September 6, 2017
By Visa Lighting Staff
“Behavioral health” is a broad health industry category. It encompasses anything that impacts a person's mental wellbeing or ability to function. Mental illnesses, addictions, eating disorders, dementia, and PTSD all technically fall under the behavioral health umbrella. So, depending on the size of a community and the facilities available, some behavioral health units may house patients with vastly different needs and risk levels.
It’s vital to design behavioral health facilities with safety in mind, since patients admitted to behavioral health units may pose a risk to themselves or others. Standard furniture and fixtures that are considered safe in a hospital setting can actually be quite dangerous in a behavioral health unit. Because of this, most behavioral clinics housed within larger hospitals require their own separate design specifications.
History and Stigma Surrounding Behavioral Health
As technology and product design progress, hospitals are more and more capable of answering those specific design needs. Unfortunately, it hasn't always been this way. People with mental illnesses have historically battled against stigma and prejudice. In many cultures, they were thought to be possessed by evil spirits.
Until very recently, medicine has echoed many of the stigmas against mental illness, causing further isolation, criminalization and mistreatment. Asylums were built to keep people locked up away from the community rather than to offer them any relief—and even into the 21st century, that model prevailed. Asylums became mental hospitals, which were still huge and densely populated. Rather than designing facilities to soothe patients and mitigate violence, we used stark colors and stifling spaces to control patient behavior. Patient conditions were worsened by their environment.
Beginning in the 1950s, mental health became slowly deinstitutionalized as patients moved to smaller clinics and outpatient facilities. By the 70s, doctors encouraged community care and more effective pharmaceuticals, and the length of patient stay fell by 50 percent. Care became more empathetic as doctors understood behavioral health conditions better.
Today’s Design Practices
Now, behavioral health facility design isn’t just about safety—it’s also about offering comfort through the design itself. Balancing these two objectives is considered critical for patient wellbeing. Since many facilities still struggle to apply evidence-based design behavioral health units, new research is piling up every year to help guide designers through the best design practices.
We’ve combed through design guides from Hassell Studios, The Center for Health Design, the Department of Veteran’s Affairs, and the NAPHS. Our goal was to find current approaches to behavioral health facility design across multiple publications, summarize these findings, and apply them to the lighting industry in particular.
Problems and Risks Inside Behavioral Health Units
First, let's identify specific attributes of behavioral health that require specialized facility design. These issues are admittedly what contributed to many of the stigmas surrounding mental health, since many behaviors fall outside what we consider to be socially acceptable. However, to design with empathy means to find solutions—not to further isolate or point the blame at patients. When facilities are designed to prevent and mitigate these issues, clinic staff have more time and capacity to focus on patient wellness.
Patients admitted involuntarily or distressed patients are at a high risk of escape, (or as one source kindly described it, an “unscheduled absence”). Basically, for the safety of patients and others, most behavioral health facilities do not allow patients to leave on their own. Facility design must accommodate secure doors and windows, maintenance, outdoor structures and fences, and staff observation. For visual comfort, it’s also important to keep patients where they are supposed to be without making them feel caged in or guarded.
Suicide, Self-Harm, and Violence
Could a patient or anyone else be hurt by the environment? That’s what designers and architects need to worry about. This touches every part of the facility, from electrical breakers to doorknobs to chairs to sprinkler systems.
Ligature-resistance (an object’s inability to have anything tied or bound to it) is extremely important. No design object should provide an anchor point or cord that a patient could use to strangle themselves.
Vandal-resistance means something cannot be damaged, and therefore its broken pieces cannot be used to commit harm. All windows, mirrors, furniture, switches, etc., should be vandal-resistant.
In order to keep ligature- and vandal-resistant elements from looking too strange or institutional, designers have to consider aesthetics as well as physics.
Providing Visual Comfort
More home-like, inviting design can work alongside therapy and medication to heal patients. According to the VA, "Warm, welcoming, and familiar environments often promote a sense of calm in patients and enhance their connection to their surroundings (often referred to as “place attachment”), rather than feel detached from or in opposition to it." We are moving way beyond clean white walls and cafeteria chairs.
There is so much literature available about this, and no time to describe it all here. Check out Norix’s whitepaper by Tara Hill on the impact of color, which also has insights on other design aspects. Or read Healthcare Design’s article on biophilic design at Swedish Ballard in Seattle, which outlines how designers were able to capture the effect of nature by imitating it rather than representing it. For example, rather than just painting trees on the walls, they painted “vertical patterns that subtly compress and expand color and pattern variation to provide a sense of movement through a forest (corridors) and toward a clearing (the activity spaces).” This center was also studied for the DOE's SSL Gateway program.
For our purposes, let’s look at those behavioral health challenges and how different design solutions address them depending on where they are in the unit.
Patient Rooms and Bathrooms
In behavioral health, risk should be measured against opportunity. Patient rooms and bathrooms have more safety issues because they are more private. Cabinets, plumbing, shower heads, and of course, lighting, should all be ligature- and vandal-proof.
But the spaces themselves should allow the patient to feel a sense of control and ownership through “environmental flexibility.” Like the researchers of the previous study found, something as small as a dimmable light fixture, water temperature control, or a choice in artwork can help a patient find stability and agency. For shared rooms, there is more accountability for safety but less privacy, so furnishings should help mitigate that.
Social interaction is crucial in behavioral health spaces. Furniture should be heavy (so it cannot be thrown) and ligature-resistant. Many sources stated that patients should be able to rearrange furniture—so nothing bolted down or built in. Chairs facing inward (socio-petal design) and interactive activities can make communal spaces more inviting and lively. Lighting and color can help code communal spaces so that patients are naturally drawn to social areas.
Interaction with staff is a big part of community in these environments. Patients tend to congregate near the nurse station, so seating should accommodate that, with no glass or walls separating them.
Nature and Outdoor Space
The biggest change in behavioral health, and really healthcare in general, is the introduction of nature into indoor spaces. Facilities now incorporate indoor plants, natural color palettes, and artwork depicting nature—not just for visual appeal, but for their calming effects.
Courtyards for outdoor activities and large windows for views to the outside are all being built into these facilities to help patients and staff connect with nature. This helps regulate circadian rhythm and eliminate any stuffy, hedged in feeling.
Let’s look at other ways lighting design can impact behavioral health environments.
Lighting Design for Safety and Visual Comfort
Lighting is unique. It is crucial for providing that warm, inviting feeling—but it is also extremely vulnerable, so many facilities opt for stark, simple luminaires. Typical hospital lighting does not work in a behavioral health setting. But that setting also opens up new opportunities for designers to use lighting in a purposeful way to facilitate healing.
Researchers have found that a big part of treatment success lies in patients being able to steer their own recovery process—and facility design can definitely help with that. In 2016, patients discharging from a brand new child–adolescence mental health inpatient unit were asked to identify which elements of the unit helped them feel the most calm. Out of all the choices, patients preferred design elements that they were able to control, like the common room music panel, colored lights, and light dimmers.
Natural-looking materials, calming patterns, and Tunability can all remove the institutional feeling of high abuse lighting. Below are some considerations for behavioral health luminaires, described according to safety concerns as well as their aesthetic opportunities.
Ligature- and Vandal-Resistance
All luminaires within reach should be flush-mounted: no protruding sconces, portable lamps, or hanging pendants. Any frame or lens should be securely fastened with no possibility of sticking objects between pieces of the lighting fixture (or between the fixture and the wall). Diffusers and lenses should be virtually unbreakable, but not look unbreakable. Light switches should be vandal-resistant and placed outside patient rooms.
Wayfinding and Security
Lighting should make sense within the rest of the space to help patients see where to go. There should be no dark spots and no irritating glare. An integral emergency lighting system should be installed so that in the event of a power outage, all patient access areas are illuminated and secure. Lighting can be used to provide visual cues to patients: centering on gathering and activity spaces or remaining at low levels and warm temperatures in quiet areas.
Lighting and art can be integrated in really engaging and healing ways. Find luminaires that include artistic imagery on their diffusers, or manipulate color with RGB LEDs. Remember, behavioral health patients benefit from exercising control over their environment.
Soft, amber night lights should be installed in every patient room or integral to the existing luminaires. Some facilities may require this light to be controlled by staff, outside the room, so they be left on for nighttime rounds. Night lights might also be installed in patient bathrooms and corridors.
Speaking of bathrooms, this is where patients spend a lot of time alone. It’s important to design for bathroom lighting fixtures that are visually beautiful and have a high CRI. Night lights can help maintain circadian rhythms so patients can use bathrooms throughout the night without becoming fully alert.
Patterns can be soothing and engaging, but in behavioral health spaces it’s important to avoid ambiguity. On shades, lenses, and luminaire bodies, avoid using patterns that change shape or color randomly or appear to move. These can agitate patients with sensory issues or visual hallucinations.
Working with (and without) Sunlight
Whenever possible, lighting should work collaboratively with existing daylight. In areas with very little daylight access, Tunable luminaires can be used in place of sunlight to mimic the natural temperature fluctuations of white light throughout the day—this is beneficial for anyone’s mental health, and it can help patients feel connected to the outside world. This is especially helpful for patients with Seasonal Affective Disorder (SAD) who can benefit from summer-like lighting in the winter months.
Daylighting, orienting windows and skylights to control optimal daylight access, is also good for behavioral health—when possible. Older buildings with smaller windows or facilities in areas with more cloudy weather or less sunlight throughout the day can find it difficult to bring sufficient sunlight into the space. A combination of daylighting and Tunable lighting would be ideal in those instances.
Sunlight isn't always good—glare can also be an issue in behavioral health facilities. Glare, whether from irritating reflections or overly bright lighting fixtures, can be annoying for anyone, but for behavioral health patients sensitive to stimuli it can be distracting and trigger agitation.
The Future of Behavioral Health Facility Design
We’ve barely scratched the surface of what patient-centered design can do for behavioral health facilities. More evidence is being collected as new facilities adopt these practices. But until then, existing facilities should do what they can to improve patient wellbeing by improving their environment.
There are a few challenges that get in the way of an ideal behavioral health space. Some units are built into older, more rigid structures. Some communities do not have the funding to design beyond basic functions. But many of the strategies outlined here and in our sources can be followed by degrees. Even painting the walls, rearranging the furniture, or replacing the lighting fixtures can be enough to make the environment safer and more empathetic.