How a Focus on Dignity, in Addition to Safety, Is Evolving Behavioral Health Center Design
The Last 200(ish) Years of Mental Healthcare
Not long ago, psychiatric facilities in America existed separately from traditional hospitals. They evolved from prison-like to park-like with a reform movement and the Kirkbride Plan as the impetus for change in the mid-1800s. At the time, there was a shift in thinking about how to address mental health concerns, as well as an architectural shift with the design and construction of expansive Victorian-era buildings where patients were housed and treated. However, the buildings (and their grounds) were expensive to maintain and eventually became underfunded and overcrowded with far from ideal conditions.
Due to economic hardship throughout the 1930s and into World War II, psychiatric facilities were on the decline. A shortage of state funding and medical personnel led to the shutdown of many facilities, which meant people were either released back into society without treatment or were sent to traditional hospitals.
With veterans returning from World War II, mental health was brought to the forefront once more, reaching the attention of lawmakers. In 1946, the National Mental Health Act was forged and in 1949 the National Institute of Mental Health originated, which allowed for training and research related to mental illness. And in 1963, the Community Mental Health Centers Act was passed by Congress to support the creation of community mental health centers across the United States.
The Evolution of Mental Healthcare and Healthcare Facilities
In modern America, there are a range of mental and behavioral health facilities that provide varying levels of care, primarily inpatient (acute, 24/7 care), residential (structured, long-term care), and outpatient (clinical-based, flexible care). This range of facility types helps support the differing needs of individuals receiving care.
Federal laws such as the Americans with Disabilities Act and the Mental Health Parity and Addiction Equity Act ensure mental health needs are accommodated and covered by insurance in the same way physical health needs are. Furthermore, each state has regulations regarding mental healthcare facilities: how they’re owned and operated, and the guidelines that govern the material specifics that must be in place for proper patient care. Thus, both private and state-run facilities must meet the requirements for their areas.
First of its kind in Southwest Montana, Bozeman Health’s Adult Inpatient Psychiatric Unit was designed to support safe, compassionate care with comfortable, day-lit spaces enhanced through biophilic design and offering a variety of areas where patients can focus on their healing journey as an individual and in the community of others.
Today, we’re lucky to live in a time when there’s a much greater understanding of mental health issues and less stigma, as well as a general acknowledgment of the importance of mental health care. However, the realm is still impacted by a lack of funding and resources, which can result in a delicate balance of priorities when it comes to designing behavioral health facilities.
Balancing Safety and Healing with Comfort and Dignity
When interviewing the Cushing Terrell professionals behind behavioral healthcare design at our firm, what I expected was a conversation about how mental health facilities have translated mental healthcare — physically and visually — into comforting and purposeful spaces for inhabitants. What I found instead was a deeply meaningful discussion about why design priorities, while intricately considered and implemented, may not have changed as much as I thought they would have.
Design strategy typically aims to meet the goals of the client with a focus on the user experience, but when it comes to behavioral health facilities, the top focus must always be safety. Designers for behavioral health facilities must first and foremost create a fully protective environment; second, ensure an effective and functional place for healing; and third, provide dignified, comfortable home-like spaces.
While there’s planning and design related to safety when developing other building types, for behavioral health centers, it truly can be a matter of life or death.
This type of work can be intimidating, especially for those who are new to behavioral health design because it’s so sensitive. We cannot forget anything and collaboration is critical. We work hard to provide as much information as possible when partnering on these projects, whether that be with clients, new designers, or other project partners. We want to share our expertise and what we’ve learned over the years so we can build the best possible spaces for the people who rely on them.
Wayne Picard
Architect, Cushing Terrell
With safety being the top priority, design strategy that supports this in all ways — for patients, staff, and visitors — creates the overall foundation of a behavioral health center. Patients in these facilities are often struggling with illnesses that can result in self-harm or harm to others; thus, every element a patient might encounter within the building must be designed to counter that risk.
These design elements include:
- Intricate spatial planning that accounts for the full circuit of a patient’s daily activities as well as staff workflows.
- Spaces (and transition spaces) that allow for unobtrusive supervision.
- Ligature-resistant fixtures and furniture to minimize any potential for harm.
With those elements covered, designers can then turn their attention to aesthetic elements that support healing and well-being, as well as human dignity.
“When you’re able to find solutions that create a pleasant environment that’s also safe, it’s incredibly rewarding,” said Wayne Picard, an architect at Cushing Terrell who specializes in healthcare design.
Project Spotlight: Bozeman Health Adult Inpatient Psychiatric Unit
Cushing Terrell partnered with Bozeman Health to design a new adult inpatient behavioral health unit with six double-occupancy and two single-occupancy patient rooms. The first of its kind in Southwest Montana, the unit was designed to support safe, compassionate, enriching therapeutic services and inpatient care. As a unit within the hospital facilities, it serves as a key transition and assessment center with a range of support spaces, including two activity and dining areas, a group therapy room, a consultation room, and a staff break area.
Patient and staff safety were at the forefront of the design process, but creating a comfortable environment with a non-institutional feel was also priority for the client. This balance between comfort, safety, and staff functionality presented the greatest design challenge for the team. To address all needs, Cushing Terrell collaborated with a behavioral health consultant to ensure the unit supports healing while maintaining rigorous safety standards. Biophilic design with murals that feature scenes from nature, large window banks in patient rooms, and comfortable seating in communal areas add softness, light, and soothing colors to the spaces.
The result is a facility that’s highly functional and safe, as well as peaceful and calming.
Utilizing the Power of Biophilic Design for Behavioral Health
With restrictions on what can be safely utilized within behavioral health environments, one of the most impactful strategies is the incorporation of biophilic design. Biophilic design — the practice of connecting people to the natural world in our built environments — encompasses a variety of elements such as:
- Murals and wall graphics with calming nature-based themes.
- Windows that offer views to the outside and bring in natural light.
- Soothing paint and furniture colors and textures that reflect biophilic patterns.
An example is the Idaho Youth Ranch’s Hands of Promise Campus, a five-building residential psychiatric facility for young people that includes a wellness center, an education building, classrooms, doctors’ offices, therapy rooms, a cafeteria, and two residence halls. For this facility, the team incorporated biophilic design into the very story of the patient experience.
Connected through a metaphorical trail head, each building on the campus supports residents as they are welcomed, begin a healing journey, find community, experience growth and discovery, have moments of respite, and when ready, graduate. This journey is emphasized by murals created by local artists that feature mountains, valleys, meadows, forests, lakes, and streams. Each building displays a different mural, representing unique challenges and inspiring progress on the path ahead.
“It (the design) follows residents through as they collect the tools they need, but the journey never stops. Mental health is not something to solve. You continue to work your way through it,” said Amy Lindgren, Cushing Terrell architect for the Hands of Promise Campus.
Flexibility and a Focus on the Individual Healing Journey
When it comes to the healing journey of individuals, there are not only different types of facilities to consider (as noted above) but also, within each facility, there’s an opportunity to design for as much flexibility and comfort as possible while adhering to safety standards.
For the Bozeman Health Adult Inpatient Behavioral Unit, our team designed a variety of communal spaces as well as more private spaces, all with appropriate site lines so staff can maintain a visual connection with the patients. Site lines are crucial when designing these environments, and smart space planning is key to ensuring safety as well as an efficient flow of staff, patients, and visitors.
Patient rooms at Bozeman Health’s facility were also designed with an understanding of the need for personal space. Even shared rooms are configured so that each person can feel respite.
Some people need to share their healing journey with others to facilitate wellness while others need more quiet, solitary time and self-reflection. While there are bright and open communal spaces in Bozeman Health’s Adult Inpatient Behavioral Unit, we also included a smaller room with warm, darker colors and soft furnishings as well as a rocking chair. Everything is ligature resistant, but it offers a quieter, more homey space, while being open enough for observation.
Beth Schaper
Interior Designer
Cushing Terrell
The Future of Behavioral Health Design
At a recent healthcare conference, Schaper said her and her colleagues were excited to see another shift happening… a greater variety of furniture and fixture options that are both ligature resistant and beautifully designed — less clinical looking and more like what you’d see in a hospitality environment.
“The industry has come a long way,” Schaper said, “and I see it continuing to evolve with the development of new, innovative products we can use to further reinforce patient dignity. We’re even seeing more materials that are both tactile and safe with a keen eye to neurodiversity and the ability to self-regulate.”
As we understand more about the types, duration, and causes of mental health issues, and realize we’re all at risk at some time in our lives and may need mental health support, the thinking becomes less about what “the other” might experience and more about what we ourselves would want to experience.
There will always be the issue of budgets, and the need to design the best facility within those budgets, but healthcare providers are smart about how and where they develop new spaces, and the design teams they employ also come with strategic ideas and solutions.
For example, Bozeman Health, a provider committed to the full continuum of care, developed its Adult Inpatient Psychiatric Unit as part of the Deaconess Regional Medical Center. The unit within the medical center benefits from a team of more than 30 psychiatrists, psychiatric nurse practitioners, crisis intervention specialists, psychiatric services navigators, registered nurses, patient care technicians, occupational therapists, and peer support specialists across the care system and care sites. The unit serves as a key transition space, a place where people can be evaluated first to determine what kind of long-term care will be best (if any). By utilizing the resources they have, with smart space planning, they are able to fill a crucial need.
Another strategy that can greatly influence how an environment feels and how effective it is in supporting healing is bringing in the voices of people who’ve “been there.” In an article published by the National Library of Medicine, Beth McGinty, chief of the Division of Health Policy and Economics at Weill Cornell Medicine, pointed to the need for leadership and mental health consultant positions to be held by those with first-hand experience of mental health issues.
A critical failing in our current system has been the exclusion of people with mental illness in its design and implementation. In addition, health systems need to embed sustained structures and strategies for engaging people with lived experience in the design of mental health services.
Beth McGinty
Chief of the Division of Health Policy and Economics
Weill Cornell Medicine
With creative design solutions married to safety, ease of use, comfort, empathy, and inclusion, we can hope to encourage more of a focus not only on state-of-the-art facilities, but artful ones that help patients feel at home.
“It’s our job to give a piece of humanity back to people who might be going through some sort of circumstance that is beyond their control and to do so in a dignified manner,” said Corey Stremcha, healthcare design specialist at Cushing Terrell.
