Australian & New Zealand Journal of Psychiatry 2015, Vol. 49(3) 203–206 DOI: 10.1177/0004867414565477 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com Australian & New Zealand Journal of Psychiatry, 49(3) There’s a growing schism in mental health services around the world. There is a broad call for person-centred models of care, a consideration of the whole person, and a focus on recovery on clients’ own terms. Yet these demands are at odds with the current paradigm of design for facilities for psychiatric care. Design paradigms (and the mod- els of care they support) have tried to pay lip-service to person-centred care for decades, but, to this day, they are designed primarily to improve the effi- ciency of staff routines and patient- management protocols, even although all the available evidence suggests that this approach is at the expense of the patient’s well-being and even best chances for recovery. The current models for mental health service design appear to reflect society’s main concerns about men- tally ill patients: suicide risk and the threat of violence, crime and arson. Reflecting this, current guidance on the design of mental health facilities trace sightlines that emanate from central staff stations and down long corridors of bedrooms and activity rooms. These ‘sightlines’ are not only literally staff-centred, but they also enforce asymmetric relationships by anchoring the locus of control with the staff on duty. Far from empower- ing patients to develop self-efficacy to better deal with life outside the facility, central staff stations mean that every need and desire is made contingent on the good will and timing of the staff. If clients want to make a telephone call, fix a ‘cuppa’ or change the TV channel, they have to rap on the glass and ingratiate themselves. This attentional focus on the staff station contributes to the ‘honeypot syndrome,’ where patients loiter around the staff stations (Figure 1 shows a typical staff-centred facility). While the staff station is widely understood to be a non-nego- tiable requirement of a mental health facility, the only evidence on the sub- ject builds a compelling case against the implementation of staff stations altogether – because when staff sta- tions are removed or made more democratic (by removing glazing), the behaviour in the facility radically improves for both clients and staff (Golembiewski, 2013; Tyson et al., 2002) (see Figure 2). The question about what the alter- native – a person-centred facility – might look like, is seldom more than that (what the unit will look like) as walls are ‘opened up’ with impervious plate glass into views of pristine gar- dens that are out of bounds to clients. A poor understanding of what per- son-centred care means, how it can be implemented with minimal disrup- tion and why it is of clinical impor- tance means that the calls for better mental health facilities fall on deaf ears. It’s all too difficult. The foremost functional requirement of a mental health facility isn’t to perform staff routines, observe and control clients’ behaviour, and so on. It’s to prepare clients to tackle the realities of the outside world. With facilities the way they are, a majority of clients perceive treatment as an incomprehensible and unhelpful process that is out of their control. This is a problem not only for clients and their carers, but also for the health service itself. When treat- ment has no perceived positive effect on a client’s ability to cope, they may feel that the effort and the sacrifices they’ve made to control their illness is meaningless. And, unsurprisingly, it’s the clients that have those rare empowering client/therapist relation- ships that benefit most from treatment. But quite apart from the demands of consumer advocates, there’s a new imperative to change the design of mental health facilities to make them better for care and more person- centric. There’s evidence that coer- cive environments cause clients to behave contrary to the intent of the threat; in other words, behaviour management leads to misbehaviour and a controlling environment leads to loss of self-control. But it’s not only behaviour that’s affected. Bad environments appear to have a power- ful causal influence in mental illnesses (Golembiewski, 2013). Effectively, men- tal health facilities are the ‘wrong vehicles’ for the job at hand, and they must change along with treatment and management protocols. Does the environment make a difference? The ways in which the environment influences mental illness isn’t fully understood. But we know it’s neither Mental health facility design: The case for person-centred care Jan Alexander Golembiewski Medical Architecture, Sydney, New South Wales, Australia Corresponding author: Jan Alexander Golembiewski, Medical Architecture, 157 Brougham St, Wooloomooloo, Sydney, New South Wales 2010, Australia. Email: jg@medicalarchitecture.com 565477ANP 0 0 10.1177/0004867414565477Australian & New Zealand Journal of PsychiatryGolembiewski research-article 2015 Debate by guest on August 26, 2015 anp.sagepub.com Downloaded from