Before making any design recommendations, we need to agree on the theory that backs those recommendations. Most theories available for design of behavioral health environments may have overlaps or support the same recommendations to varying degrees. Based on type and needs of a care area, design team may choose to follow a certain theory or the other. Reviewing the theories with care team, at the beginning of the design process, can help ensure the design team and care team see eye to eye and can follow the same priorities. Below is a list of major design theories that impact behavioral health environments, along with a brief summary of what that theory entails.
The Anthroposophical Society encourages openness to the “various spiritual realms” in human life (Allgemeine Anthroposophische Gesellschaft, 1999). They support patient evolution through shift from containment to exploration. As such, design features include softer forms that create a more human friendly environment that enables playfulness and exploration. Anton Alberts, a Dutch architect (1927-1999) once said that form is “spirit made visible”.
Evidence-based design follows the footsteps of evidence-based medicine, which is focused on making decisions based on best evidence available (Sackett et al.,1996). When it comes to design, because each patient group and each facility may have unique needs, the design team will pair up with the care team to identify scientific evidence available that can help the goals of that specific facility in the best way possible (Hamilton and Watkins 2009).
Scientific evidence may sound rigid and limiting to a design team, so the term “research-informed design” is used to describe the same intent for confident and science-based decision-making.
Almost everyone is familiar with physical space and social environment. Generative space is born from the interaction of the two, if they are in harmony and support each other’s goals. A generative space is a life enhancing space which encourages, supports, and reinforces improvements to health and wellbeing (Ruga, 2008; 2010). Social interaction is an important part of the healing process for psychiatric patients, therefore generative space is particularly relevant for this patient group.
The mission of Planetree is “the development and implementation of innovative models of healthcare that focus on healing and nurturing body, mind and spirit” (Planetree, 2014). Planetree support patient-centered care that is accessible and home-like. Opportunities for privacy as well as socialization are equally important to the Planetree model and special attention is paid to staff, by providing respite areas for them.
In 2015 the Planetree Institute took on the mission of raising awareness regarding behavioral health facilities and sponsored a design competition on the topic, producing a patient room prototype in 2016 for the Veterans’ Administration.
Antonovsky’s salutogenic theory suggests that coherence and meaningfulness in the environment contributes to better mental health, which results in improved overall health (Golembiewski, 2010). With this understanding, the salutogenic approach focuses on eliminating features that generate stress or confusion. Like so many other design theories, access to nature and daylight, personal control, areas dedicated to private and public relaxation and aesthetic spaces (Heerwagen et al., 1995) are promoted. The framework also embraces interconnections between people, events, procedures, and places (Heerwagen et al., 1995).
Two competing theories exists regarding the planning and design of mental and behavioral health facilities. One of them, focuses on specialization, or tailoring physical environment to specific needs of a particular patient population. The opposing theory, known as generalist approach, argues that the goal for treatment plans is to prepare patients for a normal life, as such the care space should resemble the environment that patients will live in after they are ready to join the larger community. Historically, normalization theory has proven to be a useful tool, but could not fairly be applied to all cases (Chrysikou, 2014).
Allgemeine Anthroposophische Gesellschaft. (1999). Anthroposophical Society. Retrieved from www.goetheanum.org/aag.html?&L51
Chrysikou, E. (2013). Accessibility for mental healthcare. Facilities, 31(9/10), 4-4.
Golembiewski, J. (2010). Start making sense: Applying a salutogenic model to architectural design for psychiatric care. Facilities, 28(3/4), 100-117.
Hamilton, D. K., & Watkins, D. H. (2009). Evidence-based design for multiple building types. Hoboken, NJ: John Wiley & Sons.
Heerwagen, J. H., Heubach, J. G., Montgomery, J., & Weimer, W. C. (1995). Environmental design, work, and wellbeing: managing occupational stress through changes in the workplace environment. AAOHN journal: official journal of the American Association of Occupational Health Nurses, 43(9), 458-468.
Planetree (2014). Planetree designated sites. Retrieved from http://planetree.org/planetree-designated-sites/
Planetree (2015). Stamford Hospital: Bringing Planetree through the locked doors of an inpatient psychiatric unit. Planetree planetalk. Retrieved from: http://planetree.org/planetalk/stamford-hospital-inpatient-psychiatric-unit/
Ruga, W. (2008). Your general practice environment can improve your community’s health. British Journal of General Practice, 58(552), 460-462.
Ruga, W. (2010). Applied ‘generative space’: improving health and wellbeing through your practice environment. Journal of Holistic Healthcare, 7(1), 36-39.
Sackett, D.L., Rosenberg, W.M.C., Muir Gray, J.A. (1996). Evidence-based medicine: what it is and what it isn’t. British Medical Journal, 312, 71-72.
Samira Pasha, PhD, AIA is a Project Executive at Hammes Healthcare and co-author of 2017 book “Design for Mental and Behavioral Health”.
