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The Architecture of Mental
Health Crisis
A thesis summitted to the Graduate school of
the University of Cincinnati in partial fulfillment of the
requirements for the degree of

Master of Architecture

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in the School of Interior Design and Architecture
of the College of Design Art Architecture and Planning
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By Allison Berry
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B.A. of Architecture from Ball State University

May 2016

Committee Chair: Ed Mitchell, M.Arch.

March 25th, 2019





ProQuest Number: 27712100




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Abstract

Mental healthcare facilities in the United States have come a long way from their inhumane
beginnings, but some problems have persisted that continue to make successful treatment and cri-
sis intervention difficult to attain for many. Treatment facilities can be intimidating, invoking senses of
shame or fear in a patient population that is already victimized by social stigma. The divide in building
typology for such facilities showcases a paralleled divide that also exists in treatment approaches.
Inpatient and outpatient psychiatric treatment facilities are criticized as being overly clinical, whereas
more patient-friendly crisis respite facilities can offer a less intimidating, more approachable option for
clients experiencing a crisis.

An evaluation of the history of care, the architecture where treatment took place, and social
perception of care helps inform decisions of what a mental healthcare center could be. Thoughtful
use of typology, program, architectural style, and relationship with the community have the power to
influence the perception of mental healthcare. These decisions are not only appropriate but necessary
to increase the efficacy and improve the perception of mental healthcare. While policy, society, and
stigma cannot be directly changed or completely resolved through design, architectural choices can
address these issues and encourage change.

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Table of Contents
i Abstract
1 Introduction
2 How is Mental Illness Defined?
2 Prevalence
2 How is Mental Illness Treated?
3 Emergency vs. Crisis
3 How is Mental Illness Spoken About?

5 Genealogy of Care
5 Early Treatment
6 Moral Judgement
8 First Moral Treatment
9 Proliferation of Type
14 Trenton Psychiatric Hospital
17 Overcrowding After the Civil War
17 Cottage Plan

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19 WWII and Changes to Public Policy
23 Treatment
25 Deinstitutionalization and the Establishment of Community Care
28 Analysis
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29 Modern Care and Treatment
29 New Typologies
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33 The Jail
34 The Hospital
34 The Home
37 Analysis
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38 Site and Program Analysis

39 Numbers in typical community
40 Barriers to Treatment
41 Site, Size, and Program

46 Design Issues
46 It is Unresolveable
48 House that is not a House
49 Scale and Context
49 Ownership
49 Materials

51 Conclusion

52 Appendix
52 Bibliography
55 Images from Text
60 Tables from Text
60 Design Sketches

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Introduction

Mental illness has always had a social stigma. Even before there was specialized care, society
considered the mentally ill to be a great source of burden on the lives of those forced to interact and
cope with them.1 The first instances of mental healthcare developed before the nineteenth century
were crude attempts to solve a problem that was not yet understood. Formed in the community,
mental illness was treated by containment in jails, hospitals, and in the home. The idea that people
with mental illness need to be separated from the city to be cured was later disseminated through
Europe and North America. Asylums in the United States began to develop in the nineteenth century
and became the first building specially designed for treating mental illness. To employ moral treatment,
the ethical treatment of patients, and refuge in nature, mental healthcare was moved outside the city.

Erving Goffman and Michael Foucault analyzed the evolution of mental healthcare over time
and provided new insights. Goffman wrote the book Asylums: Essays on the Condition of the Social
Situation of Mental Patients and Other Inmates in 1961 outlining what he calls a “total institution.”2
This reaffirmed the asylum removal process where like people are taken out of their community to
form a new community together with a single authority. Foucault wrote Madness and Civilization
which outlines the relationship between civilization and mental healthcare from its very beginnings.

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He analyzed the previous inhumane solutions and developed into a new regime of recommendations:
consolidation, purification, immersion, and regulation of movement that heavily relied on immersion
in nature.3 Sarah Curtis wrote Space, Place, and Mental Health in 2016. She resolves that such
segregation of people with mental illness from the community is harmful to the patient’s reintroduction
into society following treatment.4
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Today there are two approaches to the residential treatment of people with mental illness:
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inpatient facilities that offer a more clinical approach, and a range of outpatient care options. Inpatient
care isolates the patient from society and removes them from their daily lives for a short term. This
immediate intervention is meant to stabilize that person and provide more comprehensive around-
the-clock care. Outpatient care provides a less clinical approach, treating the patient more passively
without isolating them from society. Patients may meet with a psychiatrist, psychologist, counselor,
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or other professional periodically to help manage their symptoms. They may also check into a crisis
respite facility, which offers treatment similar to an inpatient stay without the isolation and removal from
their daily interactions with their community.

The question of “appropriate care” emerges while looking at the treatment of people with
mental illness in the past and how they are treated today. The architecture evolves to reflect current
trends and treatment methods without fully considering or implementing aspects of its past successes.
The arrangement of space, materials, resources, and the mindful inclusion of nature in context
were architectural means to provide more effective treatment in the past and should arguably be
strongly considered today. A facility’s typology, program, architectural style, and relationship with the
community also have the power to influence the perception of mental healthcare. These decisions
are not only appropriate but also necessary to increase the efficacy and improve the perception of
mental healthcare. While policy, society, and stigma cannot be directly changed or completely resolved
through design, architectural choices can address these issues and encourage change.

1 Yanni, Carla. The Architecture of Madness: Insane Asylums in the United States. Minneapolis: University of Minnesota Press, 2007.
2 Goffman, Erving. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York, NY: Anchor Books, 1961.
3 Foucault, Michel. Madness and Civilization: A History of Insanity in the Age of Reason. New York, NY: Vintage Books, 1965.
4 Curtis, Sarah. Space, Place and Mental Health. London: Routledge, Taylor and Francis Group, 2016.
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How is Mental Illness Defined?

Primary care physicians and mental healthcare professionals use the Diagnostic and Statistical
Manual of Mental Disorders, fifth edition (DSM-5), to make a diagnosis.5 Published by the American
Psychiatric Association, the DSM-5 lists symptomatic and behavioral criteria that a person must meet
in order to be diagnosed with an illness officially. A medical professional determines diagnosis by
interviewing a patient about their history of symptoms. Once diagnosed, doctors and therapists can
advise patients on treatment options and future health risks. A doctor’s diagnosis can also be used to
qualify for Social Security disability support or job protection under the Americans with Disabilities Act.

Prevalence

Approximately one in five adults in the U.S.—43.8 million, or 18.5%—experiences mental

illness in a given year.6 Approximately one in twenty-five adults in the U.S.—9.8 million, or 4.0%—
experiences a serious mental illness in a given year that substantially interferes with or limits one
or more major life activities. Mood disorders, including major depression, dysthymic disorder, and
bipolar disorder, are the third most common cause of hospitalization in the U.S. for both youth and
adults.

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Due to a lack of adequate resources to provide care, only 41% of adults in the U.S. with a
mental health condition received mental health services in the past year. Among adults with a more
serious mental illness, 62.9% received mental health services in the past year. Untreated mental
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illness can lead to self-harm and sometimes suicide. The 10th leading cause of death in the U.S. is
suicide - the 2nd leading cause of death for people aged 15–24.
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How is Mental Illness Treated?

Treatment for mental illness has many manifestations, including evidence-based therapy,
medication, education, promotion of physical wellbeing, support groups, and crisis intervention.7
Treatment varies based on type and severity of symptoms presented by an individual, and there is
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no one solution for treatment regardless of diagnosis. Treatment plans vary from person to person,
and it is important to develop a personalized treatment plan based on an individual’s specific needs,
concerns, and goals.

Managing a mental illness requires continuous regulation of symptoms. By educating a

patient on their symptoms and behavioral tendencies, a more comprehensive treatment plan can be
achieved. The efficacy of the treatment and the patient’s overall experience of care are improved when
the patient is involved in the development of their treatment plan. It is then the responsibility of the
individual to enact a regimen of self-care, cognitive correction, and symptom management to improve
their quality of life. The individual can also choose to share coping strategies with members of their
peer support network to help them provide external support.

When a patient’s symptoms become unmanageable or when a patient is a danger to

themselves or others, short-term stabilization is necessary. This can happen at an inpatient
hospitalization facility or in a less clinical peer respite environment. A higher level of care can be
provided at these specialized facilities to intervene during a time of crisis or emergency.

5 APA. “American Psychiatric Association (APA)” February 17, 2019. https://www.psychiatry.org/psychiatrists/practice/dsm

6 NAMI.” NAMI: National Alliance on Mental Illness. February 17, 2019. https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers
7 NAMI.” NAMI: National Alliance on Mental Illness. February 17, 2019. https://www.nami.org/learn-more/treatment
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Emergency vs. Crisis

Many people without consistent mental healthcare go to the emergency room often if they are
experiencing a mental health emergency. A mental health emergency is a life-threatening situation in
which an individual is imminently threatening harm to themselves or is severely disorientated or out of
touch with reality, has a severe inability to function, or is otherwise distraught and out of control.8 This
warrants a call to 911 or a trip to the emergency room. This is only appropriate n the case of a suicide
attempt; assault or threatening actions against another person; hearing voices, paranoia, confusion,
etc.; and when drugs or alcohol escalate a person’s mental health issue.

Emergency rooms and inpatient facilities also receive patients going through a mental health
crisis. A mental health crisis is a non-life-threatening situation in which an individual is exhibiting
extreme emotional disturbance or behavioral distress, is considering harm to self or others, is
disoriented or out of touch with reality, has a compromised ability to function, or is otherwise agitated
and unable to be calmed. This is an unnecessary escalation; treatment at an emergency room is for
emergency care and cannot treat the psychological issues because they are not prepared to do so.
This can also be an extremely overwhelming experience in crisis.

How is Mental Health spoken about?

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The semantics of mental illness and healthcare have vestiges of immoral treatment. Words
such as “insane,” “crazy,” “deranged,” “lunatic,” “nuts,” “psycho,” and “mad” carry a negative connotation
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and paint people with mental illness in a poor light.9 This language promotes the idea that people with
mental illness are “other than” the rest of society and should be feared or mocked. This stigmatizes the
person with the symptoms, not just the symptoms themselves. Such stigmatization can make it difficult
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or shameful for someone with a mental illness to seek the help they need.

Using a diagnostic language for neurotypical people such as, “I have to have a clean house.
I”m so OCD,” “I can”t focus. I”m ADD,” “Her mood can change on a dime. She”s Bipolar.” undermines
the arduous process of getting a formal diagnosis and perusing treatment. False identification can
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affect the perception of that disorder negatively and provide false peer support for people with mental
illness.

Dated and slang terms for mental healthcare facilities such as “booby hatch,” “funny farm,”
“insane asylum,” “lunatic asylum,” “loony bin,” “madhouse,” “nuthouse,” and “padded cell” provide
false imagery and increase negative perception. Words such as “asylum” have developed a negative
connotation over time by association and negative stigmatization of mental healthcare. These
misnomers increase the negative perception which can prevent individuals from seeking care even if
they desperately need it because othering themselves is worse than living with symptoms.

8 University of Hawai’i Community College. What Is the Difference between a Mental Health Emergency and a Mental Health Crisis?
Honolulu, HI: University of Hawai’i Community College.
9 Susman, David, Ph, D. “Ten Commandments for How to Talk About Mental Health.” Psychology Today. June 15, 2017. Accessed Febru-
ary 17, 2019. https://www.psychologytoday.com/.

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Figure x Haejin Park for BuzzFeed created these illustrations to show the differences physical ilness and mental illness in society.

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Genealogy of Care
Architecture has been a key factor in the treatment of mental healthcare since before there
were specialized facilities. As care and societal perception changed, so did the architecture. While
some methods of treatment, programming, and space were proven unsuccessful, others held an
unappreciated value that was written off to prove progress. Understanding the history of patient
treatment, facilities, social stigma, and architectural design, implementation, and degree of success
gives an opportunity to reevaluate the evolution of mental healthcare.

In a genealogy one questions whether assumptions that the emergence of various

philosophical and social beliefs are necessarily progressive or the logical outcomes of conscious
social movements. Instead of writing a history, this section briefly outlines the discourse that emerged
on the subject. Rather than containing a progressive narrative, the history of mental illness and its
treatment has a variety of treatments and relative successes. All are indicative of broader social
constructs, but in some cases treatments, facilities and situations from earlier periods might be more
relevant today. For instance, the isolation of the patient from the community, begun in the late 18th
century may not always be the best practice today. Facilities, treatments, and diagnosis are always in
flux.

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Early Treatments

Before there were dedicated facilities where the mentally ill could be treated, the responsibility
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laid with the family. For those that did not have a family to care for them often ended up in jails or
wandering from one place to the next. Before there was specialized care, society considered the
mentally ill to be a great source of burden on the lives of those forced to interact and cope with them.10
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When dedicated settings emerged, they treated patients like they were not human but some monster
that needed to be contained.
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Figure 1. A depiction of the “madman” and the types of conditions for the mentally ill before the 19th century.

10Yanni, The Architecture of Madness,

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 The earliest treatments of mental illness in the United States were cruel, and patient disabilities
were viewed as as moral flaw. People with a “lack of faith” could be subjugated to being chained to
walls, kept in cages, or holes in the ground. Doctors believed that the mentally ill could not feel cold,
so they were not clothed or given blankets. These people were put in glorified jails, where doctors tried
to remove their demons through exorcism. One example of a facility from this era is the Pennsylvania
Hospital in Philadelphia, Pennsylvania, founded in 1752. It was primarily a medical hospital but
provided a ward for mentally ill patients; this was a single loaded corridor of cells in the basement.

Moral Judgment

By the 19th century, doctors realized there were potential causes of mental illness and more
humane modes of treatment. In 1848 one doctor, for example, lists possible causes as ”ill health,
loss of property, intemperance, death of friends, religious excitement, deafness, abuse of husband,
domestic trouble, apoplexy, epilepsy, death of a lover, injury of head, insanity of wife, congenital,
stroke of sun, Mormonism, meningitis, hard study, lawsuit, false accusation, fright, and unknown.”11
Doctors worked under the assumption that their idea of “normal” was universal. Religious choices
and non-mental health related illness were cared for the same as “insanity.” “Some theorists claimed
that insanity was heritable and worsened with each succeeding generation; this dire interpretation

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coincides with developments of negative eugenics in the nineteenth century, the discouragement of
the propagation of the genetically unfit.”12
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The first insane asylum in the United States, established in the 1840s, collected the
community’s rejected people and moved them to a curated environment to regain their sanity.
Nineteenth-century doctors believed that they could cure seventy to ninety percent of patients of
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insanity, but only if patients found treatment in specially designed buildings. For the first time, the
asylum gave families the option to send their family members away, but first, the family had to trust
the institution. The asylum was a new challenge for architects. Working closely with the asylum’s
psychiatrist who was also the superintendent, they employed the ideology of environmental
determinism: a belief that a specific architectural atmosphere would shape behavior, curing the
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patient. Designers at this time set asylums apart from society, took refuge in nature, and provided a
specific location to receive care creating an environment that world cure patients of their illness.

The social stigma of the mentally ill made them outcasts in society. Doctors realized the need
for a treatment facility that removed these people from the city. The United States established the first
insane asylum in 1773. The Williamsburg Public Hospital in Williamsburg, Virginia was an intuitional
building that could be easily mistaken for a college, town hall, or orphanage. Robert Smith designed
this public facility, but the role of the architect was not all-encompassing. The architect designed the
façade, overseeing the construction process, and adjustd the plan as necessary. Dr. John Galt, the
superintendent at Williamsburg, was responsible for the floor plans and the general arrangement
of the facility, although the plans were not specialized and were later deemed not therapeutic for
patients.

11 Yanni, Carla. “The Linear Plan for Insane Asylums in the United States before 1866.” Journal of the Society of Architectural Historians
62, no. 1 (2003): 24-49. doi:10.2307/3655082.
12 Yanni, “The Linear Plan for Insane Asylums in the United States before 1866,
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Figure 2. Exterior elevations and plans of the Williamsburg Public Hospital in Williamsburg, Virginia

Reproduced with permission of copyright owner. Further reproduction prohibited without permission.