A Dinner Conversation: Solving The Behavioral Health Design Gap

By Kellie Reed: VP, OC Sales and Healthcare, Tangram

COVID’s silver lining

Years ago, before the COVID-19 pandemic, a family member of mine had to drive 350 miles from home to access a mental health facility because there wasn’t a local one willing to accept them. At the time, no one in my life wanted to discuss this systemic failure or my family member’s health.

If there was any silver lining to the COVID-19 pandemic, it’s that the stigma surrounding mental health challenges began to loosen its grip. Many struggled with mental illness during the pandemic, and now, the conversation about mental health is actively encouraged. The former “secret” has become something to address head-on.

In my role at Tangram Interiors, my team and I devote ourselves to creating spaces. For the healthcare industry, this means our work is grounded in compassion to help ensure environments that are welcoming, inclusive, and comforting to all who interact with them. For each project, we rely on research and results to create healing spaces, such as waiting spaces and patient, exam, and virtual care rooms that are safe, sustainable, flexible, and purposeful.

Ten years ago, Tangram had only three manufacturers supplying it with furniture, lighting and fixture options for behavioral health environments. Today, we have more than 10 – a direct result of increased demand from healthcare facilities and hospitals. Those facilities are responding to the increased number of individuals struggling with mental health who are willing to get help.

One of our suppliers, Steelcase, recently noted that “numbers have been climbing, year after year, for the past decade – and (have) accelerated since the onset of the pandemic. The need for behavioral health environments is rising, taxing hospitals and treatment facilities, which need more personnel and spaces designed to better support the needs of patients and reduce triggers for stress, fear and anxiety.”

I recently met with four incredible colleagues over dinner – strong leaders in the medical, behavioral health and architecture fields – and the conversation turned to this very topic. Throughout the evening, we realized that each of us had been not only professionally – but personally – affected by the need for better-quality facilities and good design to support mental health and wellness today.

The following article pulls some of the most important concepts from our conversation about the urgent need for thoughtful design in behavioral health spaces. Contributing to the conversation were:

- Anosha Zanjani: Behavioral Health Architectural Designer, HDR

- Ferial Asadies: Health Market Leader, Southern California, HDR

- Alison Birnie: RN/Clinical Director for Trauma, Critical Care, Behavioral Health Programs, Huntington Hospital; and

- Dr. Sonya Lozowski: Internist and Chair of Tangram Interiors.

Pineapple Boden

An issue of equity

Fortunately, because of the behavioral health awakening in this country, the government is allocating more funding to behavioral health programs and spaces than ever before. But foundational problems exist that require more than money.

As the pandemic exacerbated rates of depression and substance abuse, it became clear that equitable access to behavioral health is essential to overall public health and wellbeing. The pandemic especially highlighted access discrepancies in marginalized communities, communities of color, low-income communities, and individuals with pre-existing mental health conditions.

What causes the disparities? Numerous reasons include personal finances, stigma, discrimination, lack of cultural competence and care, transportation and language barriers, and a persistent lack of trust in the healthcare system, due to systemic issues. With so many barriers at play, many mental health issues go untreated, impacting the quality of life for those who suffer, and, ultimately, the broader community.

“The barrier is connecting the patient with the care – that’s where there are inequalities. We simply are not getting the people in the door,” remarked Dr. Lozowski. “Many inner cities and underprivileged areas are able to provide the care, and yet, patients are not coming. Often it’s because they don’t know what care is available to them nor how to access it.”  

She believes another foundational piece of the problem is the lack of providers. “While networks may be in place, there is a shortage of physicians, social workers, psychiatrists and caregivers to meet community needs. Without people to deliver the care, success is difficult,” she remarked.

Today, in an attempt to solve for the shortage of providers, medical communities are encouraging more people with mental health concerns to visit their primary care practitioner. This means family doctors, pediatricians, nurse practitioners, physician assistants, and internists are being educated to recognize and address mental health issues without consulting a psychiatrist. Such a comprehensive approach can certainly reach more patients, but it means that good communication across the entire spectrum of providers is more critical than ever before.

Pineapple Ryno

Engaging the community

Another important means of solving the behavioral health challenge is fostering community participation in building and designing solutions.

“I was recently approached by another architect who was working on an amazing community outreach project to provide maternal mental and behavioral health services,” said Ferial. “She had attended my talks on  Shaping the Future of Behavioral Health: Uniting Voices for Transformative Care and asked if I would connect her to Huntington Hospital, since the hospital offers a unique maternal mental health program.”

“She was right in her approach. It’s important to look at the community connection, the continuum of care, and the services the hospital is providing. At the moment, in most places, there is a large disconnect.”

In this case, it took one caring architect to connect a community organization and a hospital – both of which were offering the same things. But what if she hadn’t?

In another example, it took a nonprofit organization to connect the dots. Alison sits on the board of the National Health Foundation (NHF), a nonprofit organization with a mission to offer recuperative care to the homeless, mental health patients, and elderly homeless mental health patients.

Taking the mental health disparity matter into their own hands, NHF recently went into the community and contracted with Motel 6 to secure 20 beds. Now, they are creating a relationship with local hospitals so released patients can go to the motel instead of the street. In addition, they are providing wrap-around services. In part, the project is possible because the city has awarded NHF money to help renovate.

“It’s a relationship that pulls on the strengths of a community nonprofit, the hospital, and city government,” said Alison.

“Public-private partnerships like this are essential in addressing the continuum of care, because they bring together important resources, expertise and perspectives,” said Anosha. “Government agencies and nonprofits provide funding, regulatory oversight, and policy development expertise, while private entities, such as a healthcare provider, can contribute technology and innovation and fund services that would otherwise be beyond budget.”

Beyond “getting things done,” involving the community in designing buildings and spaces means we can better understand the traumas that prevail in the community and design with sensitivity to those experiences. One of Tangram’s goals is to ensure that healthcare facilities reflect the diverse perspectives of patients and promote ownership and pride. To this end, input from families, patients, mental health professionals, community leaders, and advocacy groups is important. For example, Tangram recently included the Inuit community in the design of a facility in Alaska, incorporating their cultural beliefs in the build. Everyone was involved.

Incredible community synergy is something that I’ve witnessed personally on more than one project, and I sincerely wish there were more collaborations. It’s miraculous to see projects with such support come together.

Steelcase Surround Lounge

Need for a staff oasis

Over the course of the evening, we all agreed that patients need better care and that communities have a large hole to patch when it comes to better facilities and better partnerships. Our conversation then turned to a long-ignored and recently distressing topic – the mental health of those providing the services.

According to a Cleveland Clinic Journal of Medicine article, medical staff burnout had reached 40% in 2020. Nurses everywhere saw their volume of patients double and many have since quit. Sadly, the suicide rate amongst physicians and other healthcare staff has gone up as well. It’s an enormous issue.

“There’s a misconception that the mental health stigma is less pronounced in psychiatric settings,” said Anosha, who recently co-authored an article on the topic for Psychiatric Times called Mental Health Stigma for Providers: A Hidden Challenge Among Us. “That’s actually not true. Research shows that stigma among mental health providers and professionals is just as pronounced and poses a risk to health care and accessibility. And this includes physicians and psychologists – they all struggle with mental health issues, and the rates are even higher than the general population.”

“I can tell you from the in-patient clinical perspective,” said Alison, “one of our nurses lost all of her patients in one day during COVID. When events like that happen, it would be ideal to have a space in which to decompress. At our hospital, we’ve tried to take spaces and create respite rooms, as we are calling them. It’s an enormous need.”

But many hospital campuses consist of a conglomeration of buildings, often built in different decades. At the time of construction, little thought was given to the staff’s mental health needs, aside from a table, chairs and lockers in a small lunch room. Today, it is obvious that a lunch room is not a place of healing and relaxation, and Tangram is both witnessing and partaking in a significant shift towards greater daylight and outdoor access for both patients and staff.  

“We are lucky enough to live in California, where we have access to such spaces 90% of the time, and we should be taking advantage of it,” said Alison.

Tangram is also designing quiet rooms for staff – places of respite where individuals can take their time, be alone, meditate, and collect their thoughts.

“For a long time we’ve tried to promote such initiatives, but healthcare hospital facilities in California are expensive and research on patient needs is what usually helps to bring awareness and secure funding,” said Ferial. “A recent hospital project I directed in San Diego actually invested in creating an outdoor garden solely for staff, which I thought was really nice, and they are finding donors who want to fund the healing space.”

Carolina Mile Marker, Ardha, Nineteen20

Considerations for behavioral health spaces

Building these supportive spaces for patients and staff is no small feat, and there are many considerations, including natural light, comfortable and flexible workstations, quiet areas for work and reflection, and access to outdoor space. Circadian lighting can also make a dramatic difference, and the privacy and confidentiality of both the staff and patients is essential. Noise, acoustics, and healthy nutritional options are other key considerations, as are opportunities for physical activity and movement within the facility. Add to the list ergonomics, water and air quality.

“In addition, we need to design spaces with cross-generations, ethnic backgrounds, and cultures in mind,” said Ferial.

Stance Kiwi

“And take into account different religions and their needs, which may mean incorporating a prayer rug or kneelers, for example, in a respite room,” said Dr. Lozowski. “Spaces need to be very creative and accommodating, and right now, they are mostly stark, cold and foreboding. Much work is required to change patient spaces into family-friendly environments.”

Staff safety is another big priority – especially in mental health facilities.

“It’s a matter of trying to find the balance between the staff’s safety concerns and the patient’s need to not feel overly controlled,” explained Anosha.

In the facility design process, Tangram is careful to always involve the staff, discussing their needs as much as the patient’s needs. Those are critical conversations. The challenge sometimes is that the spaces for behavioral health usually have limited budgets, which can limit creativity, flexible design, and a choice of nice finishes. And that’s something that also needs to change.

“One of the main reasons I switched careers into architecture from mental health is that I feel that the built environment plays such a big role in the solution,” said Anosha. “Design has been an afterthought for a very long time.”

An eye towards the future

At Tangram, it’s our job to provide excellent foresight, creating with a mind towards the future. This means considering flexible spaces that anticipate how demographics will change, how technology – including VR and AI – will advance, as well as upcoming shifts in therapeutic practices and treatment modalities. Spaces must be adaptable and responsive to change, without being cost-prohibitive, and we must involve more parties around the design table.

While we did not solve the behavioral health design challenge over dinner, the conversation Anosha, Ferial, Alison, Dr. Lozowski and I had was critical. I encourage all readers of this article, as well as all leaders whose fields even tangentially touch the behavioral health space, to bring these topics up with friends and colleagues, in staff meetings, and over dinner. In fact, it will take many more disciplines than the ones I’ve just mentioned to fill in the gaps and evolve our behavioral health environments. As leaders at all levels, we are in a privileged spot to affect change and improve the mental health of our communities.

At Tangram, we welcome further dialog as we lock arms together toward a more equitable, community-oriented, holistic, and staff-supportive vision of behavioral health.

Carolina Chrys Lounge