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Mental health facility design: The case for person-centred care

Article  in  Australian and New Zealand Journal of Psychiatry · January 2015

DOI: 10.1177/0004867414565477 · Source: PubMed

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565477
research-article2015
ANP0010.1177/0004867414565477Australian & New Zealand Journal of PsychiatryGolembiewski
Debate
Mental health facility design: The case
for person-centred care
Jan Alexander Golembiewski
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 mod-
els 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 effi-
ciency 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 men-
tally 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 empower-
ing 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
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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-nego-
tiable requirement of a mental health
facility, the only evidence on the sub-
ject builds a compelling case against
the implementation of staff stations
altogether – because when staff sta-
tions 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).
The question about what the alter-
native – 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 gar-
dens that are out of bounds to clients.
A poor understanding of what per-
son-centred care means, how it can
be implemented with minimal disrup-
tion and why it is of clinical impor-
tance 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 treat-
ment has no perceived positive effect
on a client’s ability to cope, they may
Australian & New Zealand Journal of Psychiatry, 49(3)
Australian & New Zealand Journal of Psychiatry
2015, Vol. 49(3) 203­–206
DOI: 10.1177/0004867414565477
© The Royal Australian and
New Zealand College of Psychiatrists 2015
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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 relation-
ships 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 coer-
cive 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 power-
ful causal influence in mental illnesses
(Golembiewski, 2013). Effectively, men-
tal health facilities are the ‘wrong
vehicles’ 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
Medical Architecture, Sydney, New South
Wales, Australia
Corresponding author:
Jan Alexander Golembiewski, Medical
Architecture, 157 Brougham St,
Wooloomooloo, Sydney, New South Wales
2010, Australia.
Email: jg@medicalarchitecture.com
204 ANZJP Debate

Figure 1.  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.

Figure 2.  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.

Australian & New Zealand Journal of Psychiatry, 49(3)

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Golembiewski 205
passive nor minor. Indeed, several
studies suggest that it’s perhaps the
largest and most consistent factor
contributing to psychotic illnesses
(Golembiewski, 2013). The psycho-
tropic 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 suffi-
cient to significantly increase key indi-
cators of psychosis. Before and after
the walk, subjects completed a bat-
tery of psychological tests, which
revealed very significant decreases in
health indicators due to anxiety
[t (14) = −3.57, p = 0.003] and para-
noia [t = −2.69, p = 0.017].
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 reli-
ability. To add to this, they follow a
repetitive and possibly misguided par-
adigm: the redecorations aim to make
spaces more homely. But is this the
best way forward? Is it naïve to sug-
gest homelike touches like domestic
furniture and carpet (in an institu-
tional building replete with staff) could
cure or prevent mental illness?
Some (quite reasonably) suspect
that the dependent variables in envi-
ronmental-intervention studies in psy-
chiatric facilities are insubstantial.
Higgs (1970) tried to prove it: he
pointed out that environmental
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interventions like brighter paintwork,
interior decoration such as curtains
and divider screens, and rearrange-
ments in seating and of planters
shouldn’t affect very serious mental ill-
ness, when more fundamental issues
such as neurochemistry remained
unchanged. But Higgs’ experiment
failed to support the null hypothesis,
instead uncovering impressive statisti-
cal significance, which didn’t attenuate
even over months. Despite his inten-
tions, Higgs’ study added to a growing
list of the psychiatric facility interven-
tion studies that reliably demonstrate
how minor changes exert a dispropor-
tionate 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, isolat-
ing, 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 aeti-
ology. The intervention studies rein-
force the key findings of Golembiewski
(2013) and Ellett et al. (2008), that psy-
chiatric patients are much more reactive
to the physical milieu than healthy con-
trols, suggesting that the environment
may, indeed, be a good target for psy-
chiatric intervention.
The question about the ideal physi-
cal 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 stud-
ies – when seen together, is that the
environment is holistic – the aesthetic
dynamics of the space affects inter-
personal relationships, behaviour and
Australian & New Zealand Journal of Psychiatry, 49(3)
symptoms. There’s no perfect archi-
tectural 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 per-
son-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 domes-
tic. The language should make it unam-
biguous that the milieu is wholesome.
Beyond this, the environment should
strive to exceed expectations of the
client experience with refined aesthet-
ics and by composing a stage-set like
environment, where there’s a choice
of wholesome things to do, provisions
for privacy, dignity, sanctuary, com-
prehensibility 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 leader-
ship is needed to fearlessly drive new
agendas and design, especially as this
will encounter resistance from ortho-
dox 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 psy-
chotic experiences may be eccentric
and prone to paranoia, but by acknowl-
edging that mental illness causes too
206 ANZJP Debate
much inhibition of the positive aspects
of design, and too little inhibition of
the negative, we have a good founda-
tion. 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 sche-
mata 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 win-
dows 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
Australian & New Zealand Journal of Psychiatry, 49(3)
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conventions, so these schemata do
create a common language.
Opportunities for meaningful action
are probably more important still;
working gardens, art and sports equip-
ment, 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 proba-
bly no better therapy for mental
illness.
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 knowl-
edge 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.
References
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