Take Care: The Present and Future of Crisis Mental Health Design

The United States is in the midst of a mental health crisis. According to the National Institute of Mental Health, one in five adults in the United States experiences mental illness each year. And yet, only about half of those who need treatment actually receive it. For this episode of Side of Design, host and BWBR principal Melanie Baumhover sat down with a roundtable of the firm’s behavioral and mental health designers to talk about how design can play a role in combatting the crisis.

Hosted by: 
Melanie Baumhover - BWBR Principal

Guests:
Devan Swiontkowski - BWBR Project Planner
Ellen Konerza - BWBR Senior Project Architect
Jessica Norton - BWBR Senior Interior Designer

Music provided by Artlist.io
Siberian Summer by Sunny Fruit
DuDa by Ian Post

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Transcript

Matthew Gerstner  

This is Side of Design from BWBR, a podcast discussing all aspects of design with knowledge leaders from every part of the industry.

Melanie Baumhover  

Hello, and welcome to side of design from BWBR. I'm Melanie Baumhover principal with BWBR and your host for today. On this episode, we'll be talking with a roundtable of BWBR Behavioral and Mental Health designers about the state of crisis mental health care in America, how it's impacting patient experience, and some ways to move the needle toward providing the right care to the right patient at the right time. Joining us today are Ellen Konerza, senior project architect, Jessica Norton, senior interior designer, and Devin Swiontkowski, medical planner. Thank you all for being here today.

Jessica Norton  

Happy to be here. 

Ellen Konerza  

Yeah, thanks, Mel. 

Melanie Baumhover  

In our country, we are in the middle of a mental health care crisis. Needs are on the rise. It shows up in the paper, in social media, people are frustrated with the services available, and the facilities and options of individuals who are in crisis. At the same time, there's a severe shortage of mental health professionals. Right now it's estimated one in eight patients showing up in the emergency department is there with mental health related needs, and that number is increasing. In addition, it's estimated that one in four people in the United States face a current mental health issue. That means at any given time, at least 25% and likely more of the people in an ED Waiting Room are facing complex layered issues that may include both physical and mental health needs. So we want to talk about it. Let's talk about the importance of intentional design in mental and behavioral health care. And how BWBR's approach is unique.

Melanie Baumhover  

Yeah, that's really important. We've talked about choice and control within our mental and behavioral health spaces for a long time. And recently, I read an article that framed it a little bit differently, I have always thought about choice and control, as we're putting individuals in a space where we're taking a lot of choice and control away from them. So let's give them something to control. And recent studies have shown that there are two ways that people react when they don't have choice or control. One is it deflates them, they don't feel like they have the ability to actually make a difference. And so if I can't make a difference in my environment, how am I going to be able to make a difference in my own wellness, and others get angry. So it increases agitation. And there's sort of two reactions that patients will have. Neither one of them is therapeutic or helpful when they're already in crisis. So that choice and control and providing options within the space that is appropriate to the space that they're in and what their what they can safely adjust and modify is really important for their well being.

Devan Swiontkowski  

BWBR has a design process that we like to call Human Centered Safety that we bring to our behavioral health projects. So we truly believe in innovative design that helps with these mental health patients to be able to keep them from escalating and create a pro-social and therapeutic space so that we don't have to or that the caregivers don't have to use any sort of physical components to help in a patient. So truly believing that access to daylight, nature inspired imagery, understanding social density in spaces, creating spaces, such as really calming sensory areas, options for the ability to kind of control things such as lighting or sound, they may feel very out of control in the situation. So giving them access to those types of things can help them feel like they have control of some part of their life. We're really looking to make sure that we're creating spaces that are inviting and liberating, dignified, and therapeutic, really important for our firm to bring that to clients, and not just you know about trying to get as many beds in and things like that. We do truly believe that we need to create the appropriate space for these patients to truly be able to heal.

Jessica Norton  

I may also piggyback off of that there I think BW br is also really great about including spaces within the program and the design giving patients that autonomy back within the space. I think this also really helps them and he'll feel like they do again get that sense of control within the environment and helps continue to prepare them for life outside of the facility too once they've de-escalated. They've gone through the healing process in their programs that helps them transition a little bit that easier. And I think BWBR is really great about including those spaces and opportunities, and including, you know, patients, staff and family into all the programs and those spaces, all of those different components in mind.

Devan Swiontkowski  

Yeah. And to kind of go off of your statement on staff, I think we make sure that we are considering the staff in all our designs are not an afterthought, they're not just there to do, you know, some job from a nine to five, I mean, these staff members are very dedicated to their job, and it's a very hard job. So we want to make sure we're giving them the appropriate resources for them to do their job well, to keep them safe, and then also help with their mental health when they need it, to keep them healthy of the mind as well. So including respite spaces for staff, have access to daylight for themselves in some of their off stage break rooms, and then once again, truly the safety and hoping that our design is helping to keep patients from escalating, which ultimately keeps staff safe as well.

Melanie Baumhover  

Absolutely. So one of the challenges of spaces for mental and behavioral health is the front door to the system is our emergency departments. And emergency departments were designed for medical patients who have an acute need, they move into the ED and the providers there typically want to determine what the issue is, and either admit them into inpatient or stitch them up and get them back on the street. And that is often at conflict with what a mental and behavioral health patient needs. There aren't inpatient beds available, the analysis needed of a mental and behavioral health patient takes a lot longer. And what we end up with is patients boarding in the ED for a long time. So Ellen, can you talk a little bit about some of the ED based design that we've done in emergency medical facilities? 

Melanie Baumhover  

Yeah, so as you had said, we often see that if there isn't a separate crisis unit or behavioral health unit, these patients are brought to a typical ED room, which is just not appropriate for a mental health crisis. There's equipment, medical equipment sitting around, ligature points, things that can be thrown, and then just purely the type of space that it lacks daylight, it can be loud, you know, it wasn't designed with the idea of someone who's going to be as sensitive to these things in the environment. So where we can, or sometimes we see that facilities have sectioned off a few rooms that they have been using for more behavioral type patients. And those, those are designed differently, it's really important to include items in these spaces that reduce aggression. So views to the outside, daylight, acoustic treatments to make sure that any loud noises are are dampened to keep that sense of calm in the space. And then, you know, the medical equipment and all of those things that are needed to help treat the patient are installed differently or they're covered up or they're locked up to create a more safe space. And then even the nurse station, so in a typical IDI, a nurse station may just be a counter tap and open. But sometimes staff don't feel as safe in a situation like that. And then there may need to be conversations about what kind of enclosure the staff would feel safer with. A lot different design than an ED space.

Melanie Baumhover  

Yeah, and within those ED environments, I like to advocate that clients provide safe showers. So of course, they need to have a safe bathroom. But providing a safe shower will allow those individuals who are boarding there for a long period of time to be able to shower when they need to. And they have access to it. And if we can, provide them a little bit of a, let's call it a lounge, a safe lounge within the suite. So they aren't relegated to their room the entire time. I mean, there's there's patients that are there for hours, but most likely it's days and sometimes more, more than several days. So the more flexibility the more choice and control that we can provide within that environment that really wasn't meant for them, is sort of the minimum that we can do to provide a humane environment.

Melanie Baumhover  

One thing I forgot to mention too, about the staff and the nurse station, making sure that there's multiple points of entry and exit as well. Is is really important. 

Melanie Baumhover  

Yeah. And, and what strikes me about Edie environments is it's really not compatible with a mental health patient. But at the same time, unless something changes in our system, we just need to do better with the space that we're providing for them, because trying to lock them in basically a seclusion room for days. It's not good for the patient, it's not good for the staff. And we really just need to set that aside as as an option even to consider. So what about some of the unique challenges faced by rural areas providing crisis mental health care?

Devan Swiontkowski  

I mean, I think that piggybacks right off of what we were just talking about for ED's is that I mean, rural healthcare systems don't have a dedicated behavioral health unit or even behavioral health staff. So the IDI becomes the catch all, for these mental health crisis where people know that they can go in the case of an emergency, whether it's a medical or behavioral health emergency. So I think that they just don't have the staff or the space to hopefully get these patients out of the IDI. So it kind of has to be multipurpose, I think our goal is knowing that we do a lot of critical access health care to bring that up as a point and to hopefully design their ED's with some of those elements that we just previously mentioned. As much as we would love for them to have truly dedicated mental health spaces, we just know that economically, that's not feasible. And so just to help at least architecturally provide that space for them for the safety and the well being of patients and staff. 

Melanie Baumhover  

In rural settings, we may also have to consider things like telemedicine because maybe their primary provider is not able to be on site, and then taking into consideration staffing needs. So if, if we do have a place that's flexible, and able to be used for medical or mental health, is it situated in a way where it can be staffed by the same quantity of people? Are we forcing them to bring another person in for a one on one observing of a patient who's a mental health patient to prevent elopement. That has a significant impact on those facilities. Devin and Jessica, a recent evolution in mental health care is the emergence of the EmPath model, you've worked on several of these can you talk about what it is and how it's been successful?

Devan Swiontkowski  

Sure, maybe I'll just kind of touch on maybe some of the process things and then Jessica, you can kind of swoop in with some of the really innovative design things that we've done. So an EmPath model is helping divert mental health patients from an emergency department. So very much flowing from what we have just spoken about that if a mental health patient is in the ED, they can make sure that they're physically okay, but then they can be brought to these dedicated units to de-escalate, they are being able to meet with providers that are trained in the appropriate care that they need. They're there for less than 24 hours. So they're not having to board there, because the space is allowing them to de-escalate, they're getting the care that they need, and being advised on treatment for the future. Some of the units that we've done, they've proven just in one year, a drastic reduction in inpatient admission. And it's just been a really successful model for some of the ones in the Twin Cities here. And we're starting to see those pop up in different areas, sometimes called  different things like crisis triage centers, but it's essentially just taking the place of a mental health patient needing to in the emergency department. And I think the hope is that if these become a much more widespread thing, that that presence in the ED can be drastically reduced or eliminated. And I think it just, the flow of where patients go can can really change. But in terms of what's great about an EmPath versus an ED, I think Jessica can kind of speak to that and in what we differentiate in our design aspects.

Jessica Norton  

Yeah, absolutely. So even touching on some of the things Ellen mentioned before, and why some of these elements that you know, occur in an emergency department that aren't appropriate for these patients in this setting, we really had a great opportunity within the EmPath model to really build in some of those really great design features. We had a lot of care to acoustical treatments, what different kind of different things that we can add in to help reduce the sound and keep it a nice quiet deescalation space. We have the opportunity to do a lot of really great lighting elements as well. And we had a lot of great access to daylight, which doesn't usually happen once you're kind of inside kind of deep within an emergency department, we know that that is a really important healing element as well. This EmPath model also allows patients to kind of move about the milieu spaces and open lounge spaces, I think that we also mentioned earlier before, giving them that choice and control and space and freedom to kind of move about the space as well. And designed in kind of almost a living room style aesthetic. We had nice chairs, warm furnishings, kind of bringing some of those elements that you see in the home environment into the Empath model we designed with a lot of success. They also did have access to quiet rooms. So instead of having seclusion rooms, we went with quiet rooms that patients had the opportunity to use and decide when they needed to use them to help with de-escalation or if They just needed some time away from the larger open lounge space. We also had built in some kind of snack and refreshment or beverage counters as well, and that they have the choice and control of going up and grabbing some water whenever they needed it or some snacks if they were hungry. And that really gives that autonomy back to the patients while they're in this space. One thing that EmPath, this EmPath team elected to go with was removing glass from the main nurse station, of course, there was kind of a closed off charting type station that was behind, but really encouraging the staff members to be out within the space with the patients. So that really kind of breaking down with this program at this facility, that kind of us versus them mentality, and that we're working together for care and really making sure that the staff was kind of out and the patients had access to them for questions and, and just for safety, feeling like they could safely get a question to ask or help from a staff member if needed.

Devan Swiontkowski  

And I think what's really an awesome thing that we as a firm tried to do for mental health units is that we understand that there needs to be a high level of impact resistance and things like that for materials and design. But I think we really try to go above and beyond to make sure that these spaces don't feel any different than any other healthcare space. I mean, there's obviously durability and cleanability. But, you know, we're looking at all different ways that we can find different products or detail things appropriately so that it still feels very warm and inviting and not a sterile environment. But it's still very safe. And I think between our, all of our entities within our firm, we always come up with some really great solutions for that. 

Melanie Baumhover  

Yeah, absolutely, if you're not careful, and you're not intentional about your design decisions, and you're really just focusing on ligature resistance, which is what CMS and regulatory bodies are really mostly looking for, you could end up with a space that's very stark and very prison like, and when you have a patient that is in crisis, and you're putting them in a space that makes them feel like they're being punished, it is not at all helpful to their healing and their mindset

Jessica Norton  

That's a whole different perception.

Melanie Baumhover  

There was a mention earlier that you made Jessica, about the nurse station and the nurse station is always a controversial topic. 

Jessica Norton  

Yeah. 

Melanie Baumhover  

Yeah, when we have these projects, because the nurses want to feel safe. And so they want a wall. Studies will show that the more you can interact with patients, the more direct interaction that staff have with patients, the fewer incidents there are, but we always need to make sure that we are keeping in mind the lived experience of staff. And I've noticed with COVID, the level of aggressive incidents, the quantity of aggressive incidents towards staff in these crisis environments is increasing. So as much as I really want to push for, we should always have an open nurse station, we need to make sure we're listening to the staff. And that's how we do end up with in some of these harder environments, we may have to include enclosed our stations, but we want to make sure we do it in a way that staff can still get some passive observation and passive audio of what's happening within the unit and the ability to connect with patients easily.

Devan Swiontkowski  

And I think where we do open nurse stations that we I believe we often sort of put an off stage staffing area very close, so that if a staff needs to exit for any reason they can or if they need some focused work time, which is obviously things that happen, we do still provide those even if the nurse station is maybe open, it's just more of a touchdown space.

Melanie Baumhover  

figuring out how to detail those mostly enclosed spaces are really challenging. And I'm looking at you, Alan, because your role as senior project architect, you are really looking at exactly how we are detailing those things. And those are really challenging details to figure out how to make it durable, how to be able to communicate how to reduce things being thrown at or grabbed through. So do you want to talk about that challenge?

Melanie Baumhover  

Yeah, it's a challenge. We're in the middle of it right now for a project trying to figure out what the options are. What I've noticed, when you ask staff for their feedback is it's really easy to remember the moments where it didn't go well. Where a patient grabbed, grab their computer cord or their computer screen or you know, something got thrown through a gap in the nurse station glass or something. Then step back a little bit and say, think think of all the times where like you said that, Is it the ambient sound or you know, you need to hear what's going on in those spaces, right adjacent to you to get a sense of the situation before you go or maybe check it out and see how things are going. So that's something that you just don't think about. It just happens every day as you're sitting at the nurse's station that you can actually hear what It's happening in the room next to you so, so making sure you're balancing both the safety and minimizing those events, those acute events where an angry patient is grabbing for something, but also, the day to day communication and just listening to the environment has been important.

Melanie Baumhover  

Yeah, absolutely. One thing that I find interesting, just as someone who pays attention to what's happening across the country, within this space, there's a lot of movement that seems to be counties and cities and other government type organizations trying to band together to provide crisis behavioral health spaces, and some of them look more like EmPaths. Some of them look more like flex ED's, some of them are looking a little bit like short term residential treatment facilities. And I find it really interesting that we are seeming to see some movement finally, in providing spaces across the country. And I'm, I'm hopeful that as these models are continuing to develop, they will help individuals. But it's interesting, because there's so many different nuances on how they set it up.

Devan Swiontkowski  

Yeah, I think from all of the clients that I've dealt with, you could call the project types, similar, but they're, like you said, there's so many different nuances. I mean, that's why it's so important that we have these conversations with the clients and the staff understand what is their process where Are their, you know, pain points, everyone has different challenges. Everyone has different population types. And which makes it really interesting that kind of area to be in that there's just not a one size fits all, by any means. Then how can we be as flexible as possible, because even within the same unit, they may need to swing from hosting a ton of adolescents during one point of the year to a lot of adults, and how can we can we help with that. And so I think, hopefully people look to us for that, that advice in understanding where we can help them in those, those aspects. But I think there's always a solution. And I just hope that, you know, we can provide those for our clients that it's not a barrier for them to be able to provide this care, because what they're doing is so important, and so needed, that we just want to be able to be, you know, have the architecture via the tool for them to provide that care.

Melanie Baumhover  

So you mentioned being able to, being able to serve a wide variety of age groups, what strategies have you seen used to be able to either house diverse age groups in the same place, or to be able to separate them without drawing a hard line that says, This is how many child beds you have. And this is how many adult beds you have? 

Devan Swiontkowski  

Yeah, we see a lot. I mean, it's a request from a lot of different clients. Because we just know that we are limited on space, we need to make sure that we're being flexible with that space, you'll see a lot of what we call like flex rooms or swing rooms, so kind of grouping a few 2, 4, 6 rooms, together with some sort of barrier that can be opened and closed in those flex instances, to you know, give more rooms to one side or the other that often then is comes with challenges of where is the staff zone at being able to have views on both zones, no matter kind of which way they're swinging, there's some great challenges within just kind of the aesthetic of the space that Jessica could touch on if you're trying to design for adults versus adolescents. There's, there's a great variety in that. But we have multiple ways we can kind of deal with that. And we love working with clients on how that flow works  for them.

Jessica Norton  

Yeah, I was just gonna say within, especially those adolescents and pediatric type spaces to the challenge comes where you could have patients that are as young as four or five years old, and needing to be in the same patient space or EmPath unit, even for a few days, all the way up to a 17 year old, who wouldn't quite be put in the adult unit, but they are still in the same unit. So how do we kind of create, you know, different zones or different spaces for those different age groups, because you know, a 17 year old in size even is going to be a lot different and need a lot different care than a patient who's maybe four or five years old. And then how do we kind of design aesthetic that works for all of them and create a division of space for both of those age groups within one unit too.

Melanie Baumhover  

So we're talking about age differences, different age ranges, but I think it's also been interesting hearing about different acuities too. So you know, you could design your whole crisis unit for the really aggressive patients or you could design them for just the general amount of patients and then have maybe one or two rooms that are a bit more durable for patients that are a bit more aggressive, and I think that creates a better environment for most of the patients, as opposed to, you know, designing for just a few a bit more aggressive patients everywhere. That's been interesting.

Melanie Baumhover  

Yeah, Ellen, we are you and I are working together on a project. That is a, I would call it a crisis behavioral health unit, but it might look a little bit more like an inpatient unit to folks and having those sub-acute units, or those units where you could take individuals who are really very aggressive, very dangerous for other patients or really not compatible to be with other patients, they can have their own space. And in similar to what we were talking about within the ED making sure they have a a living or a recreation space that is separate from their bedroom, they have a bathroom with a shower, and they have a little bit of flexibility on where they're allowed to go. And so we're again, we're not locking someone in seclusion, because they're being very aggressive. We are planning for those aggressive incidents, and making sure we're providing choice and control within the space. So what's next for crisis mental health care design?

Devan Swiontkowski  

I think like it was kind of touched on earlier, we've been talking about the EmPath units or things called Crisis Triage Centers, and how different you know, communities, counties, health systems are taking this challenge up and finding, you know, slight different ways to approach that. And I think everyone is really putting a good effort into that. And I'm hoping that that is, that is what the future is because people need to be able to know where they can go and freely can go to get the access in the case of an emergency, I think it truly makes the difference. If they are given the right care at the right time, instead of kind of just being pushed into a health system that kind of could lose track of them. I think that's, that is the big next step that we're seeing and seeing great success in that. So we just kind of need to get that widespread.

Melanie Baumhover  

I've seen some providers focusing on training new providers, so we do have a staffing crisis. And they are working to make sure they have facilities and capabilities to train the next generation. And they're also providing short term, I'm going to call it like an urgent care. So you can come in short term, you may not need inpatient care, but maybe you just need a one hour therapy session, and you can't get into a therapist for six weeks to three months. So really looking at how do we help people when they're approaching but not quite at crisis, and trying to defuse some of those crises. And I think some of our future approach might be in providing those short term spaces that are really outpatient care, but outpatient care on a, an urgent need basis. And I think when more individuals and providers can give that level of care on a short term basis, maybe then we can be in less of a crisis state. We don't have to wait until someone is at or nearly at a position where they need inpatient care before they're able to get immediate assistance.

Devan Swiontkowski  

And I think something that I've been involved in recently is, you know, putting an importance on mental health care in school settings. So whether it's university settings or you know, wherever, in high schools K through 12. So having a good focus on, I'm bringing that program into the education program as well for those students access.

Melanie Baumhover  

Yeah, so I've noticed that we are a lot more free as a society in talking about our mental health care challenges and attending to them a little bit better. And when we can reduce the stigma of saying, you know, I see a therapist, or you know what, I'm having a tough day, I really just need a break, or this is a, this has been a tough meeting or a tough moment, I really just need a 10 minute walk in order to recenter myself. And I think the more we can allow ourselves to have those moments of weakness for ourselves and for the others around us, maybe we won't get so so bound up in a crisis situation, when we can make it normal to have mental health needs. You don't have a problem, you are a human and all humans have mental health needs that we can address.

Jessica Norton  

That it's all part of your greater health care for your, for your whole mind and body. I think that'll help more and more in the future as it does get destigmatized and maybe those crisis mental health care centers. You know, the entrances, we were just in a seminar that had a lot of great design studies showing that, you know, the entrance to even the mental health care facility or that crisis center looked like or was adjacent to the main hospital entrance so everyone was kind of going through it, it wasn't this, you know, other entrance that these other patients have to use because, you know, it's different from you know, the Healthcare that other patients are seeking to kind of destigmatize that even through the design and and through the design of the front door. 

Melanie Baumhover  

Yeah, that's great. 

Jessica Norton  

I thought that was very interesting. Yeah.

Melanie Baumhover  

So what are challenges or opportunities that we see in the environment?

Jessica Norton  

I think the challenge will probably always be space, you know, space availability, and cost. And again, like the staffing shortage we were mentioning, though, how do we create I think even you mentioned a little bit earlier, flexibility of those beds in those rooms, and maybe even how do we place those in a strategic way where we can add in a little bit of, you know, that lounge or other milieu space, so they don't feel like these patients are, you know, stuck to their one room when they're in a crisis in an emergency department, if there is no space or opportunity to build that separate wing or separate unit or separate crisis mental health center?

Melanie Baumhover  

Yeah, I've noticed in the past five or so years that a lot of manufacturers have really stepped up their design efforts for mental and behavioral health spaces. And we're not left with just the corrections, looking products. But we have a lot of options, furniture options that have beautiful colors as standard colors and, and different elements that look more normalized, but are safer for individuals who might be at risk for self harm, I think there's still more opportunity to make a difference in that realm. But it feels like we're moving in a really good direction, as an industry.

Jessica Norton  

Feeling less institutional, and kind of more more home like fixtures and other elements that can be brought into the space. 

Melanie Baumhover  

Yeah, absolutely. 

Devan Swiontkowski  

But I think as, as designers, we're wanting to always look for a solution and to help with things. And I think it is challenging. Going into a client has just said that, you know, it's sometimes the challenges aren't things that we can actually solve. And as much as we want to say how amazing our designs and architecture are, we can't solve everything. But I think we are really great at facilitating conversations to help our clients start those conversations and how they can be solved and kind of leaving that path for them a little bit. Well, this is how the process can change. And this is how we you we can be more efficient with your staff and your flows. Look at how we can help decrease things to save money. So as it's not always architecture that solving the problem. But I think as problem solvers, we can still very much help our clients in that way. And that always makes me kind of excited to be able to help them in different ways like that.

Melanie Baumhover  

We very much have a supporting role that the staff provides really great care for their patients. And we are here to support them using all of the tools at our disposal, giving them a great space that aligns with their care model, and how they want to help the patients.

Jessica Norton  

I think something that makes me hopeful for the future that I just wanted to add quick is that I think we have a lot of really great clients and a lot of team members and a lot of passionate staff, too, that are really excited to push all of these discussions on mental and behavioral health and crisis design forward who are really ready to tackle I think this area of healthcare design.

Melanie Baumhover  

Yeah, that's a great point. I've seen so many people within our office, raise their hand and say, I'd really like to work on these projects. Those look like really great life changing projects. And we all as design professionals, I think look for deep meaning in our work. And it's really easy to find deep meaning when we're working on projects in this realm. Well, thank you all for your time today. It's been a great discussion. I think we still have a lot of work as a society to do in addressing or crisis mental health needs. But I've really enjoyed talking with you all about the projects that you've worked on and the clients that you've talked to and look forward to talking again. 

Jessica Norton  

Thank you. 

Ellen Konerza  

Thank you.

Matthew Gerstner  

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