Resilience is a word that has been bandied about in the design world for some time.
In the architectural industry, it is often used in reference to disaster resiliency and sustainability, but Nathan Howell, associate and project manager, at HKS Architects, wants us to consider a different kind of resiliency.
“Let’s talk about [resiliency] not just from the build space, but from the individual human perspective. That is, the ability to mentally and emotionally cope with change and with crisis,” said Howell.
This past year threw just about everyone a major curveball, and many have found it difficult to cope. Bouncing back from the compressive stress of Covid-19 has been more difficult for some, perhaps especially those already suffering from a mental health diagnosis.
When planning, designing, and building behavioral healthcare facilities, it’s important to remember the additive effect of this layering of stressors upon each other. Individual patients will often present with multiple diagnoses, and each individual patient contributes to the diagnostic spectrum represented within the patient collective of any behavioral healthcare facility. At an addiction treatment facility, for example, staff manage not only the addiction itself but also the multitude of conditions that cause and accompany addiction.
In addition to the broad mental/behavioral healthcare spectrum of disorders and diagnoses, you also have different populations—geriatric, adult, pediatric, and adolescent—each with unique needs. Behavioral healthcare facilities need to be prepared for the full spectrum of human variance.
The ability to design for such a wide variety of needs within the patient population is something that Howell and his colleagues at HKS Architects are proficient in. Howell believes the environment should change and flex to provide caregivers the ability to treat each patient in the best way possible.
How do you create an environment that is adaptive and provides for flexibility? They are dedicated to ensuring the built environment does not become the driver but that the structure can respond to the micro-cultures they contain and ever-changing treatment programs. These are the answers that he and his colleagues are asking themselves.
On top of those questions, the recent pandemic has spurred new conversations about what adaptability means moving forward. At HKS Architects, Howell said, they are looking toward creating more mid-size adaptive spaces with more medical isolation capability. They continue to consider new and different ways to allow caregivers the flexibility they need to do their jobs when day-to-day tasks vary so widely.
“There is no one-size-fits-all solution. The design must fit each facility’s program. The building must be designed for the unique needs of the community. It must be designed for connection—be that between caregiver and patient, patient to patient, and family to patient and caregiver,” explained Howell.
Howell says there is plenty of evidence that shows that when you increase the relational connection between the caregiver and the patient, you can have more open communication. That open communication is an essential part of the treatment paradigm.
“When a patient is more able to communicate with the caregiver and talk about potential issues, you see improved outcomes,” said Howell. “Often, it is when breaking down barriers, both physical and mental, that we’ve seen the most success.”
You’re probably thinking that you know where this is heading—the nurses’ station. Howell chuckled when we mentioned it and said, “It’s always a fun discussion with a lot of strongly held beliefs.”
But HKS has looked beyond that one physical space to find opportunities to take connection a step further.
“I’ve had an opportunity to work with providers that are really trying to be progressive in how their treatment programs can foster that relational connection—a type of treatment cohort.”
With the cohort approach, mental health professionals and patients move and progress through the treatment spectrum together. They can build a bond and empathize with one another. Together, they build that resilient flexibility back up for the patient.
Howell said they had designed plenty of both closed and open nurses’ stations, but he feels that even with an open nurses’ station, patients can still perceive a barrier, an “us vs. them” divide between patients and staff.
He believes that there is absolutely a need for barriers in certain situations, both for safety and splitting different programs and functions. Still, the key is finding the opportunities in that environment to make things as permeable and relatable as reasonably possible, in order to give back some dignity and agency to the individuals.
Howell concedes it is a challenging hill to climb, and some people are simply not open to having those discussions.
However, when he does find a client who is open to discussion, that’s when the magic happens. In one project, Howell said the client was open to the idea of creating a community connection table that sits in front of the nurses’ station. That table is open, and yes, more vulnerable, but it eliminates that barrier and allows the patient and caregiver to meet on neutral ground.
Timing Is Everything
HKS research has shown that building for resiliency and connection is achievable and that it improves patient outcomes. However, to achieve the best possible solution, their designers need to be part of conversations from the very beginning. Ideally, Howell would like to be a part of the conversation before the program has even been defined. This way, they can act in an advisory role where the client can benefit from HKS’s extensive research and broad experience from across the county to inform that discussion better.
“We can advise providers of the newer trends and different options out there, as well as different ways to look at a service model that might be a little bit more friendly on the financial side,” said Howell.
When they are invited to the party late, after the provider has already developed their program, Howell said it can really limit options for innovation, and the only place to start is with the floor plans.
When HKS is part of that early discussion, they can listen to the client and caregivers and work together collaboratively. When that happens, Howell said he can feel the excitement of the staff. Because while adaptive environments certainly benefit patients, they positively impact all occupants of the building—patients, staff, and visitors alike. They can provide staff the ability to make changes to improve their environment using evidence-based practices.
“It is a very tough environment to work in, and the turnover rate is very high. You always hear about the shortages of mental healthcare staff. When we can design adaptive environments that provide a space for respite, aid in stress reduction, and improve mental wellness for the staff, we are helping them build their own resiliency. They can then care for the patients in a better way, which can improve patients’ outcomes, as well.”
More Research, Please
While there is a growing body of evidence on how the environment affects physiological resiliency, Howell would like to see more research being done to understand the full impact on interventions.
For their contribution, HKS has an in-house research department working hard to do just that. They ask tough questions such as, “Is what we are doing having the impact we thought it would? Is it better or worse?” And then, “Most importantly, what do we need to adjust or change?” That research is then infused into the design process, helping to drive progress forward.
Ideally, HKS is looking for opportunities to work with clients who want to push the boundaries of mental healthcare. To do that, HKS had built a robust project methodology built around research and evidence, that doesn’t stop when the project ends. They are looking for access to make observations after the facility has been operating for a while in order to measure the impact of their designs on patient outcomes. This longitudinal research, HKS believes, would be highly useful in assessing what works, what doesn’t, and how they and the industry can continue to improve.
Howell said that research is one of the essential practices facilities should be participating in, and he wishes more were open to it. Similar to the design process, the research process at HKS is also collaborative, and they are studying not just the environment but also the process of providing care. The typical perception of this process is that it just adds time and cost to a project, but there is true value created through the research process for each project. Value that can truly make a difference for patients and caregivers alike.
“It’s very important to us that we are very well abreast of all the evidence-based practices out there, that the interventions we’re making are meaningful, and are doing what they’re intended to do,” said Howell. “We’re getting to work with some really good partners on that front, who are very research-minded and want to make sure that they’re doing the best thing for their patients. Not only are their treatment practices the best and most forward-thinking, but their environments are reflective of that.”
That snowballing research then also goes on to inform future projects. Howell explained that many of their clients are coming from old legacy facilities, sometimes as old as 100 years. The staff has had to make compromises to work in a physical environment that isn’t always ideal. When HKS comes in to design a new facility and shares best practices, they are not just talking about color and lighting but also sharing the latest research on the process.
“We are asking: What is your process? What are your workflows? What is the treatment regime, and everything that goes in tandem with that?” said Howell. “When we talk about an adaptive, resilient facility, it has to have something to adapt to.”
Changing Perception and Breaking Down Silos
While HKS has been able to get their clients on board with emerging best practices, Howell says we still have a couple of societal issues that need fixing in order to deliver the best care possible. The first is that we as a society still have work to do regarding the stigma of mental health disorders and treatment. We’ve come far in the last decade or so, and in a way, COVID has opened up conversations about depression and anxiety. It has also spurred a wider use of telehealth medicine.
Still, Howell says when he talks to people about what he does, they often make jokes about padded rooms. It seems the Hollywood stereotype persists. But when you boil it down, he thinks that reaction stems from humanity’s innate fear of losing control and losing our agency and dignity.
“People still think of that prison-like facility from horror movies and say, ‘Oh, well, I don’t relate to that, and I don’t see that that has anything to do with me—that’s for other people,” Howell said.
Without empathy and connection, we end up where we are today. People struggling with their mental and behavioral health also face a lack of opportunity and support in their community and often lack access to care.
The second thing Howell would like to see happen is a dismantling of the siloed healthcare system.
“You’ve got behavioral healthcare over here, and you’ve got medical care over there with a few other little silos mixed in between. Instead of discussing illness, we should be thinking about health,” said Howell.
He also doesn’t like the idea of mental health vs. physical health. “You can’t have the mind without the body and the body without the mind. We need to switch this conversation to be about health in a holistic way and how ideas can cross-pollinate.”
It makes sense because, as Howell points out, many patients with a high prevalence on the mental health side also have co-morbidities on the physical side.
“I think we’re starting to see some promise kind of on the lower acuity level with kind of this integrated care primary care model that’s starting to become a little more prevalent,” said Howell. He then added, “And while we are treating holistically, why not bring in nutritional psychology into the mix?”
Howell said that some of their clients are starting to integrate primary care components into their mental health facilities. But addressing the holistic nature of health is where we need to start.
“And we should be doing that from the bottom up, from the lowest level of acuity to the highest, not the highest down,” he said.
Howell points out that there are still far too many places in our country with either no access to mental healthcare services or a drastically incomplete spectrum of services. As a result, patients can have month-long waits to receive care or, at times, get plugged into the continuum at a higher acuity than really needed as it may be the only available option.
He said, “There is still a lot of work to be done there, but that is by far one of the biggest hurdles we need to overcome.”
Breaking down barriers between healthcare silos may be beyond anyone’s individual capability, but it is something that many in behavioral healthcare services would like to see happen. Taking these conversations to a wider audience will certainly help, as will increasing education about what behavioral healthcare facilities actually do, and facilitating open and meaningful dialogue around mental health.
For more information on some of the work and research HKS is doing in behavioral healthcare, please be sure to read their extensive report on Designing for Empathy and Resilience in Mental and Behavioral Health.