In 2016, only 43 percent of the 44.7 million adults with any mental health disorder received treatment. Further, less than 11 percent of adults with substance use disorder received treatment. (AHA, 1). The demand for behavioral health treatment has been on the rise over the last decade, but many people aren’t even sure what Behavioral Health is. So, what is “Behavioral Health”? According to the AHA:
“Behavioral health disorders include both mental illness and substance use disorders. Mental illnesses are specific, diagnosable disorders characterized by intense alterations in thinking, mood, and/or behavior over time. Substance use disorders are conditions resulting from inappropriate use of alcohol or drugs, including medications. Persons with behavioral health care needs may suffer from either or both types of conditions as well we physical co-morbidities” (AHA, 2)
While arguably a textbook-like statement, behavioral health is a serious issue that impacts everyone.As designers we often ask ourselves “What can I do to contribute to an improved quality of life for someone with mental illness?” While there is no one correct answer, there is a concept, known as Sunfeld’s Theory, that illustrates four areas of the built environment in which we can work: Geographical, Practical, Perceptual and Behaviorial.. These areas contribute to reducing stress, agitation and aggressive behavior in those who live with these challenges daily.
With the person at the epicenter, the theory refers to four “levels” of environment which can directly relate to many aspects of the design process including (in similar hierarchy) region, architecture, interiors, and the reaction of the occupant to the created space.
First, one of the most frequently explored aspects of behavioral health design, the Geographical Environment refers to the location and region of a project. By utilizing existing landscapes, a designer can create a sense of place for building occupants, both staff and patients alike. In “Psychiatric Ward Design Can Reduce Aggressive Behavior,” Roger Ulrich explains “exposure to major stressors significantly increases risk…[of] aggressive acts” for as long as a week following exposure (55). By utilizing design elements such as garden access, window views, increased daylight, and light wells, the geographical environment can permeate the building and create a positive distraction, thereby reducing stress and the likelihood of negative action (Ulrich, et. al, 59).
Geographical Environment also encompasses the relationship between regional culture and the acceptance of behavioral health treatment. With each new project, a designer must consider the impact on the surrounding community. In communities that are unsure of behavioral health, a designer can promote positive change by eliminating the stigma of “institutions” and instead, tie the design to the community’s geographical roots. Through moves such as using familiar landscape, palettes, and imagery, a design can begin to appeal to the existing ideals and experiences of the surrounding community. Further, by understanding and respecting regional perception, a design can grow from the foundation of an existing community and promote the highest level of recovery.
One of the most powerful tools is a designer’s ability to manipulate the Practical Environment – or rather, unperceived familiarity of a space to its occupant. Through intentional architectural features, a building can transcend its base function and directly support fascination, curiosity and involuntary attention that can enhance recovery from mental fatigue. As Evans states in The Built Environment and Mental Health, “views of nature, fireplaces, fountains, aquariums, paintings, and other coherent tranquil scenes…afford restoration” to the occupants of a space (546).
Beyond intentional restorative architectural features, the programmatic design can strongly influence an occupant’s level of stress. Ulrich described it best when he explained the following:
Physical environment strongly influences patient stress. A poorly designed facility that prevents privacy, is noisy, and has other stressful features can intensify the stress of mental illness and involuntary confinement, thereby worsening aggression. Architecture can perhaps reduce aggression if deliberately designed to minimize stressors such as crowding and noise and offer stress-reducing positive distractions (Ulrich eta al., 55).
These main factors—crowding, noise, air quality and light—are all controllable through design, as seen in Kahler Slater’s Evidence Based Design Wheel. At Kahler Slater, we have found the EBD Wheel very helpful in our efforts to increase designers’ and clients’ knowledge of EBD issues and in fostering clients’ understanding of the negotiated complexities that must be navigated in the course of the healthcare design process. In addition, the wheel has been useful in talking with clients about shortcomings in existing facilities, highlighting responsive features in our own designs, and focusing discussions throughout the design process.
Programming and adjacencies also fall under the Practical Environment. A patient’s ability to feel control and have access to all aspects of their care is crucial. There are many examples of ways this can be accomplished, including the overall size, location and permeability of interior rooms. For example, by allotting for flexibility of social and personal space, a design can promote social interaction. As social interaction increases, isolated, passive behaviors decrease (Evans, 544-539). Another example is the use of open nursing stations (Figure 3). By removing glass partitions or the appearance of clear separation, patient to staff communication improves drastically, patient requests of nurses at stations are dramatically reduced, and negative feelings of patients towards staff are lessened (Karlin & Zeiss, 1378). By addressing the Practical Environment needs for users through intentional evidence-based design, a designer can remove the fear and discomfort often caused by unfamiliar or stigmatized spaces and create an positive perception of the space they are occupying.
When it comes to finding the balance between pleasing the masses and catering to the individual, a designer moves into perhaps the most critiqued of Sunfeld’s environments - the Perceptual Environment. In this level, it is a designer’s task to create a space which appeals to the occupants without causing harm or upset. A practical way to accomplish this is with realistic artwork, natural textures, and a color palette reflecting the surrounding area. Designing a space to reflect the region’s atmosphere creates familiarity which can be both obvious and comforting to the user. Studies have found that the built environment has been known to promote learned helplessness, when users often give up and become more depressed, feel a sense of disorientation, and can have increased behavioral out lashes (Evans, 544). “People tend to seek out places where they feel competent and confident, places where they can make sense of the environment while also being engaged with it. Research has expanded the notion of preference to include coherence (a sense that things in the environment hang together) and legibility (the inference that one can explore an environment without becoming lost) as contributing to environmental comprehension” (De Young, 1).In discarding the unfamiliar, a designer can aid in perceived personal control and dissolve feelings of helplessness.
Before a design is finalized, the patient type must be considered. Current trends say units should be hues of blues and greens in order to create a feeling of relaxation, however, studies show this is not entirely valid. Although blues and greens are considered “cool colors” and reflect calm reactions, “blues and greens can also have a negative effect on mood for patients with depression and less energy... Brighter colors may be preferred.” (Karlin & Zeiss, 1377). This is a prime example of regional design playing a vital part in psychological emotions of users. For example, choosing a color palette for a unit in the Midwest is going to be strikingly different to one located in the Southwest, as the regional landscapes and perception of what is defined as “natural colors” are completely different. Likewise, there are regions where “warm colors” such as red, orange, and yellow, are actually seen as relaxing colors because they remind a user of home. Designers use the “whole picture” - bringing in artwork, textiles, wood tones, etc. - to balance the scenes found outside the built environment.
While there are endless ways to create familiar environments within different Behavioral Health environments, a common practice is the use of realistic imagery. With today’s technology, images are no longer limited to just framed artwork on the walls; images can be reflected in flooring, on wallcovering, ceilings, etc. Additionally, we can replicate regional aspects abstractly through color scheme, wood tones and textures, the patterning of the floor, or even the flow of the ceiling. By abstracting the outdoor surroundings, a design can suffice the aesthetic needs to both local and non-local persons; making it easier for people to relate to the space. Images and simulated textures will never replace that of physical access to the outdoors and the natural environment, but they can help reduce psychological and physiological stress for both patients and staff.
The closest level of Sunfeld’s Theory to a person’s “self” is the Behavioral Environment which involves a person’s reaction to a created space, both initial and post. Each user is going to have a different perception of a space, but through surveys, user group meetings, and research, designers can analyze the commonalities to create the best design solution possible. For example, Kahler Slater achieves these measurable results through performance-based design. This process is adaptable to specific client needs and is organized into five key steps: Discover; Dream; Define; Design; Deliver.
By utilizing the tools, we already have as designers – the ability to research, bring prior knowledge, and engage with our clients – we can better fulfil our responsibility to protect the health, safety, and welfare of the public. Sunfeld’s Theory is one outlet to enhance Behavioral Health design but is by no means the only method. Behavioral Healthcare is a rapidly growing and continuously improving field; trends in design deserve attention and careful study before application. Will the proposed innovative method work within the region of the project; is it adaptable to all levels of Sunfeld’s hierarchy; does it promote a familiar environment that encourages recovery? These are the critical questions we must ask throughout the design lifecycle. One out of every five adults will experience one or more Behavioral or Mental Health conditions in their lifetime (Mental Health America, 2018). As designers, we have the monumental task of providing the best possible solution to the rising and changing problems. Understanding and integrating regional implications is just the tip of the iceberg into innovative, compassionate Behavioral Health design.
Rahimi, Nazanin, and Amir Masoud Dabagh. “Study the Mental Effect of color in the Interior Architecture of the Hospital Spaces and Effect on the Patient Tranquility,” Amazonia Investiga, Vol. 7 Num. 13, March-April 2018.
Karlin, Bradley and Robert Zeiss. “Environmental and Therapeutic Issues in Psychiatric Hospital Design: Toward Best Practices,” Psychiatric Services, Vol. 57, No. 10, October 2006.
De Young, R., 1. Environmental Psychology, Green Organizations: Driving Change with IO Psychology.
Ulrich, Robert, and Lennart Bogren, Stuart Gardiner, Stefan Lundin. “Psychiatric Ward Design Can Reduce Aggressive Behavior,” Journal of Environmental Psychology, Vol. 57, 2018.
Evans, Gary W. “The Built Environment and Mental Health,” Journal of Urban Helath: Bulletin of the New York Academy of Medicine, Vol. 80, No. 4, December 2003.
“Increasing Access to Behavioral Health Care Advances Value for Patients, Providers and Communities.” Trendwatch, American Hospital Association, May 2019.