Design Guidelines for Behavioral & Mental Health

At the start of 2022, my colleague, Todd Medd, and I published our findings on the impact of telehealth in today’s behavioral and mental health environment. With over 30 cumulative years in the healthcare architecture industry, our professional outlook was easily provoked. However, the personal trauma circumventing our story was far more challenging and urgent. The fact is that nearly everyone, including our own families, has been impacted by the aftermath of diagnosed or undiagnosed behavioral and mental health conditions. While this country still struggles with overcoming stigmas of our past, Todd and I are channeling our energy into responding to the country’s present mental and behavioral health system. In short, we’re putting our experience to the ultimate test – exploring and demonstrating architecture and interior design concepts that work in tandem to overturn the stigma that stops so many, especially our nation’s youth, from seeking help. Today, behavioral and mental health systems everywhere are scrambling to overhaul outdated approaches and deinstitutionalize their environments. This month, we’re not just talking about viable solutions, we’re taking a walk through the mental and behavioral healthcare system, accompanied by interior design guidelines that work overtime for a more accessible and sensory sensitive model of care. 

A Search for Solutions

As a Healthcare Designer, I work closely with Todd Medd who is a Principal Architect and the Healthcare Practice Studio Leader at the Midwest-based firm, JLG Architects. Our team looks beyond the building to identify underutilized design strategies and models of care that will help to destigmatize mental illness, optimize access, personalize the patient experience, and bridge the gap between silence and seeking help. The overarching question is always how to address a collective system with fragmented levels of care and a widespread shortage of beds, while providing patient security and privacy, holistic healing, and enhanced access. We must also consider the bigger picture, behavioral and mental healthcare access throughout the continuum of care; interwoven within the labor and delivery room, family consult rooms, pediatric centers, labs and emergency rooms, to name a few. This is all part of the end goal to increase access across the vast spectrum of healthcare facilities.

The Midwest is home to many high-quality care facilities, all facing a myriad of challenges with open minds, leaning further into biophilic and sensory sensitive design to anchor modernized models of human-centric care. To gain a clearer perspective of current behavioral and mental healthcare (BMH), we sat down with some of the industry’s top experts from across the Midwest – those who are propelling positive change beyond the set standards. We spoke in great detail to healthcare leaders such as Joseph Clubb MSW LICSW, Allina Health’s Vice President Operations Mental Health & Addiction Services, Heather Siek, Psy.D., LPCC, and Kathryn Davis Tidd, MSW, LICSW of The Village Family Service Center, Kurt Smith, Corporate Construction Manager at Hazelden Betty Ford, and Kristin Roman Rehkamp of PrairieCare’s Fund Board of Directors. Each conversation, although representing varying models of care, were unified with one like-minded goal – create secure, accessible spaces that are more humane, less institutionalized, and work harder to diminish the stigma surrounding BMH systems.

Mapping the Patient & Provider Journey

As healthcare–focused architects and designers, our work must first track the patient journey and the level of crisis; from the initial point of contact, accessibility of the entrance, look and feel of the waiting room, ease of check-in, room layouts, and therapeutic amenities in patient and supportive family spaces. It’s also critical that we explore provider environments and amenities that can work to rebuild a rewarding workplace culture and provide tools to manage elevated stress. Collectively, these environments must also support the needs of pediatric mental health, the general public, and healthcare staff.  

While we are focusing on BMH outpatient environments, it’s important to point out the defining difference from outpatient and inpatient care. Inpatient care generally requires an overnight hospital stay, monitored by a healthcare team throughout treatment and recovery. Outpatient care in BMH typically refers to treatment in office, hospital, or clinic settings, all of which do not require an overnight stay. This can also equate to non-residential treatment where patients structure their treatment time to suit their schedule, either during the day or at night, returning home once completed.

Orchestrating the Experience

Today’s healthcare facilities are looking to architects and designers to orchestrate a more humane experience, in both generalized and specialized healthcare settings. Unbeknownst to many, a patient’s experience doesn’t begin in the waiting room, it originates outside; starting with accessibility of parking, proximity to entrances, and visibility of site signage that clearly communicates their destination. Kicking off our walk-through, the following is an overview of the areas post-arrival that we can work to improve in an outpatient environment:

The Check-In

Up until the last five years, a patient’s check-in experience was nearly identical throughout every healthcare system. More recently, and with concentrated pandemic focus, healthcare systems are reimagining, customizing, and streamlining the process to meet the needs of specialized departments. Powered by technology and the need for human-centric design, these features are at the top of our list when exploring the design of BMH check-in areas:

• From parking to entrance and check-in, include signage that speaks “to” the patient rather than “about” the patient.
• Offer patient choice of check-in: traditional in-person with a receptionist, electronic kiosk for additional privacy, or via an app when patients arrive in the parking lot.
• Consider the option of patient self-rooming to aid infection control in a larger waiting area with mixed ill and well patients.
• Integrate Real-Time Locating Systems like Sanford Health in Moorhead, MN, where patients can be directed to more remote waiting areas and be easily alerted of appointment readiness.
• Design with color-coded navigation for stress-free wayfinding.
• Consider a hosted check-in/medical concierge like at the Allina Health Greenway Clinic in Minneapolis, MN. The host offers patients water, coffee, or tea (served in a porcelain mug) on arrival; they check in the patient if needed, and escort patients to the exam room. After the appointment, the host walks the patient back to the waiting area and schedules any follow-up appointments. 

The Waiting Area

In behavioral and mental health systems, the waiting area is a critical stop in the journey that should ensure patient privacy and dignity. Although waiting areas are typically designed to be open, communal areas, the overstimulation can become a trigger to BMH patients. Today’s facilities require soothing lighting, smaller sub-wait areas, and informal arrangements of furnishings that respect and protect patient’s privacy. The following are concepts we lean into to better support the needs of whole person care.

• Support comfort and wellbeing by integrating informal arrangements and small groups of seating with multiple seating choices – single chair versus larger two-seaters for a parent and child.
• Further ensure patient’s psychological and physical privacy by avoiding institutional lines/rows of chairs and including partitions where possible. (Liddicoat, 2020)
• Create practical convenience with a daylit waiting area offering a counter for parents to plug in devices and work while their child is in a therapy session.
• Include a small child play zone with positive distraction elements like sensory toys, a fish tank, and artwork.
• Design smaller sub-wait areas for added privacy, helping to reduce anxiety of larger waiting areas and exposure to other patients. (Liddicoat, 2020)
• Integrate ambient light in the entry and waiting areas, reducing pre-visit anxiety. (Liddicoat, 2020)
• Visually communicate and welcome guests with local art that reflects the diversity of the region’s cultures and surrounding community.

Patient Consultation Space

Another area that is often overlooked is patient consultation spaces. In these smaller spaces, healthcare interior designers are now more than ever pleading the value of office layout that empowers both patients and providers. From adaptable furnishings to eliminating assigned offices, this is the just the beginning of a trend to encourage more comfortable communication for BMH patients. Here are just a few of the many concepts we use when designing patient consultation spaces:

• Consider eliminating provider assigned offices in support of collaboration spaces. At Allina, providers work from a team collaboration space when they are in the office and not with a patient. Patient consultation rooms become “interview rooms,” a neutral space shared by multiple clinicians where patients can feel more at ease, away from personalized office spaces.
• In general, office design and layout should seek to promote “patient self-disclosure, communication, empowerment, and psychological safety.” (Liddicoat, 2020)
• Patient consultation rooms should be prepared to accommodate both individuals and families – respecting the dominant beliefs and traditions of various cultures. While Americans often emphasize individual patient rights first, some patients prefer a more inclusive approach with family present. Certain cultures or specific scenarios may even require providers to meet with the patient’s family prior to the patient receiving a prognosis.
• Promote flexibility with movable furniture and objects that can be re-arranged to a patient’s comfort level. (Liddicoat, 2020)
• Seating between patient and professional should be at 45 degrees; seating directly opposite is too confrontational. A side table is acceptable, but no other barriers should be between the patient and the professional. (Liddicoat, 2020)
• Avoid visual or psychological clutter. While a few personal items such as family photos imply friendliness, there should still be a sense of order or purpose to the office décor to prevent the patient from getting distracted.
• Focus on dim lighting versus bright lighting – positively affecting the patient’s view of the professional and their speaking time. Sanford Health uses tunable lighting in consultation spaces that ranges from 2700K – 4000K so providers are able to customize light levels for each patient.

Biophilic Design

While interior design has always included biophilic elements, elements that reconnect individuals with the processes and patterns of nature, healthcare designers have emphasized its impact, with good reason. Countless studies over the last decade have pointed to a direct correlation between patient and provider wellness and exposure to natural light, living plants, and the outdoors. According to Stephen Kellert and Elizabeth Calabrese (Stephen R. Kellert, 2015) in “The Practice of Biophilic Design,” mental benefits range from “increased satisfaction and motivation to less stress and anxiety, and improved problem solving and creativity. Positive behavioral change includes better coping and mastery skills, enhanced attention and concentration, improved social interaction, and less hostility and aggression.” Here are a few ways BMH systems can reflect biophilic design: 

• Design patient and provider space for optimized access or exposure to the outdoors, balanced with the privacy and security needs of site design.
• Incorporate nature scenery, either digitally, via biophilic art pieces, or via views to the exterior.
• When applicable, allow patient access to the entire grounds. This can be done by prioritizing landscape design through patios and pathways for walking/hiking, giving patients the autonomy to enjoy tranquil outdoor settings. Hazelden Betty Ford’s Center City facility is set on 60 acres which greets patients with a tree-lined drive reflective of the journey towards open healing.
• Think outside of the box in considering the potential for outdoor areas like a healing garden, labyrinth, open air dining, sport court, equine therapy, and nature-inspired play areas focused on younger patients. Moorhead, Minnesota’s Village Family Services has found verbal consultations with males to be most effective when they are given the opportunity to communicate during outdoor walk-and-talks. 

Staff Spaces

While staff spaces were once considered inconsequential areas, today’s healthcare environment is prone to astounding levels of chronic stress and a condition those in the field refer to as Compassion Fatigue, more commonly known as “burnout.” According to Dr. Gaia Cetrano (Cetrano, 2017), this condition presents itself as “higher turnover rates, negative attitudes towards patients, lack of communication, and clinical errors.” As a healthcare designer, I cannot stress enough how important it is to provide sensory sensitive and active environments that reduce stress levels and reinforce the value of providers. Here are a few guidelines we follow in the planning phases of nearly every new BMH facility.  

• Designate quiet space for staff beyond the break room; this could resemble a respite room, sensory room, or meditation space.
• Provide accessible indoor/outdoor space with walking paths and access to park settings.
• Personalize staff sensory rooms with calm, soothing lighting, music/sound piped in, biophilic elements, local or biophilic art, and comfortable gliders rockers.
• Designate team collaboration spaces in addition to private offices.
• Provide calming phone rooms or huddle spaces for private conversations.
• Include active furnishings such as sit/stand desks, treadmill workstations, or centrally located, highly visible staircases to increase physical activity.

Conclusion: Humanizing Healthcare

While behavioral and mental healthcare models of the past may have been more focused on operational efficiency, today’s leadership is finding holistic architecture and design to be invaluable to a healthy bottom line, patient recovery, and staff retention. The behavioral and mental health system is readily embracing a cultural wave of innovative ideas, human-centric environments, and sensory sensitive design – design that stimulates both physical and emotional healing. The ultimate reward is helping patients get back to their lives, homes, and families faster. As a catalyst to the humanization of healthcare, this wave of change is welcomed – writing a powerful prescription for a brighter and more accessible future in mental and behavioral healthcare systems.