So today we have Stephen Parker from Stantec joining us.

Steven is a Mental and Behavioral Health Planner with projects across five continents, including work with Cleveland Clinic, Kaiser Permanente, and DA.

A RIBA rising star.

He champions architect as advocate and advances mental health design through leadership roles with UI, a Designing Mental Health Network UK and the center for Heart Design.

So please help me welcome Steven.

And by the way, we were supposed to have another, speaker Maria, an Askew joining the US.

She could not come here due to medical reasons.

She also recorded, her presentations for us.

But, again, due to some technical difficulties, we might not be able to show it today, but it will be published later on the PBS website.

Okay.

So now, please help me welcome Steven to the podium.

Great.

Thank you very much.

Appreciate the time coming out all the way out here to College Station.

Good to see you, mister man.

I will give you a couple of warnings.

Not all of this material.

Some people can grapple with.

So if you feel that the need to leave the room, take a breath.

That's totally fine.

And, you find that designing mental health environments for humanity at its most vulnerable also means you kind of have to face your own vulnerability at times.

And, I'll try to reference the variety of projects, as it relates to trauma informed design across our mental health portfolio at Stantec and what we're seeing out in the industry.

And hopefully, you can take some lessons learned and apply that to your studies.

And then later into practice.

Along the way, So let's look back at one.

So first thing, who knows anything about Stantec at all?

I've heard of it.

Okay.

So we're a fairly large firm, 32,000 worldwide, 450 offices.

And, we're headquartered in Canada.

But we do a lot of work all over the world.

I'm blessed with a deep and diverse, bench of colleagues and staff that have a variety of talents that we pull together to make these integrated solutions.

For a variety of communities.

From the Arctic.

Tell Australia.

So it's really kind of a blessing to have that resource in that network and ecosystem of colleagues to really leverage for a variety of really, deeply divisional, community problems around mental health and the environment's role in addressing those.

So we do have a couple of ethos.

When it comes to mental behavioral health, dignity driven, the idea that you are designing for humanity at its most vulnerable.

And I think there's something about taking on that responsibility that's very, very serious, because every line that you draw defines the life of another.

Someone who may be in a locked down facility, who've lost many of their freedoms, might be experiencing crisis that you or I will never really comprehend or refuse.

Baseline of reality does not reflect your own.

It's trauma informed.

The concept of a score's adverse travel experiences.

We all have our own individual and collective traumas, some more so than others.

And how do you make a space that isn't trying to coerce, confine, and retraumatize through space?

And it's little genic and it works towards wellness?

We don't define people by their illnesses, so we try to be person centered.

You're not a homeless individual.

They are unhoused individual.

They are experiencing addiction.

They are not an addict.

The idea is that a person is first and foremost a center of design, and it's incredibly empathetic beyond the evidentiary.

You really want to harmonize the empathetic, an exercise an early and often like a muscle, because evidence based design does wonderful things to teach you about what is the effect in an empirical way.

But at a human level, you really need to understand where people are coming from so you can better design where they are.

We'll talk about co-production co-design a little bit in that regard.

And then lastly, it's experiential for those of us that have a different sensory experience.

Like me, I'm a little colorblind.

I was born left handed and right handed.

Someone who might be on the spectrum might have social anxiety, or just simply be hyper or hypersensitive to understanding that we all have different experiences along the way, and built environment can either help or hinder that experience.

So first thing is to understand kind of the spatial history of mental health and to see to plan a plan like this of a facility and asylum, as they were called back in the day.

A Kirkbride plan.

Very prolific.

This is not what we're doing nowadays, where we're looking to graduate people from one wing of the facility to the next and thinking about them in a much more holistic way.

Beyond when it's typology like this, Garner, an influence, the model of care throughout this country and the rest of the world for years.

And I think that every community is addressing this differently through design.

There's not one answer anymore.

And I will say that, this also means that it can be extremely personal.

Beyond the resources and regulations that go into these.

So if it's the FDI guidelines, each one of those codes being consensus driven, it comes from a story, an anecdote, an experience, something someone experienced in a facility, about an adverse incident, about an attempt to self harm or harm to others.

And so I look forward to seeing, what you guys can dive into for the next, FDI code when it comes to 2026 about health warming and health spaces from 2022.

This is also true of my colleagues north of the border, and CSR is at 8000.

They're looking for a new update and how they address mental and behavioral health, well-being and their code and regulations.

It gives you a floor at a ceiling to work with along the way.

There are great resources out there.

Like New York six Office of Mental Health Patient safety standards.

These are products.

They are not design guides.

They will tell you what is safe to what levels and what risks they have.

But now how not necessarily how to collectively design a space around them.

And so I think for me as a good resource, is a book that the VA has on, inpatient mental health designing.

Maybe not just because I helped write it a little biased, but if you want 500 pages on mental health design with templates, it's a good place to start.

And I would be going through a couple of those different diagrams.

There's a QR code if you want to download it.

It's 500 plus pages, so have some light reading.

And I feel like.

So I think I've been on one side of a slide.

And then there's also the other research that and I'm working with Roxana on actually to help move the industry forward around the evidence.

You see a lot of great resources like the center for, Health Design around mental labor, health.

There are different toolkits.

There's a lot of information out there.

And I would look to you to dive deeply into what that evidence is telling you and how it's applicable to your designs and your spaces and your populations, because this can be very different context of context, community, community.

And that's going to get to, the trauma informed design aspects of this.

So this is a wonderful book from a group that, I've had the privilege of collaborating with in the past.

So wonderful authors, Adrian Kohr and, Professor Hart and so forth.

Created the trauma informed design framework, which is just published.

Great resource of best practices and a lot of great review in there, and I encourage you to dive into that.

And you'll learn about what aspects of trauma informed design relating to space.

So for us it's translating what SAMHSa.

So that's the substance abuse and mental Health administration here.

Talk about safety both physical and psychological perceived safety.

One is the trustworthiness and the.

Transparency that spaces can, convey to individuals who are experiencing crisis, who are otherwise in charge or, have lost a lot of their freedoms and their spaces might be dealing with collective trauma along the way that they have, peer support and peer support being individuals that have gone through crisis or a psychiatric inpatient stay or dealt with addiction have gone through and on the road to recovery.

And I've gotten the clinical training to help others who have been in their shoes.

It's really fundamental to a lot of models of care nowadays around, crisis care and then collaboration and mutuality.

What is about the space and the model of care, the on the policies that actually help an individual take charge of their own care.

They are not just receiving care, but they are active participant and agent and author of it.

Along the way, there's empowerment, voice and choice where the social settings that you can then create to empower them to move through the space and move through their care at their own speed and at their own determination.

And there's spatial considerations for that.

And then there's a lot of cultural, historical, gender and other issues that are specific to certain communities that need to be unpacked and kind of really take a step back and understand that you have to be confident enough to talk about this and be uncomfortable with it, and come from a place of empathizing for people that you have no sort of baseline understanding of their cultural background, the gender issues they face, or historical imbalances, inequities, along the way.

So for me, that's being a child with a parent with delusional paranoia.

So a few years ago, my father was admitted for the second time for delusional paranoia and dementia.

Early onset, same week my son was born.

And a few weeks ago, he's going to another time because he got very aggressive and he couldn't be handled.

So he sent to an emergency department who here has been an emergency department and an emergency department who's been admitted or had a friend or family member or they had to go with.

How long were there?

A few hours.

A day?

All day.

If you need a psychiatric consult, you're looking at maybe another day.

30 hours is the average.

If you need any sort of, consultation when it comes to psychiatric care, as the in the United States, according to mental Health America's statistics process.

On my mind.

So we've gone a little different.

Yes.

So this is what my dad showed up with because he could not be handled by his caretakers, because his base reality metro.

And so this is going to be really important for you to understand who you're designing for, because that's someone's loved one.

That could be yourself one day.

That could be a family.

That family member could be a child that will really define these spaces.

If they're going to call them, can find them and chemically restrain them by the design choices you make.

So you're not allowed to take a lot of photos in environments.

So a good friend of mine, who also went through a similar experience with professional burnout, actually sketched her psychiatric stay as her way of therapy.

And so we do a sketching workshop together called Drawn Out.

So I drew the spaces that I saw my dad in when I got to.

And oftentimes you find that being the last bastion of a dual occupant room and health care, that they have a roommate who may have schizophrenia or another, psychiatric or, crisis, condition that actually exacerbates their care and does not help them.

You realize that the choices you make in programing and planning and designing a space directly impact their care and their quality of life, and also the ripple effects across the family members who have to sort of deal with it vicariously.

So that's the importance of live and living experience, is to understand that individuals that have gone through these things have expertise by experience.

If you can draw that out, much like we do with veterans who have gone through combat experience with PTSD and involve them in the project process, call it co-design and co-production.

It's much more, advanced and, you know, UK and other places, talk a little bit about that, but it's really important to understand where these individuals are coming from, their traumas and how they've had, gone from institution to institution in some cases, whether it's not house individual on facing addiction or crisis.

So that's across the entire continuum of care.

There's a variety of facilities to deal with this, whether it's from autism or crisis care for residential rehab to forensic psych and many others.

It's an imperfect system, and it's constantly evolving.

And six months, I'm sure I'll add another typology to this thing along the way.

Is that so?

A big part of that safety when we talk about that in terms of risk.

So for the VA they look in a variety of spaces with an inpatient to see if what is the risk when an individual's alone, when they're with staff members or when they're in a social setting where they can have passive observation.

What are the risk levels associated with that?

And is that around ligature issues?

Is that about contraband and concealment weaponization?

It's going to be different person to person project, project and the scope of the model of care.

And so how do you have a trauma informed approach to mitigate these risks?

It also does not dehumanize their experience.

At the same time.

That is the really, really hard part.

Making a safe environment has to be mastered.

And whether that's the risk levels that are assigned to spaces, some, facilities only have to.

Is a patient in there or not.

And so they look at the spaces all the risk or not the risk.

Others want a very gradation of risk based on observation.

But that also means that it can be either very binary or very nuanced.

How do you approach mitigating risk for also humanizing those spaces?

How do you make them dignified and institutionalized?

So for an inpatient unit versus the residential rehab program, average length of stay, what is the acuity?

What is their model of care?

What is their treatment plan.

Number of things change or even how you call something, a veteran centered care model, versus a resident and not a patient.

What people call themselves when they come into a facility or what that organization calls them, has a huge impact on their care.

Do they have agency in what their nomenclature is at all, as well?

Then to that point, from the spatial relationships of how do you understand entry on stage, off stage, how spaces are related to each other, where someone lays their head the most intimate environment, their own bathroom to their more social ones.

And we'll talk a little bit about voice and choice in that regard of what control they're given safely, what is given in their own control and agency over environment, and can they choose the social interactions they wish by even this planning diagram or not?

So if it's a planning concept around pods, or trying to break down spaces to avoid corridors, or if you're renovating existing environment, how you take these different amenities, these different spaces, how you locate them and program them has a direct impact on whether they're utilized, whether patient or resident, or that end user of services or feels as if they have, what we call a social value, the therapy of having social spaces and people to interact with and not being isolated alone, going through recovery, whatever that may mean to you.

So oftentimes the your Ed or your front door to any mental health or addiction or crisis facility is something like this.

Does this look familiar to you?

Does this look like it's a great environment to have a crisis or go through a psychosis or withdrawal?

To be a child on the spectrum and be over escalated?

Sounds, noises?

You got er, doctors doing all kinds of things to people that are not really lovely to listen or hurt you when you yourself are going through crisis.

What about those public spaces can feel modern and welcoming and non-institutional.

It can be a 200 bed hospital like these that also feel as if they are integrated into your community.

That don't feel as if you're being kind of funneled through the maze.

That is our healthcare system at times.

And that's where you put peer support in practice.

This is a lovely project.

Stella's place, a shout out, to Dena Brown and Roger Robin Wigwam in our Toronto office.

For a youth mental health hub in downtown Toronto that began during the pandemic and, was a really great model and process around co-production and co-design, taking youth that have experienced the social anxieties of being away from home that are experiencing, you know, a lack of hope, anxiety, stress that maybe all of you might face, especially when they're away from home and their support work and a facility like this is staffed with peer support specialists, other young people that have gone through some form of crisis and have the training to help others.

And so the design process for this project try to really bring them into the fold.

And also the team was staff, mostly of younger architects and designers, to help them better empathize with those they're designing for.

And so this just won European healthcare design's like Champion Award for Mental Health, the small but mighty project, because it tells a really great story about how you can do something about the design process.

That and cancer's agency.

For those that are served by it.

And that can be a big difference.

And the entry of a facility who feels a little bit better about going into a door called law enforcement versus first responder, really depends on what community context you come from.

My neighbor was a cop.

If he was taking me into a facility like this, I don't know what my state of mind would be, but if I didn't have a great relationship with law enforcement, it might be very different.

And so even coming down to the wayfinding of when that person's going through an involuntary admit to admit like this, what is the name on that door at that?

Tell them about what's going to be expected of them and how they might react differently just by changing graphics.

Is the reception of those spaces telling you where to go and what to do?

Is it orienting you in such a way that, there is something hopeful about, you know, this use of a very green wall that you can tell what time of day it is, even if you yourself might not be able to tell what century you're in?

There are sort of cues that you can do about making space more welcoming and trauma informed based on a number of things, whether it's domestic is facility, whether it's for indigenous communities, whether there's an addiction and a variety of other, nuances.

So the spatial relationships around entry, a lot about empowerment of safety of staff, but also of, mutuality, patients and their journey.

So just an interlocking that's really like this is a very simple space.

One door does not open until the other is closed.

That's to avoid a moment, which is not just a fun terms getting married when your parents may not always approve, but, to prevent patients from escaping.

But why are they trying to escape in the first place?

We have boundaries like this as built barriers.

Instead of talking about boundaries, model of care.

And so whether it's, a facility like this or it's a hub and spoke where everything sort of funnels through, and is directed through the line of sight of one central care desk you can see easily, who's coming through the front door of the unit and who's going to what bedroom where.

It's a very common approach to understand how and where, folks are moving through the milieu, as we call it, social spaces of an environment and laid out in a very kind of simple way.

But you can do things to make that, a more gracious experience and a more safe one.

You can offset bedrooms so that they don't look directly into the doorway of another.

Because if you've ever had a sibling or roommate and the shenanigans you can have by looking through each other's doorways without your parents noticing, can escalate the unit.

For example.

Even the console and enter spaces.

So a lot of providers like two means of entrance, one where they're sitting and then one where someone is coming in so that they can escape more easily.

But that might not be it.

A trauma informed approach, depending if that is a victim of domestic abuse, and they might feel as if someone might unexpectedly come through another door that they didn't come through because they don't know who's on the other side of it.

So what might be very beneficial for the safety of one staff environment organization, maybe against the sense of safety of the patient or the resident or whoever's being served there, and there's not a right or wrong answer.

There is just a process to understand that there's a better way for those different contexts.

So whether it's this facility that looks to actually do away with all hallways and actually create these open spaces where you have a wedge of different layers of social space, so you get smaller environments as you go towards that.

Resident rooms themselves and all the social spaces are moved up against the, nurse station and that care station.

And that can be an open care station or in close one.

What's the difference between talking to someone behind glass and talking to someone in front of a reception desk?

Is that because the care desk is now just a charting area that you occasionally do observation behind, or is intended to be an opportunity to lower the barriers, between you and a patient as a provider and not have them constantly ask you for things by knocking on the glass.

So how you can do both?

Can you have a hybrid enclosed, and charging area while having open nurse station and a place to engage folks meaningfully.

And you can do observation there?

It's hard to do two things at once, at least not well, my, multitasking skills are not always up to the task since I have a toddler.

So you can imagine when someone is completely beholden to you as a care provider for everything, for a towel, for water and so forth.

Do you want them knocking on the glass every time you're trying to do your charting, or do you want to find an opportunity to safely observe them and break down the barriers for how you build rapport and engagement, what we call therapeutic alliance.

This can mean that your care does, in that care culture, have a big difference in the design, implementation and the amenities you can provide.

So I call care culture is everything.

That's not your model of care.

Your policies are telling you about treatment and curfews and average length of stay and so forth and so on.

But culture is its policy for breakfasts.

It's the habits that you will form when running one of these facilities, the habits that the patients will form, you know, being receivers of services and these facilities.

So if they have to go knock on the glass every time they want water, you can just provide that under their own agency and autonomy safely.

They yeah, you can always turn it off.

But is the space intended not to have, care desk at all but a staff station out the.

No.

You can just touch down at any one of these areas, and there's not supposed to be a barrier of physical space between you and them.

If you can do so safely.

And that's part of your peer support model.

What about those spaces can be more trauma informed while creating different nooks and crannies and social configurations that give you voice and choice?

Can you choose to socially engage with someone that's sitting by themselves and wants to be alone because they have social anxiety?

Do you want to choose to sit with someone that you've bonded with?

Who's going through a crisis like you intimately as two individuals?

Or do you want to be engaged in a larger social setting because you're dealing with, issues around depression and you need to be around activity in life, but the choice of doing that and not having that choice taken away from you is a trauma informed, approach.

And when it comes to design, just by the way that you organize the space and allow for different social settings just around furniture, do you build that end or do you let that be free for any?

So along the way, there's a number of different, sort of methodologies to plan these.

For example, I came over here, deep urban environment, but you can get, you want to say, even within a rectilinear rectangular and, sort of setting like this, but also if you need a subunit, if you need to take individuals that are extremely excavated out of the general population into a space where they're not harming others or themselves or escalating, how do you do so in a safe way?

How do you do in a way that still provides them access to face space?

To address, like historical inequities around their own faith in the practice of it when they're in an institutional setting.

How does it address, in the case of an indigenous community that's dealing with generational trauma and the Arctic?

With their entire family, you take entire kinship units into generational trauma care, mom, dad and uncle, that's going to look like a very different facility than what you might typically see in a psychiatric setting.

Or is it going to be dealing with, all the trauma that comes with domestic abuse victims and the location of the site of the facility?

Do they feel safe and their belongings feel safe?

If they have small children, do they feel safe to play the educated when they have had extreme traumas?

And do you really need to be respectful of why they have come to this place for safety?

And what about that environment really needs to be respectful of what they're going to be going through in recovery.

So these are all considerations that are going to be different based on population in the population.

And that can be, really different depending on your, community setting, whether you're in downtown Toronto and you have a black box theater as part of your therapy program.

If you're a theater kids out there, that really feels like that's a great way to have, be expressive.

That might be the best way to do it.

It's for unaccompanied minors.

It might be that they just need a place to hang out that isn't with their parents.

And that can be as casual as just finding a place for the, billiard room is the educational spaces for, children on the spectrum, or those are actually looking to complete their GED.

When they have gone through, you know, a bad high school experience and have gone through alternative schools and then been admitted to a psychiatric facility, but still feel as if they can complete their education and have some agency over their future by having educational facilities in there.

So this also goes down to more intimate environments like sensory spaces.

His has gone to a sensory room before.

Understand what that concept is.

Okay, so imagine you go into an environment where you are like hypersensitive.

You want all the stimuli in the world.

You want to like run your fingers over things.

You want to change your lights, you want to to, really get as much stimuli as possible, or you want the exact opposite.

You're hypersensitive and you want to actually calm down and lower the lights and lower the noise and, really kind of craft a stimuli avoiding, in VR to help you self-regulate.

And I think we're seeing that we're, that architecture is trying to be more sensory enabled, allowing a variety of spaces to have these sensory elements so that if you are in a classroom, there's a zone out there that you can go and self-regulate and decompress.

You don't have to go to a completely separate space is that you have a niche in a corridor where you can kind of sit and decompress and do so safely.

Breaking outside of a single room and looking at other opportunities where architecture can be that, helper and healing.

Along the way there is different modality or different, planning approaches to these facilities, whether it's a courtyard approach, that, you know, helps with indoor and outdoor exercise instead of having a fence around, a facility like this, what about the building can actually be, and crafting that sort of secure perimeter when you're, again, trying to provide, prevent elopement, but also provide exercise, large muscle movement.

I've got a toddler, two years old.

If I don't get all of the wiggles out of him before he goes to bed, it's just not going to happen.

For some people, that could be.

The exercise they need is to help them through therapy.

That activity and recreation will look very different.

If you happen to be, on a maternal mental health unit like we just completed in Louisiana and understanding that you may or may not be with your child.

And what is the activity recreation space that you need for, a small child that, you're looking to learn to live and deal with?

If that was not unexpected process of your pregnancy, or if you have a child on the spectrum, and how do you give them agency and a space to be playful and be a child and learn at the same time in a safe way?

And then there's multi courtyard approaches, for single level facilities like this that actually are trying to either craft, a more intimate environment, place to play.

So you're not thrust into these big social settings in a big environment.

Some people that, you know, love being out in blue sky country and feel as if they don't have, feel very compressed and others want to really intimate social environment or in this case, an outdoor environment.

And thankfully, both of these units are pushing towards having their own dedicated outdoor space and gardens.

More and more, because I know if anyone had experienced the pandemic without access to green space or a balcony, you kind of realize that you got a little stir crazy.

And I think it's all the more when you're in a lockdown psychiatric facility.

So that means that group therapy can happen in a number of different settings.

How do you create multi, functional, flexible environments that are allowing for these different social settings to occur?

Do you put glazing and frosting on the windows of group therapy rooms.

So that way you can tell occupancy, but someone doesn't feel spied on, that they don't feel like they're on display.

You know, how do you create those different social settings simply by putting up something on the glass?

And accommodating different therapy, like art, is one way we go about it, even to, the social settings of dining areas.

Do you put, glazing everywhere because you want to see visibility, but do you put fruits on them?

Do you, try to create positive distraction through the use of biomimicry and biophilia along the way?

And what about these units can be laid out in such a way that they can actually support, one unit to the next, because staffing is extremely limited in these settings.

So if you're trying to be efficient with your staffing, if you're actually having a backup house versus the front of house, how do you actually, make that more efficient for staffing, but also make the residential, pods or subcluster smaller?

It's a lot easier to do with like eight or 9 or 10 personalities versus 25.

If anyone's been in a dorm situation, you're going a long hallway and everyone's flushing the toilet, you know.

Right at the halftime of the game and you've realized that, you know, there are a lot of pain points for sharing a bathroom or social space where you're having a shared activity.

And how do you sort of break down the social density of that while still being efficient with staffing?

I think is really important, because the staff have to feel safe about moving from one space to another, especially if you're escorting.

If you're escorting someone from one unit to the next, or from a different floor to the next, or to take advantage of the outdoor environment.

If you can lower the number of individuals that you need to move from one space to the next, shorten that distance.

It makes it safer for a lot of staff members, as well as the patients who are trying to move through space.

So that also gets down to the patient room.

How many people, when you moved into a dorm, really felt like you were like channeling your inner Maria Kondo and like, really minimizing your stuff, like you had spent your entire, lives up to that point in a home, hopefully.

And you had a lot of crap, and then you have to move into a single room.

Maybe with another individual that the importance of your possessions.

And and if you have anxiety about who's coming into your room is a big thing, if you happen to be, someone experiencing homelessness and, you know, literally the clothes on your back, all you have, it's really important to you if there's a secure or not that creates anxiety for you if you don't have them.

Where is your toothbrush?

Does anyone mess with it?

Do I still have my shoes?

Have they taken my laces?

The most intimate environment these bedrooms and the bathrooms associated with them.

The storage of them, the amenities.

Do I have a little nightlight?

Do I have to ask someone to turn on the light?

Not to ask someone to open according to my bias?

I don't know about you, but I get a little cranky if I don't get like complete blackout darkness.

Now imagine that you have to go ask a nurse to turn your blinds up and down every single day.

That also creates friction and function because in a bedroom situation like this, you have lots of different social settings.

You can lay and recline and store things.

Almost every horizontal surface of an inpatient psychiatric room is just covered in stuff, depending on the average length of stay, because you just sort of like spread out over time.

Because each one of these bedrooms is looking to address kind of different needs of the community they're in, in a different setting.

Whereas the orientation of the bed, can you see the head of the patient at night?

Does it allow privacy?

When I sit down and sleep at night and I don't see the glare of the light and I have sanctity of sleep, because if someone has to come in and check that I'm alive or sleeping or having, you know, run off someplace every time they open that door, can you hear the click of that lock and the light spills in?

You've kind of lost a little more sleep, and you've lost a little bit more sleep.

And the next day you're probably not going to be so, you know, up an atom for group therapy the next day.

So that isn't just about, the luxury of being asleep at night.

It goes and impacts the recovery immensely.

And so I think porches in play, we have a lot of outdoor environments, especially when they look to address the needs of children, is how do you be playful with these spaces as well?

Thankfully, we're benefiting from a lot more of the introduction of those outdoor environments and lots and lots of terraces.

Whether it's the largest hospital in Canada that has dedicated outdoor space of 2 to 3 times the national average across every unit at 112 beds, you know, that goes into about an investment in space, but also about, recognizing that for a long time with the, stigmatized and institutionalized individuals, often a prisoner is given one hour of daylight and outdoor recreation time, but a psychiatric patient is not.

So every time that you take a little bit of one of those freedoms away, you obviously think about how little you might be trusted, because you go into a locked down unit and you count every single screw and every single lock between you and the outdoors.

And you might feel as if that first night is the worst night of your life.

So what about those spaces?

Can really inform you as to being trusted?

Whether you're a patient or staff member, I find that these units are very emotionally stressed.

If you're on unit for 12 hours at a time, with like, parents saying you got to keep someone alive as yourself alive and then multiply that by how many patients get to see your residents.

So staff respect, addressing burnout is also our approach to make sure that, they are taking those traumas home with them and they aren't experiencing burnout and then relaying that on to their friends and family in the process.

So what about the built environment, the way you programed the spaces, the way you detail them and design them can really define their lives.

So I always like to leave people a little bit of call to action.

You can put a nine, eight, eight sign out and any parking lot or on any building.

Anyone understand what nine, eight, eight stands for?

Yes.

No.

Maybe so.

So now I don't want to call an emergency physical.

For law enforcement, if there's a fire.

But what if you have a crisis?

What if your loved one has a crisis?

You don't want it to be picked up by a police officer if they don't need to be, you don't want them to be taken to emergency department.

If they're not, you know, physically getting it.

What about someone to talk to you?

Nine, eight, eight allows you to call someone and talk to someone.

It also gives you the opportunity to get picked up by a mobile crisis team or, trained individuals, that can help you de-escalate from a crisis.

Or, the third leg of that is that if you do need to go to a facility, if you are escalated to the point, of needing to be, admitted to somewhere, crisis centers, psych eddies and empathic units are increasingly become the norm of how we address in a dignified way, the mental health crisis in this country and around the world.

So even a simple thing like a sign can maybe save a life.

So if you want to learn more about us, feel free to follow up, but happy to answer any questions I can.

And, thank you for your time.

Thank you so much.

Thank you.

Stephen.

Excellent presentation.

Excellent review of, current issues and case studies in mental and behavioral health.

And it is especially very helpful to our students who are taking the senior level healthcare design studio because it is also your topic.

So I'm glad to see you guys here.

So let's see if you guys have any questions for Stephen.

Don't be shy.

I don't like.

Yes.

So wait for him.

Like, I mean, I can talk pretty loud.

I knew I had a camera, I think still.

Yeah.

Okay.

You know, football.

So we can.

Oh, God.

But, Okay, so, I don't know if it's too personal to ask, but, I mean, you did bring it up, your your dad and the experiences that you have with that.

So is that kind of, like, what got you into this field, or were you already in this field when all of that happened?

There was kind of like both or I'm just curious, the question I want to talk about.

That's fine.

That's fine.

It's a question I get often, I would say it's equal parts, familial interest.

Yeah.

My education and my work experience.

So, my namesake is a family member who died of addiction, and, my godfather is a veteran with undiagnosed PTSD.

And so I've always had this, these elements in my life, in my education, when I went to grad school, I focus on, PTSD and trying, like a brain injury designed for, returning wounded warriors.

So my buddies coming back from Iraq and Afghanistan tell me, is terrible stories about not just what they experience overseas, but the care or miss care they may have received over here.

And just the the misunderstanding around, not only the impact on their lives psychologically, but that that of their families.

And then so I just started snowballing work, in my professional life, doing medicine, Bay area health environments, autism clinic, Kaiser helping out at the VA's inpatient mental health.

So I got, my father's issues came up later.

And, that kind of I tell us a lot to students is that it kind of really helped transform my passion for this type of work into more of a sense of purpose and my practice.

So I think that's important because passion will really, burns bright, but it can also burn you out.

And you need something that can really sustain and be purposeful.

And in, your work, especially in this industry.

So I think that many people respond to that, they may have one degree of separation from those experiencing crisis or addiction or anything else.

And those journeys are all unique and they carry those traumas with them.

It's just nice that, I've been able to have the opportunity to advocate through the work I do and who I collaborate with, to help address that in some way when you really can't.

And in my setting and many others have much agency to help those that are being afflicted, in your personal life.

So, I always kind of think about that when you're designing these environments, but you took it was once the Skirball and your.

Sorry.

Yeah.

Thank you for your presentation for one.

That was really insightful.

I have a question about, just an example you brought up, and using the, I guess, patient exam room as an example of, having to kind of decide between patient needs and staff needs.

It seems to be like a really delicate balance between the two.

And so I'm wondering how you maintain that relationship.

And is there a lot of compromise there?

Oh, I was thinking, thank you.

Yeah.

No, that's why I try to stress that there's probably not a directly right answer for any and all situations, your context of your project, the conditions of the space that you're designing, if it's new or renovation.

The model of care has a huge part of that.

And and other constraints budget.

The institutional knowledge of the staff members who are providing care, whether that is, from their years of experience directly informing you, hey, I really need to set up a consult room so I don't feel unsafe because I don't know who's going to come through the door.

Other times, in a much lower acuity setting there.

Like, you know, I, I trust my patients because we've talked about boundaries, not barriers.

And so their care culture, might just better reflect, how they sort of make that therapeutic alliance for that engagement with their patients.

Depending on acuity.

You see, in a lot of crisis facilities, it's considered a no wrong door facility.

They don't turn anyone away.

And so the criteria for exclusion is, is very limited.

So in the intake setting, when you do, like a warm handoff and you've done sort of hey, this cop picked me up or this nurse picked me up, this er, doc, whoever it is that's coming and dropping off someone to a crisis care facility, there is such an unknown question mark.

They just want to assume the highest and worst case scenario, and then you have to sort of work through the issues of setting a door.

Does that door swing in or out?

Does it need to be barricading, preventing?

Does the furniture layout in such a way that is conducive to, mitigating, being thrown for ligature resistance, or other safety aspects?

Other times the room only has one door, it's an existing room, and you're really looking to mitigate what risks you can within those limitations.

So I think it's always a conversation.

It's always a dialog around design and how the model and care culture look to be crafted.

And, there is tension there.

Absolutely.

But that's worth having the conversation about, because it could be that there's bias on the part of the provider.

It could be that the, those what lived in living experience are coming at it from a very different perspective.

And how do you sort of way all of those and harmonize all those is kind of the key challenges of design when it comes to these spaces.

So again, no right or wrong answer, but the process of getting to that answer is more important.

Yeah.

Interesting.

Thank you.

Have one more question.

Sure.

Yeah.

It's kind of related to it's about the, about the, I guess the whole like, 1 or 2 or thing I keep thinking about, like you had said in your presentation, like there's no right answer if you need one door to door, but have you all done, like post occupancy surveys of people that views the building like staff and patients and like found like if one is preferred over the other with like so I have not been involved with any but I can see evaluation for that distinct question.

I believe there are other studies out there.

There's also that that's very specific scenario.

Like in in general, like found like one solution is better than another solution.

Yeah.

So it's a wrong right.

Yeah.

So again the context of who you're serving and who's doing the serving goes into this.

Those two examples came from the VA's design guide because they are doing both scenarios, either an existing condition that they can't change or a for a new condition where they want to help mitigate staff, safety issues.

But also their entire model of care is based on an outpatient clinic model of having back to back rooms where you have two doors anyways, so they've kind of built that into their model of care as a basis of design.

But there's also a situations where if that was, a victim of domestic abuse or somebody who was unhoused for a long period of time, it could be that that facility, that operator, is really sensitive to those needs, and especially when you're building trust with these, marginalized populations that have a lot of distrust of institutions, their way of going about and gauging that trust is to be a two way street.

They know that they want to meet you halfway.

If that is the design of a single entry, consult, consult room will do it.

I'm also seeing a variety of ways with which to mitigate this, by having some people put a door between two rooms, which is not great because you have sound mitigation issues.

Could also have, the door, swing out and not in from a barricading standpoint.

You can put the provider, entering the room last so you can change the operation of the room where the patient is in there first, can acclimate and then the staff member comes in and it is closer to the door.

There are a variety of ways with which you can mitigate these things.

And the design has a variety of tools.

I will say the products have gotten a lot better to deal with these things, because for a long time, correctional hardware or devices kind of really were the basis of design for a lot of things.

And we've seen that with the investment.

And honestly, I think the societal awareness that came out of the pandemic that many of us were dealing with mental health issues and they were underinvested in before we all dealt with a mass society wide experiment, social isolation, that there is the market is trying to address those issues and the less traumatizing way and a more dignified way and a more institutionalized way.

I would hope that there's more studies out there from setting the setting, because as any research will tell you, the basis of your data.

Who's being studied is an acute forensic psychiatric population.

Is it residential rehabilitation?

Is it addiction?

It is on the house population.

Is it different types of trauma and the service model of being outpatient, inpatient, residential, rehab all go into the context of that.

And so I can get a sample size of 500 psych patients that tell you x, y, z things and then I can get a similar size for addiction treatment.

It's going to tell me something different.

Yeah.

And that's going to change culture.

Culture.

I wish I had more studies.

I can always do better and hopefully you will continue to ask those questions.

So great question.

So just adding to what I mentioned, the question that you asked Larsen, I'm going to ask if you can think of that.

I don't I don't think so.

The question that you ask is basically one of the ongoing challenges in, not only mental and behavioral health in, different health care settings and is sometimes not, even only the issue of disagreement between staff and patients perspective or perception of care quality, environment quality.

Sometimes when you're designing an environment, let's say let's imagine an operating room where you have different types of staff.

You have two nurses, you have two surgeons, you have the anesthesiologist.

Sometimes they don't agree with one another when it comes to what would work best for that.

Just one room, not let's just not, getting to the scale of unit, just one room design.

So sometimes they do disagree.

So as Steven mentioned, more and more studies post occupancy evaluations, which not they're not always feasible because it depends on whether the client is willing to basically, provide a budget or allow you to get back to the facility and do those studies.

But the more we do, these studies, the more data that we collect, the better off we are in finding the right solution that would somehow respond to, the challenges that each team, each, care, giver is facing.

But reaching that perfect model of care, that design solution that would work for everybody.

So far it is challenging.

We're trying to achieve that, but we just need more research and more data, and it's a worthy challenge.

Because even the research process can be traumatizing to the patients or the residents or the end user.

Right.

And you don't want to exacerbate their trauma and the process of doing research.

I would also say that, it's a worthy challenge, right?

So, many communities are facing these questions.

We as designers have this ability to kind of craft more aspirational environments that don't have to look like how they happen because we're doing better.

Where have a more nuanced, dignified approach to care and models that are coming out that were reacting to you.

And so design is looking to kind of really, capitalize on that kind of movement, into the future.

I have one exercise I can do with the students real quick if we got the time, but if not, how long would it take, do you think?

60s.

60s.

Yeah, we do.

I get a volunteer.

Sure.

Yeah, that's what I was like.

Oh, go ahead.

All right.

Just stand there right at that corner.

A I should meet them, now.

So, it's one aspect of understanding, if you feel safe in the environment or not is if, you can do a proximity exercise.

So, like, what is the spatial distance between me and another person?

And at what point as I walk towards you from about 12 plus feet away, do you feel uncomfortable when I'm in your public space?

When I'm in near social space, when I start getting into your personal space, you can tell me to sit down, right?

Yeah.

So all the way up to your intimate space.

So that's going to change.

Thank you very much.

If she knows me, if I'm a known entity, I am I her same gender, my taller or shorter?

If she does know me, has she had a good experience with that?

Am I a care provider or am I the authority figure if she's had a positive experience or negative experience, and that will go a long way into understanding not just the ergonomics of how we design space for human beings and a much more typical normative range of movements and sensory experience.

But then you start layering in that understanding that we're all a little bit different.

We all have, different sensory needs.

We all have different traumas.

And so forth.

You start designing these spaces a little bit differently, a little bit more empathetically, and you can exercise that.

There are ways to do so and sort of take you outside of your own mindset and into those that you're looking to serve through your designs.

Wonderful.

Well, thank you so much, Steven, for joining us.