Okay, So let's start today's lecture.

Well, how do you how.

So today we have Frank is widely recognized as one of the leading designers of psychiatric facilities, both men of and design practice culture in North America.

He has consulted on more than 200 projects involving over 25,000 mental health beds in clinical settings located in the United States and Canada.

And in recognition of his contributions to health care design, and in particular for his work regarding mental and behavioral health care facilities, Frank was designed with a 2018 Changemaker award.

So please help me welcome Frank to the podium.

Thank you.

Well, howdy.

At least I got that part right.

I'm grateful to be here again.

It's been a while and grateful to have the opportunity to talk to you about something that's dear to my heart.

The state of the psychiatric hospital throughout the world and in America in particular is a sad and troubled one.

And while, as you'll see in a moment, there's been an enormous amount of change, I've seen a lot of change over my lifetime.

Though there are still desperately bad psychiatric hospitals operating throughout the United States and and including here in Texas, where all y'all are doing a great job and investing in new infrastructure.

We're actually working on about I think it's ten projects in the great state of Texas.

One of the seminal movies about mental health facilities was One Flew Over the Cuckoo's Nest, and that movie from 1975 depicted what was meant to be received as an old psychiatric hospital with an old nurse, something from the deep dark past in 75.

It was in the deep, dark past.

We did a new building with joke that opened in 2011 until that building opened the very wards that One Flew Over the Cuckoo's Nest was filmed in.

We're Still Operational.

That's how bad badly provisioned psychiatry has been in the United States, but it's become something that's become something very different.

The passage of time, and I'm reflecting on on 50 year exploration, 40 of it is mine.

But but I think the exploration began 50 to 70 years ago in clinical change in the approach to mental health, in academia and in research, including environmental psychology and in design practice and in the design firms approach to mental health design.

And it's been that that has been capped by an enormous amount of change over the last 20 years, both in terms of the numbers of projects.

We used to see one or two hospitals at a time, max, for 40 years of my practice, one or two hospitals at a time max.

We're now working on about $2 billion worth of work actually count everything from 2018 until now, about $3 billion worth of work.

Hundreds of there's tons of projects that are happening.

The diversity of settings that we're designing for, for the care of mental health is much broader than it ever was, from community based settings to crisis services to residential services to hospitals of various types.

The breadth of solutions that people are approaching is much more diverse.

You'll see for case studies here, they're very different from each other, even though they have very similar theoretical dangers.

And you'll also I've also experienced a much broader or exploration esthetically of what the experience can and should be like.

And today's talk is going to take three parts.

The first is a very brief look at some case studies for case studies from around the United States.

Then a conversation about how that 50 year period of evolution started.

What are the roots of it?

And then a little bit of conversation of what are the branches and trees that grew out of that roots.

And then finally, a conversation about what's really essential, not merely important, but really essential.

We have a tendency to focus on the merely important at the expense of the absolutely essential.

We're going to start with this project in Worcester, Massachusetts.

Worcester Recovery Center and Hospital.

It's a state facility.

You won't believe that.

It's a state facility.

It's a state facility.

And the state appropriated over a quarter million dollars in 2008 to build a new state hospital.

It was a big deal.

They were willing to invest that much money because it was going to replace two hospitals.

And it's a hospital that has 320 beds, 60 children's beds over on this side, 280 adult beds over on this side.

Very interesting idea about how you co-locate kids and adults together.

It's a house neighborhood in downtown hospital in that the inpatient units are seen as a much richly textured, much more richly textured, residential kind of a space than ordinarily psychiatric hospitals are seen as.

It's something we've been experimenting with for a long time, actually since about the mid eighties.

There's a neighborhood of treatment spaces, a neighborhood treatment mall that grows out of research dating to the eighties around the efficacy of treatment and care in treatment models.

The problem with the early treatment models there was that they were too far away from the patient inpatient units and it took too much work to get patients to those treatment models.

And so what we began to do an experiment in was finding a way to co-locate them so that they were in the the the span of control of the direct care staff.

But you didn't have to make an investment in patient escort and what we found was that the participation rates got closer to 100% when they were in proximity.

And then finally a zone we call it downtown, which is the kind of stuff that's singular to a to a to the hospital, the library, the café, the specialty training rooms, the gymnasium, the exercise room, the barber, the beautician, that kind of stuff.

And we literally thought to see those spaces as analogs to houses and neighborhoods in downtowns, out in the world.

And in the face of the stigma of mental illness.

To imagine this is the downtown of that hospital, to imagine it actually as this as a space that was like a commons building at a college and university.

There's also a lovely story about a street in Venice that I saw in 1980 that I was in love with, that that 30 years later I finally allowed it to inform an approach to a to an interior space that we were trying to see as an exterior civic space.

This is the porch at the head of that downtown space embracing a village green.

And so it's also it's also a hospital that surround the series of courtyards that are secure and done in a way where the amount of fencing and the signs of security are minimized.

You don't really see the signs of security in this hospital, but it's a fully secure hospital.

You don't see the signs of safety in this hospital, but it's one of the first of this generations of patient safe hospitals in terms of patient self self-harm.

But it doesn't look that way and doesn't have to work that way.

The inpatient units, if you've lived in a dormitory, I thought about this this morning and so I'll hear it again this afternoon.

If you lived in a dormitory and then later on in your life lived in an apartment, a college or a suite, you understand the difference between living in a double loaded corridor and living with a smaller group of people in an apartment.

And that's the driving idea behind this idea of the psychiatric hospital.

It's to develop an inpatient unit that consists of a small number of apartments that each have 6 to 8, sometimes ten people in them, and to organize them in such a way that it's easy to supervise them.

It's easy to run them from a from a clinical and a nursing perspective.

But where the patient experience is deeply informed by the research around social density and spatial density, the small groups research in sociology is really interesting around why people have a tendency to struggle when they are spending short periods of time with large groups of strangers, something that's influencing criminology in other countries.

But it hasn't had a significant impact on an American criminology, let alone mental health facilities.

The dining room at that hospital, dining room on each of the inpatient units.

This is one of the living rooms of one of those suites.

The bedrooms are on the left hand side of the corridor.

It's an open corridor.

On the right hand side, there's a couple there's a porch this this living room and and a console to a quiet room that's on that's on that side.

The Vermont Psychiatric Hospital is a completely different animal.

Yes, sir.

Her first slide for big trouble.

yes, it was.

That was the original Worcester State Hospital, the Kirkbride Building.

It had there had been a disastrous fire.

The building had been abandoned as unsuitable for purpose.

There was a very disastrous fire.

And and we had a series of elements that were left on the ridge of the hill that we needed to accommodate what happened with the head house.

If you see the final project is only the company lay only the tower remains because it was in progressive demolition of itself.

Self demolishing while we were in the state wouldn't stabilize it.

While we were in the process of building the new building.

Vermont State Hospital is 25 beds, much smaller hospital, same patient population, fundamentally.

And the idea here was to see the ensemble as in as a two part problem.

And we were trying to reduce the scale of a 25 bed building to make it feel like it was a smaller and more residential building.

And part of that strategy was to do it as two buildings, the brick building and the clad, the wood clad building.

It's not really wood, but it looks like it and and and it surrounds two courtyards, the brick building, which is where all of the support services and administrative services are, is around a big courtyard that has a that has a pergola in it and and a walking maze.

And then the residential areas surround this courtyard, which is a more recreational courtyard.

You see the picture in just a moment.

And the inpatient units here are 16 beds and nine beds long.

Interesting and involve story there.

We'll go into it.

Right now, if you have an interesting question about the impacts of the IMD exclusion on hospital design, glad to later on talk about that where Worcester did a thing with arms to create the apartments.

What we did here was to put a staff support zone between the two apartments.

So same effect.

You have an experience of living in a world of 16 patients or 26 at Worcester, but the staff is operationalizing it a much more efficient ratio of 16 or 26.

This is the residential courtyard at Worcester.

This is where the wood meets the brick and this.

And you can see through this gateway, through this corridor, gateway into the other courtyard.

There's a view through that.

And here's that courtyard.

It's surrounded by an ambulatory.

So there's a walking path around it and in for all weather.

And then and then the the the operating guts of the building.

This is an art therapy room in that building.

Again, it's a beautiful room.

This is not what psychiatric hospitals look like anywhere.

And up until up until Worcester was built, there were probably only ten or 15 hospitals in America that that that had gotten to this kind of a place there.

There are tons of them now being designed with an esthetic that that has this gentleness or this normalcy, a planting room or a greenhouse room at that facility, a bench at the end of a hallway that is serving all kinds of purposes, even beyond those that we ever imagined it could could serve.

It's something that's a place in between.

It's a very Hermann Hertzberg in space.

It's it's a when we talk about Team ten and in a second, it's the kind of a thing that's designed to be appropriated for an unforeseen purpose by a patient or staff for their use.

And it gets used a bedroom at at, at at the Vermont State Hospital.

It's a very simple bedroom that has three very distinct places to be, and it has a feel and a quality that's unlike most psychiatric hospital bed rooms or most hospital bedrooms.

It is.

Someone talked to me about Stefon London over the last 24 hours.

This bedroom is an homage on my part to a bedroom that Stefon did in in Joe very.

And then the Austin State Hospital, which will open next month.

We did with Paige, I should say that we did the Worcester Hospital with Ellen Zweig, and we did Vermont.

We were the prime and we had a local firm, Blackwood River Design, working with us.

We generally do about 35% of the architectural work on these projects, pretty much driving the project from the inside out through the design development phase and taking a more limited role in construction documents, but still paying a technical role during construction documents and construction Administration, because there's a lot of really important technical things that are sitting in the background behind that.

I'm not going to talk about it all today that are sitting in the background behind a successful mental health facility.

It's the main entrance to that hospital.

It's organized around a progression from public to private with a series of T-shaped inpatient units surrounding a whole bunch of courtyards.

The neighborhood in this hospital has an element that can be individualized or shared between two units or shared between all four units.

And then there's a transitional zone you'll see illustrated here where folks on other floors can get to the downtown space on the first floor.

And what's happening up front is mostly administrative and clinical services.

And by that I mean medical clinics, services.

And then way over to this side is support services.

So this is one of the courtyards at that hospital.

Again, so far, all three hospitals are a little bit different from each other.

They look different, but they're informed by a very similar kind of driving DNA.

This is the big public space in the middle of that downtown.

It's the space the downtown organizes itself around in Worcester.

It organized itself around a street in Vermont.

It organized itself around a lane.

The lane was sitting in that was that corridor that sat between the two courtyards.

This is the vertical space with stairs and elevators that get people from the ground floor up to the downtown.

And from the second floor down to the downtown, this building steps down a hill.

The hill is not apparent, but it's there.

Thank God, a typical bedroom in this hospital.

And then finally, a project that is in design development, just ready to go into construction documents that we're doing with H. Okay.

I've been working on this project since 2018.

These projects take a long time.

Actually.

I think the first time I went out there was 2016 and it's very, very different.

What's driving it is the administrative building is pulled off to the side and connected via a tunnel.

But what's happening here is that this long bend is inpatient units and they're y-shaped inpatient units that butt up against each other as a string.

And they're all in the air.

The whole ground floor is clinical, administrative and support services.

And there's a series of bridges that go from the middle of the inpatient unit to a neighborhood that sits across this green space that wanders through the site like a river.

And the downtown is in the middle of the building underneath those two and in the middle of the building, sort of sort of intersecting that green space.

Yeah, you take a walk or any kind of.

Yeah.

So these buildings are designed so that the perimeter of the buildings is is is providing the security, trying to limit the amount of fencing and walls insofar as possible.

They're also designed to allow as much patient freedom as staff will permit and to encourage staff to permit as much freedom as possible by limiting the amount of adverse stuff that could go wrong if I gave if I gave you, George, just a little bit too much freedom, I take it you would take it, but you wouldn't get the chances.

Are you getting hurt or getting out would be minimized.

So I might be I might be less guarded about letting you wander around so you're more likely to be able to go to the neighborhood without escort.

If you've been if I really trust you, you might get a card that allows you to get to the downtown without escort.

But.

But part of it is to make the travel distances, trying to get the downtown and the neighborhoods to be equidistant from as many inpatient units as possible so that everyone has equal access and that that access is as short as possible.

That kind of a driving idea also makes it much easier to run support services because the supply chains are are shorter.

And we've started more and more to do back a house front, a house things than we ever did again.

Growing out of our collaboration with Greg, it's two things.

It's doing more.

I I'm going to spend time that I wasn't intending to spend it growing out of doing more academic medical centers where the idea for the house back and I was just in their DNA, but also working with more frequently.

We've worked with over 100 firms, including some of the best health care firms in the country, and they have a hard time walking away from front of house, back and house.

It's not as important in psychiatry, but I'm starting to realize the benefits of it.

I'm starting to learn.

So this drawing of an inpatient floor gives you the basic idea of this is an inpatient unit with three sub clusters nursing core, a bridge across to the the shared neighborhood and kind of the character of that building.

So I want to talk about what I think is sitting behind all of this, at least in my own experience.

These are the things that drove our journey.

But I think it's been driving everyone's journey and we've forgotten about it or we fail to acknowledge it.

And I think the team ten in the mid 1950s, that group of architects that emerged from the 10th Congress of Congress international architecture model and that group imagined a way of designing that was fundamentally different than the folks that were at the conference, the other folks that were at the conference.

And it's people like Hermann Hertzberg or Aldo Van Eyck, Christopher Alexander.

And to a slightly less degree, he wasn't really a part, but his work exhibits it.

Lou Kahn imagined a way of designing for human experience with the understanding that space and form must be accessible, purposeful, resonant and generative.

Hertzberg is in particular an exemplar of doing an ambiguous architecture that incites human action and human interaction.

That's important to whatever, to whatever, to whatever proceeds.

Equally important and also unheralded is something that happened in Saskatchewan.

This fellow, Dr. Humphrey Osman, was headed up the Saskatchewan Hospital.

He got involved.

He's the guy that invented the term psychedelics.

He actually was doing a lot of research that today is being mimicked again in things like ketamine and psychedelics being used for treating people with PTSD.

He was using psychedelics in a scientific way to deal with alcoholism.

What happened with Timothy Leary and the other folks that were using it, who flipped the gear, interfered with his work and his ability to do that work.

But while he was doing that work, he was doing something else that was very interesting.

He was working with some architects and some really interesting psychologists that were on his staff in a way that he was developing a new way of thinking about the psychiatric hospital, but also about thinking about a new discipline.

And that new discipline is environmental psychology.

This character, Robert Sumner, Robert Sumner, worked with Osborne in Saskatchewan and was on faculty with him in Alberta.

It took it took Franz James and I forever to figure this all out.

Another really interesting long story about about research.

Osborne wrote a number of papers with Summers.

Summers became incredibly influential in the field, as was Edward Hall, as was Wilson and perchance Ski, who formed the first program at the first full program at sea.

And at that I forgot New York City, the big public university in New York City.

City, CUNY at CUNY.

Sumner Sumner gave the first course in environmental psychology at Cornell University.

And now I'm going memory and forgive me, I'm not looking at my notes.

I think it was 63, 65, 68, someplace in there relative if we recent history, this whole environmental psychology thing, relatively recent history, brand new field and then 1984, not that long later, you've got people like Roger Oelrich, formerly from here, writing that influential paper in Science magazine about Cholecystectomy and Views.

And you have people like the founders of Plain Tree, folks like Rob Knorr, Leland Kaiser, my friend and colleague Kirk Hamilton reconceived Considering what the hospital experience might be or what the health care environment experience might be in terms of its objectives, in terms of supporting the healing process, as opposed to just supporting the curing process that you needed to design in a way that took and this is short shrift, but you need to do design in a way that that that had a positive benefit and effect on both really important for health care architecture that point that perspective.

But that perspective goes back to this Humphrey Osborne character who wrote a beautiful paper 70 years ago that I hadn't read for 50 years until about a year and a half ago, and went, my God, What I couldn't really appreciate about this guy when I was 18 years old or 19 or 20 that I now appreciate is just enormous in terms of what his influence was and what he was saying to architects and to other psychiatrists and other psychiatrists are actually getting it and understanding that there's a relationship between care models and milieu.

They talk about milieu, and I'm jumping a slide and I shouldn't about I got a contract to write a chapter in this academic book that no one will ever read that's edited by the chair of Psychiatry, Siskowski and his assistant Sidney Harris, at the Dell Medical Center.

I'm sorry to bring up you two here in your August presence.

And but Steve asked me to write a chapter.

I was actually honored.

Everybody else in here is a clinician.

I write a chapter about the architecture of the modern psychiatric hospital, hoping that I would share the relationships between clinical care and environment.

And.

And I was scared to death.

And I thought, Wow, I've got to organize my thoughts.

I've been doing this for I've been doing this for 40, 45 years at that point.

And and how was I going to sum up what I knew?

How was I going to tell this audience of academics and clinicians what it was is driving me?

And I began to think of a rubric and it grew out of something I did with Mardell a few years back around.

What are the what are the features that we're building in and what are the goals that are that we have that are related to those features?

And I started this exercise and a lot of research around mapping things and diagraming them and putting this matrix together of interrelationship.

And I realized before I got very deep into the whole thing that I was lost in a thicket, that I actually was missing the whole freaking point and the rest of this is about the whole freaking point.

And it'll sum up in something that's really simple and very complex.

And the first is to just admit that the predecessors and precedents in psychiatry are mostly meaningless to what we're doing today.

They really, if you understand the ideology of of treatment, you you get a sense of hopelessness because nothing was ever cured.

It was it was a bunch of promises.

But but in the end of all of this, this interesting thing starts to happen with psychosocial rehabilitation and recovery.

And recovery is something that is built on personal hope and built on a clinical relationship where someone helps George understand what his capacities are and to understand what is disease is and to understand and to understand how to achieve his goals in life.

Despite the fact that he has this disease.

By capitalizing on your goals and your hopes to achieve those goals.

It's a really, really simple, simple, complicated thing.

It's about life.

It's really about life.

But so and so I'm here, I'm supposed to say primary driver for what we do as designers to support the care of the care model in the mission, to support the patient and the caregiver.

And what George needs is recognized by thoughtful people as palliative care.

Palliative care is care provided in medicine.

This is a place where medicine has gone awry.

Medicine has come to believe that palliative care is end of life care.

And they will.

I'll talk to a roomful of doctors and it'll take me take me far too much time to get them to go, it's not just end of life care.

This thing you're talking about is all of these things.

It's diabetes, it's COPD, it's heart disease, it's cancer, it's Lewy Body, it's Alzheimer's, it's all kinds of things that medicine cannot absolutely cure.

But they can treat it and they can reduce the symptomology, but they're only going to be successful and you're only going to be successful if they connect you to yourself and to the disease and convince you to live a life that acknowledges the disease and empowers you to have success.

All of these diseases are just like mental illness.

I love seeing mental illness on this because it's no different from all of those other things.

It has a very significant difference in terms of stigma.

Almost every disease comes with some form of stigma, but mental illness comes with a very profound sense of stigma that has an implication for caregivers.

It has an implication for patients and families in terms of whether you're going to go and get receive care.

And a lot of mental illness gets postponed, mental illness care gets postponed.

But it also has an implication in my own experience for for designers.

And I'm going to jump over that and what it's really doing this this form of care is focusing on the person, not on the illness.

And a wise clinician that I met a long, long time ago, Dr. Chapman, Marvin Chapman said mental illness, a condition where human need is accentuated, don't see it as aberrant.

I see it as fundamentally and foundationally human and the interaction as a human interaction.

And so if our role then is to provide support as a designer for the caregiver, we have to understand and support both human and the role based needs of patients and care providers.

We find fundamentally program and plan building around the role, but not around the human being that has the role.

And people who show up for programing meetings with us and design review meetings are showing up too frequently.

They can't help themselves as the role.

I am a doctor, I am a nurse, I am a janitor, I am a patient, and not approaching the question from the perspective of their basic humanity and the interaction between human beings, which is the fundamental architectural problem the Team ten was writing about and advocating for.

And so for me, a way of thinking about this in terms of mental health is to reflect upon an experience I had designing a monastery and to understand that in a monastery you're designing for people who want to live a contemplative life within a brotherhood, who need to do work, and you need to design a new way, and the abbot needs to design the monastery experience in a way that supports the contemplated life, but also supports brotherhood and also supports the work.

And I'm not going to read the whole slide.

It'll be it'll be distributed.

But but it's all about how you design to support all of those things.

But an interesting thing happens at a Benedictine monastery and an Benedictine monastery.

And I was a brother of Benedictine monastery.

I was a guest initially, and Benedict was a wise guy, a wise man, Benedict said.

The danger of a contemplative life, the danger of the monastery, the danger of a brotherhood apart, is that we will to see Christ's lesson about the brotherhood of all people and about the Christ that lives in everyone.

Therefore, you will.

It's in his rules.

You will provide hospitality to all who come and you will see Christ in them.

And so the question now becomes, how do you design for a guest that comes to a monastery?

Well, first and foremost, you need to help them be comfortable in being a guest.

We've all been guests with people where we're not comfortable being a guest in the first place.

Some of it's our father in law, Some of it, you know, everybody's got a story about.

I wasn't accepted as a gift.

I'm not comfortable.

I can't get beyond that.

You need to be comfortable as a guest first.

Then they need to help people who are visiting center, settle down, get ready to do the work, and then they need to engage them, learn, and he'll help them do the work.

And the monks themselves need to be good hosts that facilitate centering and actively support that healing.

That's sort of the design brief at the end of the day for me in designing that monastery with respect to this, one question gets to it.

Well, the funny thing is it's actually what the care provider and patient relationship is In a psychiatric hospital.

You have to get settled in, become comfortable in being a patient, you have to center and then you have to do the work and staff needs to help a patient do all of those things.

Just like at the monastery.

But we're not in a monastery.

There's a lot of trauma that's coming in the door and you want to make sure that you're not doing anything that's adding additional trauma to it.

This is important and you need to focus on hope and recovery and capitalize on the resilience that patients who have traumas frequently have a very interesting field of study and understand that the physical milieu is as important as the social milieu in treatment.

It's easier for us as architects to see that The reason that Steve invited me to write a chapter was he understand that I understood that environment was a facilitator to his clinical milieu.

His clinical social media is part and parcel of the whole thing.

And ultimately we're supporting the care model in the mission by supporting the patients and the care providers.

We're doing the fundamental stuff.

We're housing them dry roof, warm food, You're you're providing housing, you're providing comfort and letting them settle down.

And then you're enabling the healing of mind, body and spirit.

But I think that there's two fundamental things that for me are the touchstone about what's essential and what's essential in palliative care for anyone, but in particular for mental health, is to create an environment where you are supporting a patient's ability to develop insight, insight into both themselves, their capacity, their illness, their hopes, so that they can have agency and have a successful life.

And at the same time, you're trying to create an environment that facilitates a clinician having discernment, discernment about this particular patient discernment about.

Thank you, Doctor.

The thing about what their what really is needed next to frequently mental health has been provided in a large hospital as something that's commodified because it's almost impossible in those environments to see the individual patients in their human unique human form in order to be able to really understand what's important for them next, how to best help that particular patient.

That's what recovery is all about, providing that level of care at a personal level.

And as designers, our job is to help people do that.

That's what ultimately, ultimately essential.

All of the other stuff, all of the other stuff is really, really important, but not at the expense, not at the expense of creating an environment where a clinician can gain discernment and where a patient can gain insight.

And I think this applies to all medical care, but it particularly applies to mental health care.

So any questions or discussion and one question maybe should be what are the kinds of things that you can do?

But to us, you're welcome.

You mentioned earlier that maybe a question should be what are the impacts of I think it was I am the exclusion.

yeah.

So if you were in class this morning and I think you were, we talked about how there's all kinds of little details to sweat that influence things and that it's important if you're going to have mastery, to not just have good intentions, but to also really, really understand the subtext and understand what your client and what your end users drivers are.

The AMD exclusion is something that happened.

We'll do this really quickly.

When Social Security came and came to be in the thirties, someone said, I'm going to have a system that's going to provide Social Security to every American that that that works and, and, and and to some degree to every American.

And then someone went, But what about all of these people that are wards of the state?

We don't want to we don't actually want to assume the federal government doesn't want to assume the state's responsibility to the folks that are sitting in mental hospitals and and facilities for the folks that are developmentally disabled.

That and so they wrote into the law something called the Institute for Mental Diseases Exclusion, and it excludes that class of people from receiving Social Security.

It still exists.

It still excludes people that are in residential settings from receiving Social Security except in limited circumstances.

And then when Medicaid and I'm here, I'm going to go awry.

It was either Medicare or Medicaid when it came to be.

And I think it's Medicaid.

I know it is.

They also extended the AMT exclusion to those same patients, except they did a very interesting thing they wanted to fix.

They wanted to simultaneously also encourage the development of community based treatment facilities and hoped that the large state hospitals would become smaller.

What happened was disastrous, but that's another story.

And so they said we will, however, have an AMD exclusion I'm sorry, an exception to the AMD exclusion, and that'll be a facility that's serving 16 people or less.

That's why so many facilities, including a piece of Vermont, are designed around this magic number that's 16.

There's no magic to the number except that it's written in a piece of law, but a lot of the behaviors that we see.

So there's a second thing about the exclusion, and that's that it's it's the exclusion is that any hospital where more than 50% of the patients are primary diagnosis is mental illness or who are being cared for because of a developmental disability, the community has completely gone to 16 bed facilities everywhere, everywhere.

There's hardly any congregate training facilities except in the state of Texas.

A little bit, just a handful.

But most of the country is going away from it.

So that that has a powerful impact on how, how, how hospitals will partner to do to do things.

It's always a mental health facility, will partner with a much bigger hospital in order to keep the denominator in the numerator in the correct proportion, or they'll drive 16 bed things.

There are states like Minnesota that are just right in tons of 16 bed freestanding hospitals.

It's all driven by this same the exclusion it's it's it's the wrong it's a it's a tail wagging a dog fundamentally.

So thank you, sir.

Thank you for asking that question.

Thank you for your question.

Thank you as well for coming.

I really enjoyed the precedent or the case study you showed us for Worchester, Massachusetts in the psychiatric hospital.

And I guess I was what really caught my eye was the way that you kind of kept describing the different case studies with the downtown.

And so I was kind of curious, how did that come to be where it seems that you have these different levels of public to private and how you design the building where you it kind of felt like it was already in a city, if that makes sense, within the building and how you had like it separated, but it was still inside.

So I want to do that.

I want to do that.

The a simple answer to this, because it's a it's a complicated question.

the thought first occurred, no, I'm not even going to do that.

Two things were going on.

The first was I was recognizing that there were these, in hospitals all around America and this is a long term stay hospital, but, development pattern, it's not appropriate for a short stay hospital.

So just, just know that, we were seeing, beautiful, beautiful activity buildings and recreation buildings on these big hospital campuses that were empty.

There were no patients in them, just a handful.

And, and as we talked to people about, it began to realize that it was because it was too hard to get a patient to that place.

It cost too much money.

You had to escort them and the number of patients that you would trust to get there alone was real, relatively limited.

And frankly, if you trusted a patient to get there alone, why were they in the hospital in the first place?

Why couldn't they negotiate a community as easily as they were?

Hospital?

You mean negotiating the way across the hospital?

So we began to think about how do I make that program element come into the building and what does it become?

And at the same time, we were thinking about, Kevin Lynch, who wrote beautifully about, about human navigation and, and, and how in the, in the old school cities and villages were designed understanding inherently something that the neurosciences are very explicit about, about how the human being negotiates and navigates through space.

And quite literally that hospital was very deeply informed by Kevin Lynch's ideas about movement through space, about things like paths, Node, Portal, Square View, Sun, and provide a continuous gradient through the entire hospital of that kind of texture.

Thank you.

Thank you.

Thank you.

Emira.

Any other questions, Danny?

I guess.

I guess first you wanted to.

You also said that we should ask what can be done?

yeah.

So this is my version of, of of what I said to you this morning about looking at your own life experience and and and seeing it as a part of what informs your work and looking at how other people are being and letting it inform your work.

So when I was working as a rehab therapist, I saw this thing happen where it was.

It was evening, it was after dinner.

It was sort of downtime in the residential area.

And I was standing at what essentially was the care desk with one or two other staff.

And and, you know, you have to also realize that at the time I weighed £128, I'd weighed £128 and a bit exactly this height since I was eighth grade.

And I'm close enough to it at the time that I'm recognizing male adolescent behavior in the presence of bullies.

I'm tweaking on to the fact that this is going on in the space that I'm in.

It's it's unavoidable.

And I'm watching some kids do this thing.

The kids that are being bullied or the target, I'm watching them take positions around us in ways that are feeling safe.

But and I can tell, you know, if you're if you're in it, if you're that close to it and you're in it, you can tell close enough to be safe, but far enough away that they weren't signaling vulnerability.

Ah, so what do we do about that?

This is this is one of those accentuated human needs that Marvin Chapman was talking about.

It's a particular accentuated human need in young male adolescence.

I don't know the female version of it, but it's a human need.

And so we decided to start to create what I call places in between, like that bench, the end of the hall that were deliberately situated in a way that they were public, that they would allow someone to position themselves that in a way that felt safe without appearing vulnerable.

And then as we started to elaborate the idea and think about it, we realized that it also became a really interesting place to sort of hang out at the edge of a congregate room where there might be all kinds of people in there that I don't know yet.

And I could hang out here and get a sense of, well, who are they and what are they like?

And before I thrust myself into the middle of it.

And so it it's it's thinking like that about what's it like to come.

And this is a part of that journey mapping.

And I think it's actually the more important part of the journey mapping to think about time and to think about emotion and to think about need.

And the and I'm not a big journey mapping fan, I will confess because I think it I think that that that the explicit process dampens some things that are really, really important and to think then deeply about what are the ranges of the kinds of gestures that I need to make that someone can appropriate for a range of needs that I can't even necessarily imagine, but that are predicated on observations about human behavior.

And from this perspective, I think the Christopher Alexander's always been one of my one of an important touchstone for me, because when Christopher Alexander in Pattern Language, what he's writing about fundamentally is about those kinds of things, You know, some Thank you.

Thank you all very.

Much of our time.

Thank you.

Again.

Thank you.

From our School of architecture.

Thank you.

Thank you.

Thank you all.