"Humanizing Behavioral Healthcare Design", (c) Jay W. Schneider, Building Design and Construction, 02/01/08

I t wouldn’t be surprising to discover that a good part of the AEC community is unaware of the activity surrounding behavioral healthcare design and construction. These very specialized psychiatric facilities don’t typically garner the attention associated with some of today’s top healthcare projects, and their construction accounts for a small fraction of the work in the healthcare sector, but the projects are increasing in number and keeping some very prominent firms quite busy.

For example, Cannon Design, Grand Island, N.Y., has worked on 12 new behavioral healthcare facilities in just the past two years, and Gilbane Building Co., Providence, R.I., currently has six such facilities on the books, with more in the pipeline.

Contributing to the boom in construction of behavioral healthcare facilities is a paradigm shift in the way mental illness is viewed by society. “The philosophy regarding the treatment of mental illness has completely changed from storage to treatment,” says Mark Hanchar, director of preconstruction services for Gilbane.

No longer are these facilities expected to warehouse patients indefinitely. Instead, patients are being treated with the expectation that they can be rehabilitated and returned to their communities as quickly as possible. Depending on the severity of the illness, the average length of stay in a behavioral healthcare facility is only 9.6 days, according to the National Association of Psychiatric Health Systems (NAPHS).

There are two reasons for this truncated admission period, according to Jaques Laurence Black, AIA, president and principal of New York City-based daSilva Architects: modern psychotropic drugs, which greatly speed up the treatment process; and pressure from health insurance companies to get patients out of expensive modes of care.

Mental healthcare professionals are finding it difficult, however, to quickly and effectively treat patients within the confines of ancient facilities designed for dramatically different (and outdated) treatment methods. Most of the nation’s operating psychiatric facilities date from between 1908 to 1928, according to Hanchar. Not only are they antiquated, their physical state is rapidly deteriorating, which helps explain the influx of new projects, both public and private. An NAPHS trend analysis released last May shows that the number of licensed psychiatric beds increases approximately 5% per year.

Also driving behavioral healthcare facility construction is the sheer number of people suffering from mental disorders. The National Institute of Mental Health reports that about 26.2% of Americans aged 18 and older—about one in four adults—suffers from a diagnosable mental disorder, and 6% of adults suffers from a major mental illness (see sidebar). As a result, acute-care hospitals, where these patients are frequently sent for short-term treatment, are overwhelmed, so the construction of new behavioral facilities helps free up hospital beds.

A lack of acute-care beds is not the only reason psychiatric patients need to be treated in specialized facilities. This patient group has unique problems and behaviors that are better addressed in facilities designed specifically for their needs. Psychiatric patients are generally physically healthy and capable, but their behavior is wildly unpredictable—acting out and self-harm are major concerns. In general, they react better to surroundings that feel more familiar and personal rather than clinical. Projects that address those behavioral concerns within the built environment are becoming models for successful 21st-century psychiatric healthcare facilities.

Following are major design considerations for today’s behavioral healthcare facilities:

Aesthetics. Patients need to feel as if they’re in familiar surroundings, so the architectural vocabulary has to feel comfortable and normal. It must also reflect the architecture of the region in which the building is located. As a result, no two facilities should look too much alike or be the same size or style.

“Our approach to designing these facilities is to view the facility as an extension of the community where patients will end up when they’re released,” says Tim Rommel, AIA, ACHA, OAA, principal with Cannon Design in the firm’s headquarters office near Buffalo, N.Y. A facility in Arizona could be adobe stucco, for example, while one in Maine could be shingle-style. “Interior finishes also depend on geography because you want to replicate the environment patients are used to,” says Rommel. Nor should the building look like a hospital: “You want to destigmatize the facility as much as possible,” he says.

Right-sizing. New behavioral healthcare facilities tend to be sprawling, single-story buildings with a campus feel. This design preference is driven by the demand for natural light—a light, airy environment is calming to patients—and the desire to have direct access to the outdoors—visual and physical contact with the outside world is hugely important, according to mental health experts.

“When you look at the program mix in these buildings, there’s a high demand for perimeter because there are a lot of rooms that need natural light,” says James Kent Muirhead, AIA, associate principal at Cannon Design in Baltimore, Md. “Offices, classrooms, dining areas, community rooms, and patient rooms all demand natural light, so you end up with a tremendous amount of exterior wall, and it forces the building to have a very large footprint,” he says. “It’s one of the biggest debates we have with clients because that layout can add to construction costs.”

However, many healthcare-provider clients prefer large, single-story facilities (which need roughly 1,500 sf per patient), not only because they allow for abundant natural daylight, but also because they provide immediate access to the outdoors from almost anywhere in the facility. A large building footprint enables the facility to wrap around itself, creating secured courtyards where patients can enjoy the outdoors without being surrounded by fencing and barbed wire. Aesthetically, single-story buildings look less like barracks and more accurately reflect building types that patients are likely to encounter within their communities.

The downside to sprawling facilities is, of course, higher construction and operational costs. To control costs, Cannon Design’s Rommel looks for more-efficient construction methods (such as thinner but stronger walls, and, following LEED guidelines, uses high-efficiency HVAC systems. He offsets the large footprints of a one-story structure by making the most of space that, in a multistory building, would be used for stairs and elevators. “Capital expenditures for a new behavioral healthcare facility are only 6%, versus 94% for operating costs over 30 years,” says Rommel.

However, Gilbane’s Hanchar worries about how out of whack the aspect ratio of single-story facilities can become. He advocates going up a few stories, but generally no more than three or four—again, depending on what’s appropriate and familiar for the community. “You can do half the amount of foundation, do less façade and roof, and save on extended services like water and electrical,” he says. “This may sound like a no-brainer, but believe me, it’s a major deal.”

Manageability. Managing patients is, of course, a major concern in large mental health facilities, where distances and adjacencies are critical to patient treatment, safety, and security. “When you get above 120 beds, it’s very difficult to do a single-story building,” says Frank Pitts, AIA, FACHA, OAA president of architecture+, Troy, N.Y. “What ends up happening in a large building is that patient units get too big and outgrow support services and are located too far away from those services,” he says. Direct access to the outdoors—one of the main benefits of a single-story building—should never outweigh access to treatment, says Pitts.

The facility size Pitts advocates is one where nursing units (often called “neighborhoods”) average 24-30 beds arranged in sub-clusters (“houses”) of 8-10 beds; thus, each neighborhood consists of three houses. However, the features in each neighborhood will vary from one facility to the next. Some will include a common area where patients can congregate, with a separate quiet room where individual patients or small groups of patients can get away from crowded, noisy areas.

Meals are frequently eaten in the neighborhoods. “There’s a move away from central dining facilities,” says Pitts. So, while facilities will still have a central kitchen, it’s a whole lot easier moving food than it is patients, he says.

It is important for patients to frequently leave their neighborhoods, however, because this activity helps simulate a normal day outside the facility. Patients do this most often to attend treatment sessions or exercise classes—gymnasiums are frequently part of these facilities—and managing that movement is critical.

Cannon Design’s Muirhead recommends that hallways be no longer than 100 feet and no wider than eight feet. “When groups get too big, they become risks, and long, wide hallways can become problems for staff to manage,” he says.

Patient rooms. Most behavioral healthcare facilities are moving away from semi-private rooms in favor of private patient rooms with private bathrooms, even though there is no official mandate to do so. “There is a very active conversation about moving toward private bedrooms,” says architecture+’s Pitts, who serves on the AIA Guidelines Revision Committee. Patient safety is one issue, with some experts saying the risk of suicide is less in semi-private rooms because the patient sharing the room can report an incident. Others counter that clinical staff shouldn’t rely on patients to maintain safety. (The most fragile patients—the ones most likely to commit suicide—are generally assigned private rooms anyway, says Pitts.)

Experts advocating private rooms also say that behavioral disorder patients tend to be very sensitive to noise and crowds and sleep easier and are less stressed when they have their own rooms. Opponents argue that mandating private rooms reduces flexibility in the nursing units and significantly increases construction costs. Pitts thinks it will take some time for the AIA Guidelines Revision Committee to resolve the matter.

Patient room size varies depending on code and program requirements, but Cannon Design’s Rommel suggests that private rooms have a minimum of 100 sf. Aesthetically, bedrooms are usually modestly furnished, painted in calm, soothing colors, such as light blues and greens—avoid bright colors such as purple, red, yellow, and orange. They are usually outfitted with heavy, solid furniture, which is customarily bolted to the floors or walls—often drywall over plywood or concrete block to look less institutional without compromising security—to prevent furniture from being thrown or being used to blockade doors.

“These facilities need to be some of the most durable buildings in the healthcare segment,” says Rommel. “We know that our clients are budget-challenged, so we’re looking for what’s most appealing for the patient for the least money.”

Safety and security. Often the biggest safety and security concern in behavioral healthcare facilities is the damage patients can do to themselves.

“There are three rules I had drummed in me,” says Gilbane’s Hanchar. “First, there can’t be any way for people to hang themselves. Second, there can be no way for them to create weapons. Third, you must eliminate things that can be thrown.”

Hanchar says that the typical facility is “a hospital with medium-security prison construction.” That means toilets and sinks must be stainless steel—porcelain can shatter too easily. Windows must have shatter-proof glass. Countertops must have solid surfaces—laminates can be peeled apart. And furniture should be bolted in place.

Hardware—hinges, door handles, screws, sprinkler heads, etc.—has to be selected with great care. DaSilva Architects’ Black tells of one facility where conical-shaped doorknobs were installed and the patients were afraid to use them because of their unusual appearance. Push-pull door latches, installed with handles pointing down, are considered the best option, according to the NAPHS; the handles are familiar to patients and eliminate the risk of being used in a suicide hanging. (Last June, the NAPHS released the second edition of its Design Guide for the Built Environment of Behavioral Facilities, which reviews preferred products of all types: www.naphs.org.)

Removing barriers between the nursing staff and patients is also a safety consideration. It may sound counter-intuitive to remove barriers to increase safety, but as architect Pitts says, “Glass walls around nursing stations just piss off the patients.”