Elsevier

The Lancet Psychiatry

Volume 7, Issue 10, October 2020, Pages 915-920
The Lancet Psychiatry

Personal View
Principles for designing the built environment of mental health services

https://doi.org/10.1016/S2215-0366(20)30038-9Get rights and content

Summary

Although there is an increasing amount of literature on the key principles for the design of mental health services, the contribution of the built environment to outcomes for the service user is a largely neglected area. To help address this gap, we present evidence that highlights the pivotal role of evidence-based architectural design in service users’ experience of mental health services. We propose six important design principles to enhance the care of mental health service users. Drawing on research into the delivery of mental health services and best-practice approaches to their architectural design, we outline a holistic conceptual model for designing mental health services that enhance treatment outcomes and experiences, provide benefits to families and the community, and promote community resilience. In this Personal View, we argue that the design of mental health services needs to extend across disciplinary boundaries to integrate evidence-informed practice across individual, interpersonal, and community levels.

Introduction

There is considerable evidence for a link between wellbeing and good architectural design practice. Evaluations of specific design interventions show that good design of the built environment in a clinical service leads to better clinical outcomes and lowers stress for both service users and staff.1, 2, 3 The importance of the built environment could be even greater for patients who receive mental health care. Although service users “are not always consciously aware of the patterns of behaviour and the subtle interplay between experiences and environmental features”,4 these factors can have a powerful influence on mental wellbeing.4 However, given that the built environment represents a modifiable feature that influences perceptions of quality of care and ultimately the development of healthier communities,5 it is surprising how little the design of mental health service facilities has been considered.

Contemporary research into behavioural health environments is moving away from the creation of visually plain environments (so as not to overstimulate service users) to richer, more complex spaces and increased access to the outdoors.6, 7 Trends in the contemporary design of psychiatric facilities encourage environments that support recovery,8 induce shorter stays, and allow service users to share decision making in their treatment.9

Research advocates the design of built environments that reflect treatment goals and challenge the stigma attached to the use of mental health services.10, 11 Given the interplay between architectural design and quality of care, several researchers emphasise the need for architects and designers to cooperate with the staff and service users who work within and experience mental health-care facilities.6, 12

The field of evidence-based design operates on the principle that a close relationship exists between wellbeing and the built environment within health-care facilities. Evidence-based design endeavours to measure how the psychological response of an individual to a built environment affects physiological, cognitive, emotional, and functional outcomes. Research into evidence-based design has affirmed the links between good design practice and faster recovery from acute episodes of mental illness, higher service user satisfaction, reduced inpatient hospital stays, decreased pain and anxiety, fewer incidences of violence and aggression, and increased staff performance and retention, among other important outcomes.2, 6, 13, 14, 15 There is a growing body of literature on guiding principles for the delivery of mental health services, which includes an emphasis on principles for therapeutic design.16, 17, 18

In 2002, WHO released its international guidelines for the provision of health services that were youth friendly, which set the benchmark for research, practice, and progress in the area.19 At the heart of these guidelines lay three key characteristics of quality service provision; namely, services should be “accessible, acceptable, and appropriate”.20 In other words, services should be offered in the right place, at the right time and price, and with particular relevance to design, they should be in the right style to be acceptable to service users, their family and friends, and the broader community.20 Since the release of these guidelines, much funding has been invested in the development of optimal approaches to youth mental health service delivery, which has culminated in clear guiding principles for best practice.17, 18 To date, however, promising synergies between principles such as these and evidence-based design remain to be explored. With this in mind, we used a small number of clearly defined principles that were emphasised in literature on youth mental health to organise a conceptual review of consonant research into evidence-based design, with a view to derive a preliminary set of guiding principles that might be used to inform the architectural design of mental health facilities in general. We do not suggest that the six principles outlined below are definitive or exhaustive; we simply aim to show how evidence-based design can be readily incorporated into the design of mental health services more broadly, and to inspire new discourse surrounding the development of clear guidelines to expedite progress in this area.

Section snippets

Evidence-informed best practice

Within health-care environments, the emerging field of evidence-based design rests on a commitment to evidence-informed practice, by researching the connection between wellbeing and good design of the built environment. By optimising design processes and outcomes, increasing knowledge in this field can be used to improve staff performance, to augment the healing of service users, and to enhance service user experiences and outcomes.21 Consistent with this, multiple studies suggest that the

Implications

We have developed a conceptual model that incorporates the six principles of architectural design that are outlined in this Personal View to illustrate the deep interconnections between physical environments, the community, service users, and their relationships with others (eg, family and carers) (figure). On an individual level (ie, the service user), the design process should incorporate a range of questions that appeal to the complementary principles of acknowledging lived experience and

Conclusions

The physical environment of mental health services can have considerable implications for the service user and important repercussions related to staff experiences and the ongoing costs of treatment provision. Research suggests that the design of spaces for mental and behavioural health is central to providing best-practice mental health care and can influence therapeutic engagement, aggressive behaviours, emotional states, service outcomes and experiences, and perceptions of the quality of

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