Nineteenth-century architecture for the insane produced grand palaces of
healing, ex pressing in brick and stone the enlightened therapeutic ideals of
their age. They were paradoxical structures: massive, but allowing patients to
view the natural world outside. Light, air, decent accommodations, useful
work, and kindly staff were supposed to help patients recover or remain in
compassionate care (Psychiatric News, September 2,
Planned new psychiatric unit at the Veterans Affairs Hospital in Palo
Alto, Calif. A large, central courtyard and four smaller ones within each unit
provide access to the outdoors while maintaining patient safety. Architects
are The Design Partnership of San Francisco.
The Design Partnership of San Francisco
Of course, that idealized marriage of design and psychiatry did not
New policies led to overcrowding and mere custodial care of public patients
by the late 1800s. Still later, shock at those conditions and the development
of psychotropic drugs in the mid-20th century led to an emphasis on community
care and deinstitutionalization. The number of patients in state and county
mental hospitals declined from 337,691 in 1970 to 49,443 in 2002, and the
number of hospitals decreased from 315 to 232, according to the most recent
data from the National Association of State Mental Health Program
Yet the need for psychiatric hospitals has not disappeared. Public or
private, they still offer long-term care for the most difficult cases and
provide short- to medium-term settings for diagnosis and treatment. At least
11 states are now in the process of replacing older hospitals or building new
ones. Some private facilities, such as the Sheppard and Enoch Pratt Hospital
in Towson, Md., have also constructed new wings in recent years.
As they build, however, the people who design and run psychiatric
facilities still put their ideas of how to care for patients into the very
walls of their buildings. Over the last two decades, the design of new
psychiatric hospitals and new psychiatric wings of general hospitals reflects
the emphasis on recovery, shorter stays, and the patients' role in their
treatment. Today's facilities still have their boundaries but, more than ever
before, are less places of confinement and more places of treatment and
preparation for return to the outside world.
“A psychiatric hospital should recapitulate a real community in which
patients will live after treatment,” said Richard Lippincott, M.D., a
professor of psychiatry at the University of Arkansas for Medical Sciences,
articulating the views of many architects and mental health professionals.“
You make the inside represent the community outside.”
Lippincott was formerly director of New Hampshire's Department of Mental
Health and Developmental Services and managed the creation of the New
Hampshire Psychiatric Hospital in Concord, which opened in 1988. The new
building was constructed, like others, around a central courtyard and includes
a shop, gym, library, and dining hall for residents, staff, and visitors.
Riverview Psychiatric Center, Augusta, Maine, designed by JSA Architects
Interiors Planners of Portsmouth, N.H. The main lobby shows the dramatic use
of light and art to give life to the walls of the building.
The dining room provided an especially vivid example of how design had
altered social patterns in the hospital, said Lippincott. The space became a
crossroads for more than patients and staff. Families met with their
hospitalized relatives there. Previously discharged patients found the
atmosphere so congenial that they returned for meals. Legislators from the
nearby state house would even drop in for lunch. While this setting was open
and friendly, access was also closely controlled, with only one way in or out
of the room.
One state over, the Riverview Psychiatric Center in Augusta, Maine, which
opened in 2004, is also constructed around an enclosed courtyard, so patients
can go outside as they wish but still be in a secure setting, said Marya
Faust, M.S.W., director of the Office of Adult Mental Health Services for the
state. Riverview was designed by JSA Architects Interiors Planners of
“The center offers a humane and welcoming environment without
compromising security,” said Faust. “The challenge was how to make
it look inviting. All rooms are private and have windows that give views to
Those windows express the combination of security and patient autonomy
guiding the new architecture. Blinds are enclosed between glass panes so that
patients can control light entry but not damage the blinds or injure
themselves. Building design can also influence staff practices. Two units at
Riverview do not have seclusion rooms, so the staff improved their skills in
de-escalating potentially violent situations, said Faust.
Light and color fill the interior spaces. Window walls let in the sun, and
art, some by professional artists and some by patients, lines the
“Just being in the building gives one much more hope,” said
Similar ideas are evident in the plans for a new psychiatric unit that the
Department of Veterans Affairs is building on its Palo Alto, Calif., campus.
There, subunits cluster around courtyards, and small gardens are built into
the ends of each cluster.
Enclosed courtyards are a common theme because they allow patients to move
freely into the open air without fear that they will wander away.
Like all the new structures, the VA hospital will provide ample daylight in
patient and common rooms. Views of the natural world outside can reduce
psychological distress and recovery time and enhance staff functioning, wrote
Bradley Karlin, Ph.D., and Robert Zeiss, Ph.D., of the VA in the October 2006
Psychiatric Services. Interior design makes the building feel less
like an institution and more like a home—cinder blocks and echoing
hallways are out. Furniture must be heavy enough not to be thrown but light
enough to move around and create informal social
The central cafe at Riverview offers both indoor and outdoor dining with
direct access to the central courtyard.
“The VA is moving to an interdisciplinary, evidence-based, recovery
model of care,” said Karlin, the newly appointed director of
psychotherapy programs for the VA's Office of Mental Health Services in
Washington, D.C., in an interview. Karlin and Zeiss were part of the design
team for the new inpatient psychiatric building. In that process,
representatives of all divisions of the hospital were included in early
discussions with the architects, Design Partnership of San Francisco.
“Creating these new hospitals is an intense collaborative exercise
for both architects and staff members,” said Karlin.
When faced with planning a new building, psychiatrists should talk to each
other, visit other facilities, and ask what worked and what didn't, said
architect Frank Pitts of architecture+ in Troy, N.Y., in an interview.“
Simply because they are psychiatrists, they should be able to
articulate what they see and how they feel about other facilities.”
The image of village—houses, a neighborhood, downtown—underlies
the new movement, said Pitts, president of the American College of Health Care
Architects and past president of the American Institute of Architects' Academy
of Architecture for Health.
The “house,” in this case, is the patient's room, a place of
comfort and familiarity, Pitts told Psychiatric News. When ready, the
patient can move from the bedroom to a seat just outside the door (the“
neighborhood”), to places farther along the hall, and to more
open shared spaces. The “downtown” may include the treatment
areas, gift shop, or other common areas. The patient can emerge or retreat, as
feelings dictate, while an observant staff can increase or decrease security
In the traditional rehabilitation model, said Pitts, movement depended on
accumulating privileges. In the village model, patients can exercise more
responsibility and control of their actions.
“You have to look at patients as individual human beings,” said
Pitts. “They have had to leave home and face a lot of stress. You don't
want that experience to further destabilize them.”
Early in his career, he said, when he began designing psychiatric facilities,
he talked to everyone who would use the building, including patients.
Courtyards are next to residential areas at Riverview. Each patient
residential unit has direct access to secure, landscaped courtyards out of the
public eye with pastoral views across the Kennebec River Valley.
“I would sit quietly on the unit just to see and hear what was going
on, or I'd talk one on one with patients,” recalled Pitts. “The
most singular thing I found was how frightened patients were about being
harmed in the hospital.”
It became important to give them a range of options so that all patients
housed on the unit (typically 24) were not in the same day-room at the same
time, he said. Their fears could be lessened if the architect could provide
tools for them to find their own safety. Pitts designed a clock tower near a
nurses station in one building so patients could sit near staff but not right
next to them. A place to sit near a dayroom allows patients to see and
understand what is going on in the room before entering. Corners or bay
windows in a dayroom added structural “texture” that allow
patients the choice of being alone or with others.
“They can seek out society or solitude,” said Pitts. “The
architect provides the tools to help them find their own safety.”
Today, even health insurance rules can affect building design, he said.“
Shorter stays for patients increase the importance of having clinical
zones close at hand. You can't take the time and tie up a staff person to walk
the patient across campus to another building for treatment.”
So far, the new psychiatric architecture appears to work. Patients and
staff like it, and that may be reason enough to create more of these
buildings. Nonetheless, people like Frank Pitts and Richard Lippincott want to
go one step farther to see whether design innovations can have a measurable
influence on clinical outcomes. “Evidence-based design” may be the
next stage in psychiatric therapy, they said.
Lippincott has put together a team of six researchers and is preparing
grant applications to investigate the effects of the physical environment on
patients. At present, treatment outcomes are measured by length of stay and
readmissions, but those criteria may have as much to do with changes in
psychopharmacology or patient profiles over the last two decades rather than
the design of the new buildings, said Lippincott. He wants to document the
effect of architecture on the incidence of suicide and assaults, staff
retention, readmission rates, medications, and length of stay.
Whatever the status of research on the intersection of architectural design
and psychiatric care, the new approach seems to have had success in practice.
Take, for example, the old Rochester (N.Y.) Psychiatric Center, a 16-story,
1,000-bed, concrete-block high rise built in 1955, just before the
introduction of chlorpromazine.
“Everybody felt disrespected by the environment,” said to
Laurence B. Guttmacher, M.D., now chief of psychiatry and acting clinical
director at the center.
A new building, designed by architecture+, opened in 1995.
“The minute they moved over here, the patients started acting better;
the staff started acting better,” said Guttmacher. “Working in
this building is fundamentally wonderful. It really impressed me with the
power of architecture.” ▪