Throughout the last century, the shift in perception of mental illness from incurable to controllable disease has expanded the possibilities of traditional healing. Medication and therapy are now seen as successful techniques for conquering and managing mental health disorders. To further healing, rehabilitation facilities looking to incorporate holistic healing programs should consider the impact of the physical environment on the mental, emotional, and physical states of patients. Specifically, evidence-based design (EBD) techniques provide opportunities to enhance patient well-being through manipulation of the physical environment in ways that support the patients' psychological and environmental needs.

Although the application of EBD in the general healthcare arena is well researched and widespread (Geboy, 2007), understanding how the physical environmental affects patients undergoing psychological rehabilitation is less studied. Moreover, awareness of needs related to various age groups suffering from mental illness is negligible.

As interior designers, we strive to protect the health, safety, and welfare of the public. Undoubtedly individuals with mental afflictions and illness are in need of this protection.

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The devastating reality of an individual's actions suffering from untreated mental illness astounded the nation recently with the Fort Hood Massacre in Killleen, Texas. Before that tragedy, adolescents shook country with the Virginia Tech massacre, the Northern Illinois University Valentine's Day shooting, and the Omaha Mall shooting. As society becomes aware of the grave dangers associated with untreated mental illness, a re-examination of our society's preventive and rehabilitative psychological care programs and facilities is essential. Parallel to a designer's own affidavit, preventative and rehabilitative psychological care organizations protect the health, safety, and welfare of patients and the public.

To provide greater understanding of adolescents' needs while suffering from mental illnesses and interior design opportunities to suit those needs, a research and design journey began; the goal being to understand how implementation of EBD principles meets the needs of adolescents residing in behavioral health facilities.

Historical context: Behavioral health facilities

The stigma associated with psychiatric facilities varied greatly within the last century and a half. In the mid-nineteenth century, writings by psychologist Dr. Thomas Kirkbride suggested that the design of psychiatric facilities should incorporate cheerful and comfortable appearance while discarding “everything repulsive and prison-like” (Cotton & Garaty, 1984, p. 624). Kirkbride noted, “No one can tell how important this may prove in the treatment of patients nor what good effects may result” (Cotton & Garaty, 1984, p. 624).

By 1875, researchers found that “many great lessons taught by Dr. Kirkbride and the moral treatment era…were lost and mental healthcare [has] frequently been based on narrowly defined institutional models” (Anderson et al, 1976, p. 807). In 1930, the organization that was to become the American Medical Association conducted an investigation of the nation's mental healthcare facilities led by Dr. John Grimes (Ozarin, 2002). Reports, however, were not published because of the dire conditions uncovered. Grimes found conditions such as “overcrowding, understaffing, rampant inappropriate political influence and lack of treatment…patients rocking slowly hour by hour…every year until death” (Ozarin, 2002, p. 3). Historians suggested that the deterioration of mental healthcare developed in the early 20th century because of financial hardships during the Great Depression and in combination with the influx of mental health patients, including those suffering from post-traumatic stress syndromes (Weddle, 1998).

After a century of unhealthy institutions, which have encouraged the stigma associated with the insane asylum, Kirkbride's recommendations now echo a movement that has accelerated in the last 40 years and promotes “the importance of the physical environment for psychiatric rehabilitation” (Devlin, 1992, p. 66). Advances in psychotropic drugs during the past 50 years and the emphasis on deinstitutionalization of mental healthcare communities have aided this movement (Levin, 2007). The Design Guide for the Built Environment of Behavioral Health Facilities suggests all design of behavioral health facilities and units to be “designed to appear comfortable, attractive…[avoiding] an institutional look” (Sine & Hunt, p. 8).

Defining the adolescent

Adolescents, as a cohort, face negative societal stereotypes. The ambiguous understanding of adolescence as a phase between childhood and adulthood creates a challenge for adolescents to define themselves and for society to understand and place them.

Although adolescence is often seen as a luxury phase in American culture, it is a difficult developmental period of “rapid physical, mental, and emotional change” (Mental Health Resource Guide, 2002), which complicates the recognition of mental illness in adolescents.

Changes in identity, biological development, and peer interaction may result in behaviors that generate mistrust by adults. Willis (1992), in discussing adolescents, finds that “adults generally dislike and mistrust adolescents more than any other age group” (Rice, 1992, p. 3). Although this statement does not account for every adult's opinion, the stereotype may compound society's difficulty in understanding adolescent needs.

Overcoming ageist stereotypes to recognize the cognitive and emotional development of adolescents is essential to determining adolescent environmental needs.

Defining evidence-based design

One criticism of design has been an absence of analytical reasoning. Critics accuse design as relying solely on aesthetics and the subjective. If design practitioners did not previously have the opportunity to defend their design solutions from such criticism, they do now courtesy of EBD. Much like evidence-based medicine, EBD is an amalgamation of the scientific process and design principles. More specifically, EBD can be defined as “a process for applying research findings about the physical environment to improving the design” (The Nurture Report, 2007, p. 1). Roger Ulrich's study, “View through a window may influence recovery from surgery” (1984), linked the natural world to healing through quantitative data collection. Ulrich's work has since instigated further studies aiming to link physical and architectural characteristics with human wellbeing through the “common denominator” of stress reduction, (Malkin, 2007, 26). The results of EBD investigations provide designers with a greater validity in their design decisions.

Evidence-based design findings in adolescent behavioral health

An assessment of existing literature covering design for adolescents and design for mental health facilities provides a junction point regarding the mental, physical, and emotional needs of adolescents and mental health facility design. Privacy, access to nature, choice and control, social support, and positive distractions repeatedly proved to be incremental in health, development, and need. Additionally, issues of control can be addressed through access
to communication and opportunities for privacy. Spaces for social support from visitors and peers, and positive distractions such as entertainment and views to nature promote visual connections to the outside world and community grounding and promoting rehabilitation into society.

Practitioner research

To verify existing studies, a team of designers and researchers from Perkins+Will, an architecture and design firm that specializes in healthcare design among other disciplines, conducted interviews directly with adolescent residents-both male and female-of a behavioral health facility in Suburban, Maryland. The facility treats residents suffering from behavioral and emotional disorders, including those coupled with substance abuse, between the ages of 12 and 18. To incite conversation, residents were shown images for visual examples of shape and form, color, applied pattern, seating, and lighting.

All interviewees requested opportunity for individual “calm down” spaces relating to adolescent need for privacy. Although only one resident requested realistic imagery within meditation or “calm down” areas, all interviewees preferred the inclusion of murals and were drawn to realistic, detailed imagery. Murals and artwork offer opportunity for mental escape and can be defined as a source of positive distraction. Cool colors, such as varying hues of blue and purple, were preferred by all six residents. These findings are supported by numerous studies and articles that have found an association of cool colors (green, purple, and blue) to feelings of calm and relaxation suggesting resident's need for calming spaces (The Advisory Board, 2007). Not surprisingly, residents disliked imagery with strong primary colors, child's toys, and small-scale furniture.

Residents universally noted a desire for natural lighting. EBD research relates natural light as one form of connection to nature and; therefore, a stress reducer by distracting patients from the difficulties of treatment or procedures (Akridge, 2005, p. 2).

Throughout the interviews, adolescent attention was drawn to images with a variety of chair options and seating arrangements. The resident's preference for the varied seating relates to needs of choice and control of where they sit, how they sit, and whom they sit with. All male resident participants noted a preference for seating to be focused around the television. The request for focus on media speaks to adolescent desire for connection to peers through media and observation to further the development of their identity (Rice, 1991, p. 101).

An overall assessment of data produced three key findings defining the environmental needs of adolescents and informing the design solution. First, available and designated areas for privacy are necessary. Although bedrooms may be classified as designated private spaces, residents are often not allowed free access to bedrooms due to safety concerns. For that reason, it is critical to provide private spaces within areas of free use to residents. Gulak's 1991 article and Gabb's 1992 article resonated with this finding of adolescents' desires for private spaces.

Second, options in arrangement and type of seating should take precedence in the design. Throughout the interview process, adolescents mentioned a desire for options in seating to fit desired activities such as group interaction, solitude, or watching television. Additionally, the adolescents took great interest in photographs which illustrated alternative seating that would support different postures. Paramount to the type of seating selected, are issues of safety. All furniture must be heavy enough as not to become weapons. Nevertheless, some portability is desirable as it allows for residents to alter and exhibit limited control over their environment. Previous evidence-based findings will inform the appropriate type of arrangement for supporting social interaction; specifically focusing on Gabb's finding that clustered seating allows for conversation with adequate personal space and promotes socialization (1992).

Adolescents' concerns with regard to daylighting were prevalent and should be incorporated. The impacts of light on human health cannot be ignored. Research demonstrates that light aids performance of tasks, helps manage the circadian rhythm, affects mood and perception, and enables chemical reactions within the body (Joseph, 2006). Beauchemin and Hays (1996) cite correlations between the amount of sunlight in hospital rooms and the reduction of Seasonal Affective Disorder (SAD), a mild winter depression. However, practitioners should be aware lighting can have negative aspects within behavioral health facilities. The position of lighting and surrounding material reflection may create “exaggerated images and sensory distortions” for the patient (Duffy & Huelat, 1989, 99).

Similar to furniture precautions, glazing and space adjacencies present safety concerns. In heavily monitored areas, large windows are appropriate. However, in areas of less observation, access to windows should be limited to prevent attempts to exit or damage rendering glazing and window hardware a weapon. Easy monitoring of public spaces and corridors was requested by staff because of the sensitive nature of patients.

From research to the built environment

Two distinct design languages coalesced to encompass the variety of functions required of the adolescent behavioral health facility. The first language focuses on horizons: the need for open spaces conducive to social interaction and opportunities for floods of natural light. The second design language of cradling speaks to the adolescents' stipulation for privacy. Success of the concept requires a delicate balance between horizons and solitude and balancing an innovative design with a normalizing environment.

The design embraces the futuristic feel patients were drawn towards during the interview; however, considering the sensitive patient mind-set, futuristic shapes were grounded in organic, familiar forms such as the ellipse and the pod.

Lounges and corridors are some of the key spaces available for behavioral health patients to freely interact with each other, which is a crucial component to treatment (Malkin, 1992, p. 272). Studies by McGuire, Cole, Shordone, Sillers, and Richards observed “heavy use of the day and TV room by patients in addition to the hallway and adjacent to the nurses' station” (as cited by Shepley, 2007, p. 5). Design for this research focuses on incorporating natural light, shaping circulation space, and compartmentalization of large lounge space.

Group lounges may serve multiple functions throughout the day and throughout the course of treatment, including space purposed for social interaction, watching television, group therapy sessions, occasional special activities, and private meditation. Large and ambiguous rooms send mixed messages to residents because patients are required to change their behavior to meet the function while the space remains unchanged. Patients “find themselves forced into random, relatively undirected behavior patterns” (Spivak as quoted by Malkin, 1992, p. 272) in unidentifiable rooms. Therefore, the use of the ellipse, a shape that was well received by adolescents in the interview process, is used to segregate generic lounge space. Smaller ellipses represent private areas offering refuge while the largest ellipse identifies the television lounge. Intermediate ellipses designate small group seating and interaction. Dropped ceiling elements, color choice, and furniture configurations further emphasize space and function separations. All lounge spaces benefit from the positive distraction provided by large picture windows with views to nature and mural opportunities on elliptical partitions.

Secure built-in seating and gently encircling walls within the private nooks create a safe level of seclusion. Sociopetal seating, or clustered seating, is chosen for group acti
vities, based on Holahan's 1972 study, Seating patterns and patient behavior in an experimental dayroom, which found sociopetal seating arrangements to promote socialization. Television viewing is placed furthest from the private space utilizing group seating as an acoustic buffer. The radial positioned sofas offer a variety of seating positions and provide for relaxed posture. Additionally, the space enables connection between peers and connection with media, which serves for proposes of bonding and positive distraction.

Corridors become living walls to break away from an institutional feel, expanding convexly and pushing upwards to increase the opportunity for light penetration. At the intersection of the sloping roof line and the curved corridor partition, clerestory windows are created. The dynamic clerestory runs continuously through the space flooding the corridors with light and defining circulation paths and lounge boundaries.

The design solution of clearly delineated spaces avoids ambiguity of function and, therefore, ambiguity of action for occupants.

Conclusions

By examining the relationship between EBD principles, adolescent developmental needs, and environmental needs of those suffering from mental illness, a foundation for understanding a unique population was accomplished. Incorporating opportunities for connection to nature, choice and control, privacy, social support, and positive distraction as determined by previous EBD studies allowed for a more holistic healing environment tailored to specific needs in an effort to maximize healing.

Through continual research regarding the specific needs of the behavioral health patient population, researchers and designers can combat some of the ills that face society, thus improving societal health, safety, and welfare. HD

Jamie C. Huffcut, LEED AP, Allied Member ASID, Associate Member IIDA, has spent two-plus years as a Project Designer with the Perkins+Will Healthcare Market Sector in Washington, D.C., while completing her masters in Interior Design at Marymount University, with a focus on evidence-based design.

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