Exploring the Relationship Between the Built Environment and Behavioral Health, an interview with Mardelle McCuskey Shepley, M.Arch, D.Arch, EDAC

You recently co-authored a paper that looked at the relationship between the built environment and behavioral health. Can you tell me a little about what prompted you to focus on this topic?

I am an architect, and I also have a doctoral degree involving research. Recently, I have been trying to identify the biggest gaps in healthcare research. Behavioral health is one area that has been overlooked, and specifically, the link between behavioral health and the built environment has been ignored. That led me to recently co-author a paper with Samira Pasha called “Design Research and Behavioral Health Facilities,” available on The Center for Health Design website. This is really a literature review to determine what we know about the relationships between behavioral health and the physical environment.

What did you discover in your research on this relationship?

There are a lot of books on this topic written in the late ‘50s through the early ‘70s. However, one of the problems is that there is not a lot of substantive work out there. It just doesn’t exist. We used a predecessor document to guide us, and we had some indication of factors that might be effective, but we did not have any strong evidence for any specific practices. There were indications, though, that some elements were backed up better than others. Therefore, we created three categories to group the research that does exist according to how substantial the information is.

Can you describe these categories and the highlights of each?

The first and strongest category is for emerging evidence. We came up with this category to classify information where we still needed to do more research, but there was at least some evidence that supports the practices that fall within this group. If architects don’t have any other information, this is a good place to get started. Some of the suggestions in this category include things like creating a flexible, de-institutionalized, homelike environment, providing high-quality furniture and landscaping, and choosing furnishings that resist damage and are easily replaced and repaired.
 
Behavioral healthcare settings need to be flexible enough so that one day you can accommodate someone with an eating disorder, and the next day you can use the same space to treat someone who is clinically depressed.
 
The second category is for elements that require additional corroboration. We can’t confidently say these practices should be followed, but people could do additional research to see what else they can learn about approaches that fall within this area. This includes practices like incorporating open closet arrangements, creating a welcoming reception area, and minimizing staff walking distances.

The third category is for best practices. We compiled recommendations from experts in the field. For instance, one recommendation is that a mental health facility should consider how to incorporate safety measures against aggression, impulsive behavior, and absconding into the setting, while accommodating a range of therapeutic activities.

Behavioral healthcare settings need to be flexible enough so that one day you can accommodate someone with an eating disorder, and the next day you can use the same space to treat someone who is clinically depressed.
 

While these categories—particularly the highest one—provide a good framework from which to start, architects should not follow these practices blindly. They should also gather data from their own clients to be sure they are going in the right direction.

What do you want people in the design field to take away from your efforts?

There are two areas that designers should think about. First, they can look at the emerging evidence and use it to provide direction. We also list pre-existing tools that people can use. So basically, people can follow our emerging guidelines until we have more data, and then second, they can collect their own data based on the information and tools mentioned in our research.  

Overall, were you surprised by how little concrete information exists about best practices for the physical space of behavioral health settings? What are some of the challenges in conducting research in this area?

Because there has been a flurry of activity around the built environment and behavioral health in recent years, I had expected things to have advanced further. Part of the problem is that there is very little funding for healthcare research in general, and even less funding for behavioral health specifically. A big issue when you talk about behavioral health is that it’s so wide-ranging. You could be talking about an eating disorder, drug rehabilitation, or schizophrenia. That makes conducting research and drawing conclusions challenging, since there is no one environment that will meet the needs of all those populations. As you can imagine, treating someone with an eating disorder doesn’t require the same setting as treating someone with schizophrenia. This makes it important to understand that one size won’t fit all.

To that end, healthcare settings need to be flexible enough so that one day you can accommodate someone with an eating disorder, and the next day you can use the same space to treat someone who is clinically depressed. We also need to remember that the way we treat children may not be same way we treat adolescents, and we may treat adolescents differently than adults.
 

It’s important to remember that a behavioral health facility is not a medical facility. It’s a residential environment. So we are not looking at a medical model that has to be sterile and cleanable. A psychiatric unit is supposed to have softer character.
 

Since there isn’t much to go on in terms of evidence-based design principles in this area, are there some general trends in healthcare that designers can incorporate to guide their efforts?

Right now, the move to private rooms is the gold standard for healthcare. Some people think it is a good idea for behavioral health facilities, too, but this is a controversial topic. Others feel shared rooms are better to help with social skills, and to have a second pair of eyes to keep people from harming themselves. As a result, there is conflicting info and advice on this trend. Overall, though, more behavioral health facilities are being built today with a private room setup.

The notion of positive distraction is also starting to find its way into behavioral healthcare, although it’s been more commonly used in standard healthcare design. By positive distraction, I mean things like access to nature, artwork, and natural light. These features are thought to improve one’s mental state or have a calming influence. Another trend that is growing in general healthcare is moving care to an outpatient setting as much as possible. For behavioral health, we used to institutionalize people in large numbers, and then there was a movement to put people back in the community and provide outpatient care. In my opinion, though, we did not have enough of a safety net to make this work. Now there is a bit of a movement back to caring for people with mental illness in residential settings. This is the opposite of the direction we are moving in with medical care.

What can you say about the need for the physical space of a behavioral health facility to be different from a medical facility?

It’s important to remember that a behavioral health facility is not a medical facility. It’s a residential environment. So we are not looking at a medical model, which has to be sterile and cleanable. A psychiatric unit is supposed to have softer character. Therefore, when hospitals take the same medical unit and turn it into a psychiatric unit, it seems to be a misfit. It’s an institutional environment for a population that’s really averse to being in an institution. It’s a stigma. Architects and designers need to keep this in mind when they work on such projects.

I know you are working on another research project in this area. Can you tell me a little about it?

I am working on a Mental and Behavioral Health Facility Evaluation, which is a project supported by the Academy of Architecture for Health Foundation and involves interviews, focus groups, and survey methods that explore behavioral and mental health facility needs. As part of this effort, we sent a survey to four psychiatric nursing associations and a mental and behavioral health facility. While the findings have not yet been published, I can provide a few highlights of what we found. For instance, respondents said that the most important features in a facility were good maintenance, access to nature, and a high level of aesthetics and attractiveness, in that order. Regarding questions about specific environmental attributes, staff safety and security was paramount. One of the most frequently debated topics in inpatient mental and behavioral health facility design is whether patients should have private or shared bedrooms and bathrooms. The subjects evaluated the importance of private bedrooms and bathrooms as 5.84 and 5.82, respectively, on a scale of 1 to 7 (with 7 meaning the respondent strongly supports such private space). Opportunities for positive distraction were also highly evaluated.