The Future of Psychiatric Care: Designing a 'Best-in-Class' Space
A Response to Justin Murphy's 'Walls as a Service'
I succumbed to the terrible habit of opening my email this morning, on my phone, before getting out of bed. But I’ve got night mode 24/7, so reading Justin Murphy’s message didn’t jolt my sleepy brain too much. If anyone isn’t paying Justin at the subscribing level, I recommend it. He basically gave a brief thought that walls – physical ones – are used/have impact in a certain way, and that reading and writing does this too (creates special walls) for our minds and thus is absolutely essential right now with the crockery of information always aimed at us, we need to protect ourselves.
My morning brain took this and fed it into my lifelong dream of designing the perfect psych ward. It’s an interesting focus, walls. For many reasons, hospitals are designed a lot like jails—lots of walls. Anyone whose had to stay in them for long periods knows this, the feeling of entrapment that comes from a lack of mobility. (In hospitals there’s even a condition ICU patients usually experience, “IC delirium,” which creates similar psychological symptoms a schizophrenic feels, tragically.) Personally, I think I would do fine in jail. Might actually like it. I don’t mean to minimize the experience—loss of freedom is tough (I’ve felt that)—but if you have outside privileges, to me, not a horrible exchange for getting to hang with friends and read as many books as the library has. My second lifelong dream is to help anyone who sources and creates libraries for jails, but I think a lot of folks work on that already. My dream of The Perfect Psych Ward incorporates this detail anyways. (There would be a library, but it would have to be carefully curated because broken minds are sensitive and shouldn’t be reading anything).
So, walls.
My background in property management allowed me to ruminate on the possibilities of how I would run a psych ward. The operation needs to align with design. Now that I work in sustainability that belief is solidified. Good, time-tested buildings (spaces) are flexible with their use, but at their center, are made well for the type of people that use them.
I fell in love with the idea of pastoral care (hospitals in the country) after reading about a brief time in the history of psychiatric hospitals when people understood physical space and nature were crucial components to healing. (Sidenote: duh!) Then I learned about Phillipe Pinel’s work (you can here) which should be inspiring for anyone desiring to fix modern day mental healthcare. If you’re familiar with the system in America, I’m sorry that you are, and you know there are not enough beds and an exponential amount of people who need care—the critical type that requires space. It’s now an accepted belief that your environment, especially the one you ‘work’ in, is crucial because it affects your mood. Architecture is art. Everything around you sets the scene. This is important for minds flailing around or stuck because it helps a lot to be in a safe, peaceful place. Pinel knew this. Others know it. And even now Kennedy is saying if he’s elected, he’s going to build farms as wellness centers. The irony that his uncle (unintentionally) played a huge role in creating the homelessness crisis (mental health crisis) we have today should be lost on no one. JFK was responsible for pushing The Community Mental Health Act of 1963, which closed psych wards and forced sick people into community centers that were not ready and also, not built. Great idea. Poor execution. I hope whoever becomes president adopts this idea, which would serve as a nice end chapter to JFK’s intent.
To summarize my dream push to take psych wards back to their pastoral roots: lots of evidence-based therapies could more easily exist on farm-like setting (or maybe just out in ‘the country’). Things like manual labor--a term that needs rebranding--animal therapy, nature walks, etc. Seeing stars and staring at open spaces would help a lot of people. I’m not saying that’s the care. I’m saying that should be the setting of where care takes place.
Anyways, back to Pinel. I’ll be brief, but I love this man. He existed in the post French Revolution world when liberty, equality, and fraternity were all the rage. (If I may make a brief comment as I found it funny, Macron recently tweeted ‘pride’ in addition to these emblematic French notions, if you do not know there was scrutiny with the Olympic opening games theatre involving men dressed as women, and I just would like to say—as an English major—he’s trying too hard. Less words are better, and he’s showing himself as an idiot for not understanding gay pride is imbedded intrinsically in the existing parts of liberty and equality and fraternity. Ugh politics, sorry. By the way if you watch the opening ceremony with history as a guide it’s a little better, still not the best art performance IMO.)
So, back to 1793. Pinel is appointed as physician-in-chief of the infamous Bicêtre Hospital for men. In France. It’s a converted orphanage. Patients are kept in shackles. Their shackles are bolted to walls. They sleep standing up. Let me say that again: patients are kept in chains attached to walls. Took me a while to get back to the topic of walls, but I think you get why I got distracted. Also, I could pause here to dissect what being bolted to walls would do to a human brain, but I won’t waste your time. You understand already that defines torture. Pinel mandates three things:
1.) Better food quality
2.) New beds (at this point in time they are made out of straw, old ones soaked with urine and feces)
3.) An exercise routine
No joke. Pinel solves the TRILLION dollar health industry with three basic reminders – pathways – that he believes will help the poor patients at Bicêtre. Things we’re all told as children to do: eat well, get sleep, exercise. He goes on to shock the world by removing the shackles of forty-nine (49!) inmates who—surprise, surprise—don’t immediately bolt and become violent like everyone thought (feared) they would.
I think you can start to see how my dream of designing the perfect psych ward would work. And how the operations of it are crucial. And just how important the designing of walls would be—both metaphorical and physical type.
On a last thought. There’s a lot of people involved with trying to solve the homeless mental health crisis. One of my favorite efforts is a company called LifeMoves which takes a holistic approach (giving a home, personal walls) to people who are in between critical care and self-sufficient stages of recovery. The creation of a space like this is unique. It took massive coordination between strong people with vision, the state of California, San Manteo County and private donors. Breakdown of funding:
State of California grant -- $51,552,800 (Homekey program)
San Mateo County -- $25,000,000 (to cover 5-year operating costs, $5M annually)
Private Donors – (I believe the Sobrato family is a big one)
Just attempting a fix of the system like this takes a ton of money. And it got lucky, being based in San Mateo (CA), where funding exists at different levels, and which coincidentally is also the birthplace of NAMI (biggest grassroots-led mental health advocacy group started by moms who felt their kids weren’t getting adequate care). I’m keeping my fingers crossed that their model is so successful it gets adopted and scaled up across the country. There’s a chance, they’re doing a case study, and the results are good. People who stay there are making their way back into society. Everyone please hold your breath that those in decision-making power positions maintain a budget for the operational costs to continue.
Ok but back to my dream. The perfect psych ward. I think it exists. There’s a recent trend in real estate to convert prisons in such a way, which may work and help some. It makes great financial sense as there’s a ton of built-but-empty buildings, and ground-up (plus regular) building costs are always significant. I just hope someone burns the incense to clear the energies there. And what about the walls? The design dynamics of a prison and hospital are similar. Therein lies the crux I think – business bottom lines, room counts, chargeable rates.
I have more ideas and insight—about natural designs, a return to the country—but I’ll stop there for today. If anyone knows someone working on The Perfect Psych Ward, please hit me up.
Oh and here’s some good art.
Pinel releasing patients from shackles at La Salpêtrière in France, 1796. Painted by Tony Robert-Fleury.