but more recently the hospitality-oriented colors and patterns have been introduced to the traditional observation and evaluation unit to provide a more comforting and relaxing environment.”
While not every facility exhibits these design sensibilities, architects at firms across the nation are working to create hospitals, clinics, and specialized environments that better reflect the wants and needs of the behavioral health community.
Here comes the SUN
One recently completed project at NK that Newton is particularly proud of is SUN Behavioral Health’s inpatient/outpatient hospital in Erlanger, Kentucky.
“The fantastic thing here is that it was a ground-up,” Newton says. Many projects in this field are upgrades or renovations, she notes, which limits an architect’s ability to start from scratch. Here, the team at NK could pursue their full agenda with the support of a committed and knowledgeable healthcare client.
The hospital came in at just under 150,000 square feet with 197 beds. It’s entirely devoted to mental and behavioral health; SUN prides itself on being a community-oriented company, which means an emphasis on community spaces and on providing resources for everyone. They even have their own emergency room, where patients in need can be seen immediately.
“Good design, even in a field like this, doesn’t always have to cost a lot of money.” - Erin Sharp Newton
One of the biggest trends in behavioral health design involves nurse stations; designers are grappling with how to make them safe and secure while also creating a feeling of openness that does not inspire alienation or frustration among patients.
“You need to do a risk assessment,” Newton says, “and make sure the client helps you understand the patient population and their needs. If there is a high potential of danger, you have to design for that. It can’t be a certain way just because it’s beautiful.”
For this hospital, the NK team took advantage of the blank slate to design super deep, solid-surface nurse stations that simultaneously exude a feeling of openness with protection. They also incorporated visible lines around the stations to set perceivable boundaries that didn’t make the patients feel walled off.
“Boundaries can be created subtly without having to be aggressive,” she says. “It doesn’t have to be complex or expensive either. Good design, even in a field like this, doesn’t always have to cost a lot of money.”
Laying a foundation of research
In addition to smarter, more thoughtful behavioral health projects, researchers in the design world are examining certain strategies to ensure they work for populations in need. Lesa Lorusso can speak to that firsthand; before becoming the healthcare director of research and innovation at Gresham Smith, she started a research project on reducing agitation and aggression in veterans with dementia that may help solidify how exactly environment impacts mood.
“Designing for dementia care is moving away from an institutionalized look,” she says. “Healthcare everywhere is headed toward patient-centered design, and that’s very relevant for the work we’re doing.”
As a PhD student at the University of Florida, her efforts were focused on how multisensory environments might improve care for dementia patients. Her grandmother was a Korean War veteran who suffered from dementia; from personal experience and from the literature on the subject, she found that problem behavior often spikes during assisted bathing or personal care assistance.
“This is a common issue,” she says. “In nursing homes, 90 percent of residents need assistance with personal care, and 89 percent of the problem behaviors in these facilities happen around that time. It can often last for a very long time after.”
She brought up this issue at a meeting of the Vital by Design Initiative, the University of Florida’s program that operates within AIA’s Design & Health Research Consortium. A physician from the Department of Veterans Affairs (VA) recognized it as something his team had also been studying; the university, the VA, and eventually Gresham Smith formed a partnership to research potential solutions.
“For people with dementia, you have to remember the person is still in there. As designers, we have to look within that person and try to support them through the built environment as best we can.” - Lesa Lorusso
“Our overarching question was, ‘What impacts can multisensory environments have on behavior for people with dementia?’” Lorusso says. These environments were made up of ergonomic furniture, bubble tubes, music, aromatherapy, and color-changing LED lights; the VA had been working with them since 2010, and Lorusso wanted to prove their value in critical moments of personal care assistance.
The project included a literature review that was published in The Gerontologist and a questionnaire that went out to 53 different VA facilities, asking staff how they felt about the effectiveness of these environments. The answers—all constructive and largely positive—led to a 20-week observational clinical trial with four dementia patients within the multisensory environment.
“Everything was kept constant within the environment, including the nursing staff,” she says. “The only difference was, when the intervention period began, the technology would switch on. Suddenly, you had LED lights and bubble tubes and music; the environment was transformed into a customized sensory experience.”
Lorusso and an associate tracked behaviors using specially developed software; though everyone responded differently, on average all four participants exhibited increased positive behaviors and decreased negative behaviors. Some responses were drastically positive while others were a cooling of the negative, but there was no doubt that the environmental intervention mattered.
“Our findings showed that the environment really made an impact,” she says. “It would be really exciting to replicate this study, further develop this observational software, and maybe find a way to create another multisensory room like this with even greater customization.”
“For people with dementia,” she adds, “you have to remember the person is still in there. As designers, we have to look within that person and try to support them through the built environment as best we can.”
Stephen Parker, AIA, is part of the next generation of young architects rising to meet the challenge of mental health design. Parker, an architect in SmithGroup’s Washington, DC, office, and AIA Strategic Council representative, recently finished Kaiser Permanente’s first autism spectrum disorder (ASD) clinic on the East Coast. Intended for the diagnosis of young patients on the spectrum, this pediatric outpatient clinic is designed with families in mind.
According to the CDC statistics, 1 in 59 children is diagnosed on the spectrum each year. This new outpatient clinic is intended to diagnose young patients, typically under the age of 8. Often accompanied by their parents and siblings, thoughtful consideration of family spaces is equally as important; this means incorporating soft seating spaces with direct staff visibility and finding ways to reduce stress to compensate for long diagnostic sessions, which could last much of the day.
“We know from evidence-based research that a number of design features can alleviate stress, such as natural light,” Parker says. With that in mind, each provider office is designed with transom windows, illuminated with diffuse natural light via adjacent light wells. Full lighting controls can adapt to patient needs, helping create a low-stimulus environment if necessary.
“Healthcare design creates spaces for humanity at its most vulnerable. We should strive to design with dignity in mind.” - Stephen Parker, AIA
The diagnostic space is set up with a playroom for testing younger patients, with an attached observation room for clinicians and accompanying families. A large one-way mirror allows for unobtrusive observation while maintaining acoustic privacy. Additional acoustic treatments—such as modular wool felt panels—lend color, texture, and dimension to meeting spaces.
As an architect who has advocated for healthcare since his graduate thesis work, Parker embraces the ascension of mental and behavioral health as comparable to physical health, along with the enthusiasm of designers who’ve devoted themselves to this line of work.
“At every firm I've visited, the architects were passionate about sharing their lessons learned and helping others grasp the nuances of mental health design,” he says. “Their passion to serve a misrepresented population—and bringing great design to patients who haven’t always benefited from well-conceived, therapeutic spaces—makes for a thrilling space to be in as a young architect.”
“Healthcare design creates spaces for humanity at its most vulnerable,” he adds. “We should strive to design with dignity in mind.”
Steve Cimino is a Los Angeles-based writer and editor with a focus on architecture and design.