Shepley: Mental hospitals have an unpleasant reputation

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There may be no building in American society more shunned than that of a mental hospital. Few want to see or know what goes on behind the walls because the atmosphere has an inherently unpleasant reputation: the stuff of horror movies. Even the old-fashioned name "sanitarium" evokes the unclean and alien. Something dirty requires sanitizing and must be shut away.

The irony is that such places ought to be the most pleasant, welcoming and open institutions in America because there should be nothing separating mental illness from diabetes or Crohn's Disease or any number of physical maladies.

Even in a progressive nearby state like Massachusetts, however, there were conditions inside at least one public mental hospital that resembled the days of leeches and quack cures. Until a lawsuit forced policy changes last year, disruptive patients at Bridgewater State Hospital were routinely subject to solitary confinement and restraints. One patient died this way in 2009.

Court scrutiny may now soon be focused on the Brattleboro Retreat, the only child and adolescent inpatient unit in the state of Vermont, after the parents of a 15-year-old girl sued for wrongful death when their daughter died two months after attempting suicide, possibly out of the watch of the institute's staff.

Tighter oversight is a good start in New England but real change in the general treatment of the mentally ill is still a long way off, thanks to this nation's pervasive use of county jails as de facto mental hospitals.

A 2015 study from the Vera Institute of Justice found that the majority of inmates in local jails are too ill with mental health or drug issues or too poor to appropriately care for themselves. Is a prison -- an environment with restricted access to normal life activities, limited access to the outdoors, and mind-numbing spaces — a good environment in which to treat mental health? The evidence suggests not. Recidivism is extremely high for mentally ill inmates. The U.S. Bureau of Statistics reports that 81 percent of mentally ill inpatients in state facilities have prior convictions.

Even in facilities that are dedicated to individuals with psychiatric issues, the environments may not be supportive. Patients are expected to adapt to institutional, sterile environments, which would never be tolerated in a regular hospital. These sterile environments are characterized by limited access to nature, daylight and art, institutional furnishings, lack of spaces that support healthy social interaction and the absence of privacy.

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Environment safety is also troubling. In 1985, the Subcommittee on the Handicapped of the Senate Committee on Labor and Human Resources gathered data from 31 facilities and 600 interviews and concluded that mental health hospital patients and staff were subject to injury and inadequate living conditions. Not much has changed since then.

Clearly, our environment can affect our physical and emotional health. Hospital architects have been aware of the potentially positive impact of good facilities on the health of patient and staff and for the past 30 years have been using design research to improve those environments. Researchers have provided evidence that healing gardens reduce stress and creating spaces that support the presence of families increases patient satisfaction. Additionally, the provision of acoustical controls in inpatient units increases sleep and supports the healing process.

While the shift to using research-based design interventions has improved the healthcare of the general patient population, minimal efforts have been made regarding behavioral health patients. But the potential contribution of research is promising. In 2012, Swedish researchers compared the frequency of chemical or physical constraints used in two hospitals and demonstrated that design attributes including private rooms, movable furniture, better acoustics, views of nature, art, daylight, homelike design, and supervision from staff stations appear to decrease patient aggression.

On his last day in office in January Massachusetts Governor Deval Patrick signed a bill that had been filed in 2005 granting "daily access to fresh air and the outdoors" for patients in mental health facilities. It seems incredible that such a fundamental need would have taken more than 10 years to be legislated, but it reminds us of the low bar mandated for psychiatric settings.

Best practice suggests that the ideal facility addresses basic safety (supervision and suicide resistance) as well as a homelike aesthetic ambience, an enriched sensory experience, the opportunity for both social interaction and privacy, visual and physical access to nature, appropriate daylighting, and flexible spaces to allow for the varying preferences of patients. This costs money.

But funding may not be the biggest challenge. Social stigma against mental and behavioral illnesses still exist. Mental health patients can still be perceived as culpable for their health status and therefore less deserving than other individuals. Society needs to embrace mental illness with the same compassion that it expresses for individuals with other illnesses.

What else can we do to reverse these trends? Apart from the construction of new inpatient and outpatient facilities, funding agencies must acknowledge the critical nature of behavioral health evidence-based design by allocating funding in support of design research. Architects, landscape architects and interior designers must listen to clinical staff and facility managers to increase our understanding of good mental health facility design. Until then, we will continue to harm rather than heal those seeking mental and behavioral health treatment.

Mardelle Shepley is a professor of Design and Environmental Analysis at Cornell University.


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