Trauma Informed Design for Behavioral Health – part 2

Trauma Informed Design for Behavioral Health- part 2
Guests: Meredith Banasiak / J. Davis Harte

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Janet: In this series we will be discussing specific examples of design techniques that make a positive difference for people living with certain human conditions.

Carolyn: The more a designer understands the client and or the community the more effective and respectful the design will be.

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Intro

Janet: Welcome to Inclusive Designers Podcast, I am your host, Janet Roche…

Carolyn: And I am your moderator, Carolyn Robbins.

Janet: We have a really great show for you today, we are taking a look at how to improve the standard of care in behavioral health using a trauma-informed design approach. And for this important discussion, we are talking to the amazing Meredith Banasiak.

Carolyn: Let me tell you a little bit more about Meredith… she is a Fellow with the Centre for Conscious Design; maintains an advisory role with the Academy of Neuroscience for Architecture. She has published in psychology, medicine, and architectural research journals and books. And now she is here to share her passion for research and evidence-based design with us today.

Janet: And to make it even more special we have asked Davis Harte, or as I refer to her as Dr Harte, to be my co-host. Together we have co-founded the Trauma Informed Design Society and will be adding our insight from that to this discussion.

Meredith has done some incredible work on sensory issues and designing for human health along with Trauma-informed Design, to foster inclusivity and a healthier environment.

Carolyn: There is so much to explore here, that we’ve decided to make this a 3-part series. You can listen straight through or choose to hear each section separately, let’s call it ala carte.

Janet: In this section, we will look at the stigma of mental health, and what the research is telling us about how best to design for these environments. Meredith will provide specific examples of Behavioral Health facilities where these were successfully implemented.

Carolyn: And of course, if you want to know more about any of the places or studies mentioned, we will have a really rich list of resources for you on our website: InclusiveDesigners.com.

Janet: Carolyn, I think we’ve covered all that needs to be said here up front, so I guess we should just start the show now, don’t you?

Carolyn: Agreed. Without further ado, here is our thought-provoking look at combining neuroscience with evidence-based design, with insights from Janet, Meredith Banasiak and Davis Harte …

Interview- Overview

Janet: Hi, and welcome to Inclusive Designers. I am your host, Janet Roche. And today, we’ve got a special guest host. You’ve seen her before on this show, Davis Harte. And today we’re going to be interviewing Meredith Banasiak. Welcome Meredith. Welcome Davis. How’s everybody doing today?

Davis: Great. Thanks Janet. It’s wonderful to be here…

Meredith: yeah, it’s great to be here.

Janet: Thank you for coming.

Interview- Section 2

Janet: So Meredith, let’s talk a little bit about behavioral health facilities, and then how they’re being improved by using trauma informed design. You want to talk a little bit about that? Maybe talk a little bit about Boulder Community Health program or the pediatric inpatient part that you’ve been working on.

Meredith: So yes, we’re seeing this move toward trauma informed design in behavioral health services. And if we, you know, think about behavioral health facilities, they’ve historically been designed to support care that can trigger a patient’s experience of trauma during treatment.

So think about, you know, the use of seclusion and restraint. if you’ve never been in a behavioral health facility, I, I’m not saying that Hollywood paints an accurate picture of that at all, but that there are practices in some of those movies that we’re familiar with which we see historically in behavioral health treatment programs like seclusion and restraint, very sort of barren institutional environments that lack environmental complexity. So, you know, for example, the thought is, you can’t put furniture in or art hanging on the wall or something, because that could be used to hurt someone or the patient themselves. (J: as a weapon). Yeah. (J: right).

So, and also isolation from family and loved ones. So the support system of the patient is often removed from the treatment plan during inpatient stays. And so that makes the transition, you know, when they go back to home really challenging because the family or loved ones don’t know how to support the patient, they’re not aware of like what that recovery process includes.

So all of those practices really historically again, you know, have created adverse effects, certainly for the patients, but also the staff. They’ve sustained injury by having to put patients in seclusion or in holds, and also for the family, just kind of having that sense of isolation and separation and not being involved in care.

So, the change moving into trauma informed design is one that is coming from our behavioral health clients themselves. They’re moving toward a trauma informed care model of how they’re delivering care and how they’re delivering treatment. So, I’m going to just read a definition of what that means, and this is from the ‘Substance Abuse and Mental Health Services Administration’, which says “trauma informed care realizes the widespread impact of trauma in clients or patients, families, staff, and others involved in the system, and responds by fully integrating knowledge about trauma into policies, procedures, and practices to actively resist re-traumatization.”

And I think trauma informed care really recognizes the context that the treatment occurs in, what the role of context plays on outcomes. And so that’s where we have this really amazing opportunity to come in and design the context to support this new model of care.

So how are we doing that? Roger Olrick wrote a lot about this cycle of reducing a patient’s stress and then how that stress reduction in turn creates better outcomes for the patient and also for the staff. So, a stress reduction in the environment would include fostering more opportunities for control, patients to have control; to mitigate crowding stress; to minimize environmental stressors, like noise; and then, you know, promoting exposure to restorative elements like biophilia, uh, nature, kind of that sort of thing that have been shown to reduce stress.

So when the environment is designed to reduce stress, then there’s less triggers for patients, and, and we see better outcomes: reduced physical violence; reduced verbal aggression; and ultimately, reduced restraints and isolation.

Janet: It’s such an important part… you started off talking about, like Hollywood has like the fair portrayal, but you kind of really don’t see what really happens afterwards. And there’s not a, the built environment is an afterthought, I think anyways, within these, I think things are getting better. I see things are getting better, but it’s still pretty ragged.

Davis: Might I interject that it seems to me that there’s a very much a risk averseness that is so interested in reducing possible risks that they are doing harm in doing so. (J: Good point). We see the same trajectory in playgrounds, (M: Exactly). You know, we’re so concerned about risk and somebody’s hurting themselves that there’s actually nothing there for the kids to do. (M: Yes).

Janet: Here’s your little feather, go play, right? (laughs). But there’s a lot to be said for that as well. But I think there, I mean, Meredith can tell me if I’m wrong, but there’s a way to have that. There is a way to show biophilia without, there’s some sort of risk to them. There’s a way to have different types, even just like have things non-institutional, because people tend to think that then they’re broken and they think it just kind of spirals from there, but there’s a way to present that, there’s a way to have those types of things and make them feel like they’re also worthy, right?

Meredith: Yeah. I think the stigma around behavioral health is a huge problem and that, you know, trauma informed care is this kind of model of treatment is really trying to address that. In some of the interviews I’ve conducted with parents and caregivers of pediatric mental health patients, you know, they say, ‘why is my child treated differently than, you know, the child who is an inpatient and being treated for some kind of medical, cancer or something like that. Why is my child treated, almost like a criminal’, because this is what that child is being taught and that carries with them and they’re more prone to live that out.

And so definitely the stigma is a big issue that these new sort of treatment models are trying to address and the design is also trying to address. I love the analogy you made of the playground and sort of safety first and sort of then people become bored and agitated.

And, you know, I think of animals who, when they’re bored or in crowded situations, they pick at themselves or they pick at each other, right?

And, staying on this theme of animals, we have this amazing wild animal rescue sanctuary in Colorado. And it takes in animals that have experienced great trauma and lots of abuse. And the people who have worked with abused wild animals for so long really understand the kind of environments that they need to sort of reduce their anxiety, reduce their sense of threat. And when you visit, you’ll notice the animals are really calm. They don’t have those sort of pacing behaviors like you see when you go to the zoo. I mean, I haven’t seen tigers and bears in the wild, but I would imagine it seems like their behaviors are more natural.

And, you know, some of the design features that they have in this wild animal sanctuary are lessons we can take kind of in our own sort of trauma-informed design. Like one is low density. So these animals have large acre habitats, and there’s not a lot of them in the same enclosure. They have environmental complexity. They have toys to play with that are appropriate to their species. So if they’re cats that like to climb, they have lots of climbing structures and opportunities. If they’re bears who like to explore there’s different scenarios for them to do that.

And then the other thing they do is with transition. So when an animal comes in, it’s not this sort of abrupt and here’s your new home, which is super scary and super threatening, and you don’t know what to expect. But the transition is very gradual and takes place over a pretty long period of time. So the animal can become more trusting and understand that this isn’t going to be threatening for me.

Another feature of the wild animal sanctuary is that as a visitor, you observe them from a 30-foot-high elevated walkway and you’re never on their ground level. And so for these wild animals, this space exists above their visual field. it’s beyond their body or their scope of reach. And so they don’t perceive you as a threat.

And this is different than humans because we’re one of the few species who have this notion of extra personal space. And cognitive neuroscientist, Colin Ellard writes about this phenomenon a lot where there’s a part of our brain that understands this sense of the infinite or kind of, sometimes we associate with divinity when we see these distant expanses and stuff like that.

And that when we look up to the sky or to these distant expanses, it primes us to think about these very positive notions of kind of sublime, or like I said, maybe divinity. And so this idea for humans of lifting the gaze to inspire these positive thoughts could be really beneficial in all of our environments, but especially for trauma informed design. (J: like a healing environment). Yeah. (J: Right). So, that’s not one that’s in our kind of typical playbook of evidence-based design, but it should be. Kind of this idea of lifting the gaze and what kind of positive thoughts that inspires…

Davis: Right, I am so interested in that Meredith…

Janet: I don’t know if you noticed that I leaned in, right. I was like, really? Yeah. Okay. (laughs).

Davis: We need an invitation to do some research on gaze and how that affects our sense of calm and relaxed versus alert and attending and what that does to our nervous system and how the built environment can facilitate it. We all hear over and over again about, oh, the window view is so beneficial. Well, is it the view out of the window or is it the fact that the eyes are moving and tracking in a way that is different than focused on some focal point that’s creating the sense of stress. So that’s fascinating discourse there. (M: Yeah). More, more is needed, right? (M: Yes, yeah) …

Janet: Absolutely. (M: Yeah). Well, I mean, you know, the whole idea, like you said, the whole famous study with the window looking out to the brick wall versus the, it was a park, I guess it was, but that goes back to sort of our more animal instincts of being able to kind of see the distance and see whatever kind of threat is coming at us. But yeah, I wonder if, you know, when you’re downtrodden, right, like you keep your gaze down, right? (M: uh huh). And you, maybe you’re not creating some sort of eye contact, your shoulders are slumped, you’re maybe not breathing as well. But if you’re lifted and you’re looking and up that the physiology of that as well, might… (M: Yes). Am I going too much into the weeds here, ladies? (laughs).

Meredith: I don’t have evidence to point you to, but I’ve always felt similarly, Janet. I mean, in one of our behavioral health settings, the design team talked about sort of using this flooring pattern that had a biophilic design and biophilia is healing. And I was like, really, do you want to draw their attention down to the flooring? Is that really where you want their attention to be? Because that, that just doesn’t feel right to me.

Janet: Right. No, well, it does… all right, so let’s talk about a design challenge here. So I was doing a piece with a trauma informed design in terms of sex trafficking. It was with this group of students and, and somebody had come up with the idea of designing stuff on the ground for help to do some wayfinding. And at first I was thinking that, you know, you’re coming in, you’re probably not maybe doing eye to eye contact. I think that the sign should be up above, but I also thought, well, why the hell not to have designs on the bottom? You know to have some sort of a wayfinding on the ground as well, but now I’m starting to maybe rethink that. Any, any thoughts on that?

Meredith: Oh, I would say wayfinding is different. And also exterior environments are different, but, but with, you know, with wayfinding, I would say, be redundant with your cues all over as much as you can. Especially, you know, in healthcare when people are coming to that setting often under stress. If they’re in the emergency room or something, you know, you’re under acute stress and we know stress diminishes your, your cognitive capacity and your ability to problem solve.

So we need to make sort of wayfinding cues, like, in my opinion, super redundant across all the senses and across all your visual fields to, because we don’t want to add to people’s stress. I don’t know that, you know, if someone’s coming into the emergency department with the severed leg, I don’t think we’re going to be able to necessarily reduce their stress in that moment, but we certainly don’t want to add to it by making wayfinding more challenging for example.

Janet: Right. Well, anybody who’s ever been into a hospital knows that like, even if you’re just there to visit someone, trying to find where you’re going is usually pretty, it’s pretty stressful. (M: Right). Even as, as a general rule. Well, so I appreciate you talking a little bit about that, uh, Davis, do you have anything to add?

Davis: This is so fascinating, but I know we have lots of other interesting things to talk about, so I’m happy to put a pin in this…

Janet: Yeah. And we’ll keep talking about things. So Meredith, can you give us any examples of some of the work that you have done.

Meredith: Yeah, sure. Do you want me to talk a little bit about kind of pediatric inpatient and kind of point to some of those examples as part of trauma informed design in some of our behavioral health projects?

Janet: yeah, we’d love to hear more.

Meredith: NBBJ, the design firm NBBJ, has done a couple of really amazing pediatric inpatient units.

One is the Nationwide Children’s Hospital in Columbus, Ohio. And here they’re changing their care model to include parents and caregivers if the patient treatment plan works to do that— it doesn’t always— but to include parents and caregivers in the stay.

So just like parents and caregivers are, often stay in other inpatient hospital rooms for medical stays, parents can do that with these patients in behavioral and mental health. So the bedrooms are designed to accommodate that. And a lot of the other rooms are as well. And so this really helps.

So in the interviews I’ve done with parents and caregivers, they’ve shared that, one of the most traumatic moments during their child stay is leaving visitation time. So the parent or caregiver comes to visit, visitation is over, and then there’s this huge separation. And it’s hard on the child, it’s hard on the parent. And so kind of having the parent there avoids that, but also it helps include the parent in the care plan. So that they’re understanding, what the treatment plan is. And they can, when the patient goes back home, they can really be part of that recovery. And there’s more continuity of care going on there as well.

Another pediatric inpatient behavioral unit is Seattle Children’s Hospital. And that group also has adopted a trauma informed care behavioral management philosophy. And so, the design of those units don’t include seclusion rooms, so they’re seclusion free and restraint free, and they really strive to avoid these hands-on interventions. So again, for that to work, the rest of the environment has to be designed to reduce stress so that you’re not having those triggers in the first place.

So those are two examples of how the care model itself is changing, and then how the design is also changing to support that kind of care.

Janet: Right. Yeah, that’s pretty great. Davis, do you have anything to add?

Davis: Well, yeah, this is just such a gift to be able to hear in depth live from you, with what all you’ve been working on. And my mind is spinning in many directions and taking lots of notes. But the supporting the supporter part for the parent and child dyad to me is core. And it’s something that, well, I have an affinity for it because that was my topic of my PhD work in childbirth environment.

So the supporter is expected to be there. They want to be there. They’re beneficial. Evidence shows that there it’s important to have them there, yet the space itself is discouraging actively or, you know, creating this unbelonging paradox of, well, you shouldn’t be here, you’re getting in the way. you know. (M: yeah) So having the core understanding of this social cohesion that is necessary for true human potential to be activated is key. And so having spaces where parents are not only allowed to be there, but designed, yes, this is your place, be here. (M: Yeah.) This is part of the plan. I love it (M: Absolutely).

Janet:  it’s, it’s, it’s taking a village, and that support is really quite important. So terrific. These are great examples. And I think moving forward, we should find solutions other than restraint and seclusion, and to ultimately make better design choices, right?

Meredith: Yeah, so there’s this interesting shift that we’re seeing at a professional level that’s happening. And specifically, I’m talking about the AIAs code of professional ethics and conduct which now includes this accountability for human dignity and health and safety and welfare. And one thing that happened last year in 2020 was the AIA code of ethics included a mandatory rule of conduct against designing spaces for torture and solitary confinement in prison and justice facilities. Did you guys know…

Janet: Oh, not only did we know about that, (M: okay,) yes, I did a whole thing on prisons and trauma informed design. (M: that’s right) We definitely want to talk about that because it was such an important, I don’t think it got the press that it probably should have.  I think it was such a huge, huge step (M: Yes) for designers, and for them to basically say no more, (M: Yes) and I was over the moon.

I’m a big advocate in terms of trauma informed design. I used to be a therapist for juvenile delinquents in incarcerated facilities. So I’ve always had this little soft spot in my heart for incarceration and people who are in incarceration. And of course, they have been through a lot of trauma. And then it is the ultimate environment to retraumatize, right. (M: Yeah) And so, yes, I was so pleased that they had done that, so please continue forward…

Meredith: Right. And yeah, as you said, there so much advocacy for it. I want to say like almost 10-years leading up to this and, you know, ultimately the neuroscience evidence did show it’s not just psychological harm, it’s structural damage to the brain that’s occurring as a result of solitary confinement. And for me, the new rule really was significant because, now we’re talking about affordances here, we’re talking about having ethical standards for space programs. So this is sort of beyond just our ethical obligation to do no harm as far as like, you know, make sure our buildings don’t fall down and kill people or make sure, you know, we have guard rails if there’s an elevation change that people don’t fall off the edge. This is about space program and affordances here.

So, you know, I want to be careful, long-term solitary confinement is not the same as temporary seclusion, which is used to sort of protect patients from harming themselves or others. So I’m not trying to make that analogy at all. But I do think this new code of ethics that’s really getting at dignity and health and safety and welfare. And thinking about space program is really important for our profession and thinking about how we can minimize the use of traumatic practices, like seclusion and restraint, because we are designing the environment to reduce stress as we were talking about earlier.

Janet: Right. And it was even going back to what you were talking about earlier about ‘why is it my child? Why is my child then being treated very differently than somebody who might have had cancer?’ And I’m really kind of not trying to exactly equate the two, (M: right) but it does come down to, you know, it’s usually the people who are impoverished and people who have disabilities and that are in these particular types of correction facilities. And yes, occasionally we do need to separate people from the greater population, just in order to help reregulate themselves. But it’s a really important, I think conversation and I think we’re only going to be doing ourselves some sort of justice at the end of the day if we take care of this stuff. And that includes pediatric, psychiatric and incarcerated individuals.

Meredith: Yeah.

Janet: Well getting off of my soapbox. Well, that’s it, that’s the show (laughs). We fixed the societal ills, it’s all good.

Outro- Section 2

Janet: Her work using Trauma-informed Design, or TID – in behavioral health, especially for pediatric inpatient environments, is so inspiring. As Meredith pointed out, we as designers need to minimize the use of traumatic practices, such as seclusion and restraint, in order to help design the environment to reduce stress.

Carolyn: She also pointed out that the code of professional ethics and conduct by the American Institute of Architects, or AIA, now includes this accountability for human dignity, health, safety and welfare.

Janet: As we said at the beginning, we decided to break our discussion with Meredith into 3 sections that you can listen to either all at once, or separately.

Carolyn: even if you listen to this as the straight through version, you may want to take a short pause for a bio break, or to grab something to eat, or just to digest some of this information before moving on.

Janet: in this next part, we will look into how Social Determinants of Health can be used to improve medical care as well as access to healthcare.

Carolyn: And also, some future trends that may surprise you. I know one in particular that really surprised Janet.

Janet: yes, it did. I think I actually said ‘What?’ …

Carolyn: And if you do stop here, we’ll just add a quick thank you to Meredith & Davis. And thanks to all of you for stopping by too. Either way, we hope you enjoy all three parts of this forward-thinking series.

Janet: and as always, we will share the links for Meredith; Davis; Trauma Informed Design: and of course, many more things mentioned during this discussion… on our website at: inclusivedesigners.com…

Carolyn: That’s: inclusivedesigners.com… And of course, if you like what you hear, feel free to go to our website and hit that Patreon Button, or the link to our GoFundMe Page.

Janet: we hope to see you soon.

Carolyn: … and maybe very soon if you are continuing on to the next part of the discussion.

Janet: and if not, stay well and stay well informed.

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