Trauma Informed Design for Behavioral Health: 3-part series/All (Season 3, Episode 2)

Inclusive Designers Podcast
Inclusive Designers Podcast
Trauma Informed Design for Behavioral Health: 3-part series/All (Season 3, Episode 2)
  • By: Janet Roche & Carolyn Robbins
  • Co-Hosted By: Janet Roche & Dr. J. Davis Harte
  • Edited by: Andrew Parrella
  • Guest: Meredith Banasiak
  • Photo Credit: Caleb Tkach AIAP

This just in… new changes are coming for those who create spaces for Behavioral Health. Combining the scientific knowledge from Neuroscience and the research evidence from Trauma-Informed Design is opening up new ways to optimize health, performance and access.

IDP is excited to share this 3-part series with Meredith Banasiak that explores the transformational shift in design towards an evidence-based, person-centered culture. She shares her insights for designing for behavioral health projects, from family clinics to eating disorder facilities.

Part 1- Meredith’s story; sensory issues; and the concept of a ‘Shared Experience’

Part 2– The stigma of mental health; Solutions using Trauma-Informed Design for Behavioral Health Facilities.

Part 3- Social Determinants of Health; improving access to healthcare; designing for eating disorders facilities; and a new way to look at Post Occupancy Evaluations (POE)

Guest: Meredith Banasiak, EDAC, Dir. of Research, Boulder Associates; LinkedIn; Twitter

– References:

Academy of Neuroscience for Architecture, ANFA

American Institute of Architects, AIA

Basic Science of Light / Color

Boulder Associates

Boulder Community Health- Della Cava

Boulder Community Health- Tunable Lighting



“Bridging the Gap” (Healthcare Design Magazine article)

Clinica Family Health

Eating Recovery Center

 Colin Ellard – Cognitive Neuroscientist

Evidence Based Design, EBD

Flexsim Simulations

GoInvo-Social Determinants model

HIPAA: Health Insurance Portablitiy and Accountability Act 

Lifting the Gaze – How to focus to Change Your Brain

Nationwide Children’s Hospital, Big Lots Behavioral Health Pavilion

Adverse Risk in Playgrounds

SAMHSA: Substance Abuse and Mental Health Administration

Seattle Children’s Hospital, Psychiatry and Behavioral Medicine Unit

Mardelle McCuskey Shepley, BA, M.Arch, MA, D.Arch, EDAC

Trauma-informed Design, TiD

• Roger Ulrich Study

USC Santa Barbara ‘Dormzilla’ (Construction Dive article)


Trauma Informed Design for Behavioral Health- part 3
Guests: Meredith Banasiak / J. Davis Harte


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.

(music up, then lower)


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, Meredith takes us through her life experiences that led her to the exciting field of Neuroscience and Architecture. We will also focus on sensory issues and the concept of a shared experience.

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:

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 1

Janet: So Meredith, let’s start this off a little bit. Let’s talk a little bit about your background and how you got started and, we did a little intro at the beginning, but we’d like to hear a little bit more about you from yourself.

Meredith: Great. Well, thank you so much for having me and thank you for all the work that you are doing on trauma informed design, and all the resources that you’re making available.

So, I’m going to kind of go back to, all the way to childhood, because I have always struggled with sensory issues in the environment. And, when environments are overstimulating like in the city or the sort of sensory experience is just sort of really invasive, and intense, the first thing that comes to mind is, is almost like a church situation where, you know, as a little child and you’re in this very dense environment and you don’t have a visual field cause everyone’s taller than you and the smells are very invasive.

Those kinds of sensory experiences, I struggled with. And I felt they almost sort of hijacked my ability to think and my emotional state. And so, I always kind of wanted to understand what was happening in my brain, so I could kind of suppress it and make it stop. And at the same time, I wanted to design environments where I didn’t have to feel this way, or, you know, I didn’t know if everyone felt like I did. I kind of assumed that they did, but I kind of want to design environments where people didn’t have to feel the way I was feeling.

So, that’s my background into kind of this track of understanding people and then also designing environments. And so when I was in undergrad, this career of design research didn’t exist. And so I was, you know, I think we’ve all sort of forged our own path of how do you prepare for a career that doesn’t exist yet? For me, I was pre-med because I wanted to kind of go into the science and neuroscience, which even then wasn’t really a thing. And then I also followed this path of classics. So studying Latin and Greek and classical archeology.

What I came to realize later in life is that architecture is just doing archeology in reverse. So archeologists study artifacts and ruins to understand people and how they were behaving and what groups of people were doing. And architects, ideally speaking, should study people and cultures to be able to design our artifacts and buildings that can support those behaviors and support those cultures. So I feel lucky to kind of have experienced this equation from both ends, and it’s the same equation you’re just sort of solving for different variables along the way.

So, kind of, that’s my background and sort of how I got into this field. My professional degree is in architecture, but that came later in life. And when I graduated, I learned of an organization called the ‘Academy of Neuroscience for Architecture’, which was just emerging. This was around 2004. And it sounded exactly what I had been sort of preparing my whole life for.

And I reached out and said, you know, how, how do I be part of this movement, of this initiative? And, at the time they had what they call the pioneer program. where they brought a small group of people on to essentially pioneer what would be a new discipline in neuroscience for architecture.

So, I, I sort of took that on as a full-time role for a time, moved to Washington DC because that’s where the scientific funding agencies were, the AIA headquarters was located there. And as part of my training, I also got to work with a neuroscientist at George Mason University who studied learning and development in twice exceptional children.

So these are children who maybe have like attention deficits and giftedness, or maybe dyslexia and giftedness. And, and so, that was really interesting to study a population who also had an experience that, where they might be struggling with sort of environments. Cause if you think about attention, if (pop) there’s something in the environment that’s grabbing your attention, that’s preventing you from internally sort of focusing or staying on task.

So kind of that experience of being able to work with her, as well as just kind of my own sensory background, really motivated me to pursue a career in designing for inclusivity. And for people that fall outside this, mythical average, which most of our world is designed for.

Janet: Right. it’s kind of always fascinating to me that people like yourself and me, and I can’t really necessarily speak for Davis, but you’ve had this personal experience. Right. And you realize that your own built environment, maybe wasn’t what it should have been in order to foster you and you recognize that, that’s pretty amazing. I think most people just kind of go about their way and think to themselves that there isn’t anybody like me. I can give you a quick example. I’m allergic to latex and rubber, and I used to blow up balloons when I was a kid. And I would ask everybody else, like all my kid friends, and ask them if they too felt like their throats were closing up, if their tongues were getting fat, their lips and cheeks were on fire.

And then blowing up balloons is kind of a hard activity on your mouth and your cheeks and everything like that. They’re like, oh yeah, us too. And I’m thinking to myself, I can’t breathe. It can’t be the same thing. But for you, I think it’s really kind of interesting that you recognize that this is not, you know, this was not working for you.

Meredith: Yeah, absolutely. And, you know, in the seventies and eighties, there wasn’t really, sort of a label other than ‘sensitive child’ or ‘picky eater’, probably ‘my mom spoiled me too much’ was kind of the explanation.

Janet: The list goes on. I remember that. Right. (M: yeah). You know, it was sort of like, suck it up buttercup. (M: yeah). So I don’t know, Davis, did you have an experience like that?

Davis: well, I have a few thoughts just from this early part of the conversation is that, yes, this lived experience is so invaluable. And the more we talk about evidence-based design and research and information gathering, real-lived experiences are becoming more appreciated for their value that they bring to how we shape our spaces. So that’s one point, in the one bucket. And then, I mean, the second bucket is, is very personal because of knowing how my own family members experience, um, sensory processing issues and watching them navigate the world.

And what I’m feeling is that now we are coming to a place where the podcast and the information and the people are, we’re finding each other and realizing, all right now, we are outside of the, the bell curve, let’s center the edges of the population into this core of our designs, very attunely, in a way that can meet the needs of all kinds of allergies and all kinds of processing needs.

Our nervous systems are all at the core the same as each other’s but some are much more finely attuned and other, you know, how we process information coming in (J: Right) and circuitry can be de-emphasized with lower stress environments, as well as managed upwards once this knowledge and knowing about it.

My person is very aware of their sensory processing and they’re still young and they, to a certain degree, they know what’s going on in their brain. They’re happy and ready to articulate it to anybody and advocate for their needs in a way that was non-existent a decade ago. Never mind, when we were all children. So, I just applaud this, the wave that’s happening. And I am so excited to hear what else Meredith can share with us because it’s, it’s amazing. It’s an amazing place we’re in.

Janet: Right. And, both Davis and I really think that the Academy of Neuroscience for Architecture is a really kind of remarkable and wonderful place. We got an opportunity to present our poster earlier this year, or maybe it was even a couple months ago— time is but a blur at this moment— but we were really thrilled with that because we knew it’s such an important part of what we’re trying to do, how we’re trying to create this inclusive environment for everybody. So, yeah. It’s great. (M: Yeah).

Janet: So Meredith, tell us a little bit more about the role that you have now and what you’re doing with Boulder Associates and how do you describe what it is that you do?

Meredith: Yeah, sure. So ultimately I ended up in healthcare design, where, you know, inclusive design is an ethical obligation because everyone needs access to healthcare. So you know, when access to care or quality of care is somehow diminished or compromised for certain populations who are again outside this mythical average because of design, because designers weren’t thinking of them when they were doing these designs, then I think we failed as a design community in a major way.

So the firm I work for is Boulder Associates and we do exclusively healthcare and senior living work. And my role is Director of Research for the firm, but the cool thing is I am part of a group that we call BA Science which is our science-informed design entity under the design firm umbrella. And, and in a sense, we kind of function as a startup with the services that we provide.

BA science brings together human factors, which is sort of the effort that I lead.  And then I have a counterpart who does process and operational improvement, so kind of like using Leed methodologies. And then a third expert in sustainability. So often you see in firms like these, or even in projects, if these roles exist there, they’re kind of siloed out. And I found that, you know, when we came together and integrated, we were really able to approach projects as an ecosystem, where we weren’t just sort of told to stay in our lane.

And, you know, only, in designers, I think we feel this all the time, like all we can control is the design of the built environment. And when you consider that the built environment is this larger ecosystem which includes people and relationships and operations and processes, it’s a very sort of narrow and limited view. And you’re not fixing, you’re not solving the issues of the entire system.

So, you know, once we started working together, um, as a BA science group, we would come into projects, and, you know, sometimes it wasn’t always a design solution. It was an operational kind of process improvement solution that we were giving to the client. And that just felt right, because I, I think this sort of systems approach, that buildings environments are sort of this ecosystem. And so approaching it that way is just a better way to solve the challenges.

Janet: Right. For you, I think it’s more of like a personal project. Do you feel like that’s, sort of what you’re seeing with some of the shifts and the changes within the design world? Like, are people bringing their, their own experiences to it, or people are just recognizing that things are shifting? Do you want to speak a little bit on that?

Meredith: Yeah, no, I mean, I think there’s this growing need for expertise, but then the more experts you bring, sort of does it make things more disconnected? And so I think there’s also this responsibility to consciously integrate and work together, to again, to try to address the whole system. So ideal state, I would love for architects and designers to culturally begin to approach projects this way. Realistically, is this happening? Maybe not as much as we would like right now, I mean, you know, change takes time.

Janet: Right.

Davis: Yeah, the notion that it’s a way of working that is more, both expansive, but also more intentionally focused. So, you know, what is transdisciplinary work or translational work, where, you know, you and other scientists are taking the time to do evidence, but we want that to be very hands-on tools for the architects and the designers. And they’re able to hit the ground and keep in budget and time. (M: Right).

And where the two shall meet, you know, that’s the excitement of trying to create these bridges that don’t add a lot of extra time and effort for all of those involved in doing it. because everybody agrees. ‘Oh, right, right. We do want to build spaces that are more inclusive’. it’s not like that’s really the problem so much as how the work experience is same as our lived experiences and the same as how we learn. There are many ways of knowing. It’s a shift that’s happening, but how do we help make that happen even more is the question… (M: Right).

Janet: Yeah, how do we help make that change? Because I think Davis and I have both run into this at the Boston Architectural College, where we look at designing for human health, (M: yeah) and then Davis and I in our work with trauma informed design. And I still talk to architects to this day that basically will say things like, ‘we do that anyways’. And I’m like, ‘but no, you don’t. I can point to, like 12 things that you have that you just have not, you have either glossed over it or have thought very little of it or have not implemented it.’ (M: Yeah). So, you’re absolutely right. We need to, we want to kind of talk about how maybe we can make some of those changes or designers moving forward can start making those changes.

I don’t know what Davis’s experience has been with students recently, but I’ve noticed a real shift in how they are designing in just one semester, because now they have been now through three semesters of COVID, and their design outlook is looking very different than it was just even a semester ago. (M: hmm) So I don’t know, Davis if you’ve, have seen that as well, or…

Davis: Yes, something along those lines. I hadn’t named it that way, but I think we’re all forced to look inward and be with ourselves in a way that we hadn’t ever had to before. And that’s creating a lot more of an uptick and understanding about human physiology and basic ways of responding. And what, how am I feeling in my body when this is happening or that’s happening or, and so, it’s forced us to be in our built spaces in a way that is very illuminating. Absolutely.

Janet: Right. I was so surprised at it. It was such a dramatic shift, right? Because now these particular students have just spent their entire academic career in COVID at this point. So, I don’t know Meredith if you want to jump in…

Meredith: Yeah, well, I love hearing your experience of students and COVID because this idea of the environment impacting us, our brains, our bodies, our ability, our behaviors, all of those things up until the pandemic was sort of a, had a niche following, I would say, but the pandemic, the general population understands that the environment impacts our health. and I think what’s frustrating is how much time we’re spending protecting ourselves from our built environment. There’s such a burden on us as human beings, instead of extending that out into the environment. Our environments shouldn’t cause us harm and they are right now.

So now this is now kind of mainstream knowledge. Everyone, the general population has accepted sort of the built environments really do impact their health. We live with this every single day.

And so it’s no surprise to hear sort of how your students are, are reacting in turn. you know, the other thing I was thinking is the work you’re doing as educators and sharing this knowledge, this evidence, with the focus on human factors with your students is really important, but if we think about sort of how long it takes for your students to actually, I don’t have a hand in managing projects and actually designing real public buildings, that might be 10 years from now. So, you know, are we looking at a 10-year long limbo period before this is sort of accepted as part of our design culture and practice?

Janet: I was almost going to hit the desk cause you’re absolutely right about that. I actually said that to the students too, because I was, as they were going through their finals, it was funny. I talked to each one of them individually and I knew what they were all doing, but it wasn’t until I had them essentially all in one room when we were sharing the finals with the whole cohort, I realized, I’m like, ‘oh my God, they’re like, they are now interpreting the world very differently. Right? And maybe it’s much more about no further than their own backyard, a la, you know, Dorothy of Oz, right? But I did think to myself, I’m like, well, wait a minute, like these are not people that are just start making some of these decisions for another 10, 15, 20 years…

Davis: I’ll counter all of that because it’s true that many people are pivoting and are new in the field. But in our cohort of students, there are some, you’ll meet them as they progress through the curriculum, Janet, who are actively working at firms right now and going back to school to get a master’s so that they can implement more sustainable human health changes at work today. (J: interesting).

Similarly, many students wonder, when I mentioned to them that they’re contributing to the field, that’s like unheard of to them. They can’t imagine what I’m talking about. But the fact of their interest cumulatively as a collective, as design scientists working together, their interest in certain topics, such as nervous systems or trauma informed design, that’s helping to shape the discourse, (J: right), and its building momentum.

So there may be— as is true for, you know, white coat science— it takes a while to show up in the public. But the urgency of the situation is for built spaces is such that there are folks doing things today. I got an email last week from somebody in Colorado who said, here’s the work my firm is doing, working with law enforcement officers in their space and how we’re putting ‘Design for Human Health’ principles into place to the best of their abilities. So not discounting all that has been said, but another layer of information for the conversation.

Janet: Absolutely. And it’s an important layer to have. I think both ends are correct, right? I mean, again, just the shift within these young designers, they were starting to look at things very differently because of the pandemic, right? And more involved with the idea of health and uh, human factors and really kind of understanding the brain and how we also work within the environment. I mean, just talking about biophilia, I’m not even talking about healthcare or you know, residentials or what have you. So I think both are very, very true.

And it will be interesting to really see, Davis and I, we already knew this was going to be a thing, but it was still a little bit of a hard kind of nut to break. But I think with the pandemic things have changed quite a bit and have really made a difference within the design community.

Meredith: yeah, absolutely.

Outro Section 1

Janet: Meredith is so great… Her own story on how she got into Inclusive Design and Research is inspiring.

Carolyn: And since then, she has done so much more… as you’ll hear in the other sections.

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

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

Janet: coming up in the next section, more with Meredith as we explore how Behavioral Health Facilities are making good use of Trauma-informed Design, or as we call it here at IDP…TiD.

Bumper – Section 2

Janet: Welcome back. So in the first part, we learned Meredith’s own story of how she became passionate about Inclusive Design and Research, even before it officially existed as an acknowledged field of study.

Carolyn: And now it’s time to move forward in time to the present… as we dive into Meredith’s work on Behavioral Health Facilities and how they use Trauma informed Design, or TiD, to improve the experience for both staff and patients.

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 out 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: Yeah, 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 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. 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, well now 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 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 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 parts 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?’ …

Bumper- Section 3 

Carolyn: Welcome back. So far we learned about Meredith’s passion for bridging the gap between life experience and design, and also how Trauma informed Design, or TiD, is being used to improve behavioral health facilities.

Janet:  In this next part, we will discuss the benefits of collecting data to make sure the perspectives of both the patient and the patient’s caregivers are all included in the design process, and to measure all those results.

Interview- Section 3

Janet: So Meredith, how is behavioral health being integrated into healthcare?

Meredith: Okay. So we’re seeing kind of a move from healthcare systems, changing their care practices. And then in turn, we’re kind of changing the design of clinics and facilities to better support those models of care. So the move to include behavioral health in healthcare generally really comes from healthcare systems who recognize the totality of factors impacting health beyond just medical care or clinical care.

And here I’m really talking about the social determinants of health kind of model here which just includes all the non-medical factors that influence health outcomes. So addressing those other factors is really fundamental for improving health; reducing inequities in health; and even increasing access to medical care, which is kind of what we consider when we think about healthcare, and we only consider that realm.

But if you look at one of the models by ‘Go Invo Boston’, they have a social determinants of health model and their data suggests that only 11-percent of health is attributed to medical care. And the other 89-percent is these other things, like your social circumstances, your individual behaviors. And those are usually not very separate from each other. (J: hmm).

So, for example, your income or your employment status or unemployment status can very much influence your individual behaviors— your sleep patterns; your stress levels; your substance use. And those in turn will manifest in health outcomes and, you know, diabetes or what are considered deaths of despair, which include like suicide or substance related deaths. And those are largely preventable deaths. So, we have to kind of address all those other 89-percent of health factors if we’re really interested in working for a more healthy population.

So, the more innovative healthcare systems— and these tend to be, like community health centers who are working with populations that have more inequities and disparities and health inequities— they’re able to sort of see that totality of factors influencing health and really connect the dots between the way they’re delivering medical care. and then also, providing opportunities for nutrition, or housing, or behavioral health. (J: right).

And one of our clients that we’ve done some community health centers for is ‘Clinica Family Health’. They’re in Colorado. And they were one of the pioneers to sort of introduce integrated or team-based care into their practice. So, team-based care includes your traditional kind of family doc or primary care provider, but then also on the team are a behavioral health provider; a dietician; someone from dental, like a dental hygienist; a case manager. And they all work together in the same shared clinic team space. So they can support the range of patient needs.

In these community health centers, they also have co-located services that can provide housing assistance or nutrition assistance like WIC. So these co-located services, this team-based care model, can really increase access to care for patients who have these diverse needs. So, they’re also really innovative in thinking how to design for supporting this new model of care. They introduced group visits to create support systems for like diabetes management and that sort of thing.

They, before the pandemic, were doing car care. So they were administering flu shots. So kind of the whole family gets in the car. These often happen on weekends or after hours, you know, because that’s another problem with access to care. And sort of drive up and everyone gets their flu shot. It’s really easy. It’s also easier for children, so, right. I don’t know if you’ve had the experience of taking a young one— yes, okay Davis, yes— for their vaccine recently or a flu shot, but transitioning from the car into, for me, we had to go into this clinic, into the basement, it just was an opportunity for anxiety to build up and fears to build up.

So, there’s lots of innovative things that they’ve introduced, and they’re very nimble. They’re quick to change. So, they don’t have that kind of risk aversion, like a lot of other kind of healthcare organizations have. They’re very nimble in order to support the needs of the community and deliver the best care and get healthy outcomes.

Janet: Right. Yeah, I talked to somebody who has a child who has autism and she uses the parking spots. They’re labeled for handicap, and lot of people have yelled at her (M: oh), because she’s not in a wheelchair. How dare she use the handicap placard or handicap parking spot.

And I bring this up because it takes heaven and earth to move her non-verbal, kid who has autism from the car, just to the, you know, go into the supermarket just to pick up whatever it is that they need to pick up. (M: yeah). And so, yeah, the thought of like, maybe you’re getting a shot, like people have aversions to getting shots and they get freaked out by all this, and then it just, it’s just another layer.

So to be that kind of nimble and to be able to make things easy, go figure, right. To make them a little bit easier to make them a little bit more accessible, a little less stressful. Pretty great.

Meredith: Yeah. So, in that example where behavioral health and medical care and those other services I mentioned are coming together. We’re also seeing campuses specific to addressing behavioral health come about. There’s a great group in California called ‘Be Well’, that we’ve designed two projects for and so they’re bringing together behavioral health services to address again, the continuity of care from crisis, all the way to management and prevention.

They also include transitional housing. In this case, it’s in the same building. In another project it’s on the same campus, so that they can support patients and clients at every step of the journey. And that’s, that’s usually not a linear journey. It’s a lot of, kind of back and forth, but they can support them at any stage that they’re at. (J: Right).

One of the design challenges with those campuses— so it’s, it’s great to have all these things co-located to support access and continuity of care— but I think one of the things we learned is that you have to have these strategic separations. So for someone who’s coming in in crisis or in need of detox services, you know, how do you support their transition into the center in a way that supports dignity and offers privacy and anonymity, and also doesn’t sort of frighten people who are coming in for just an outpatient. (J: Right). Yeah.

Janet:  It’s, it’s interesting. I was just going to say what were your challenges? Because you know, you’re bringing a lot of different services. I’m sure when you do all the initial interviews and stuff like that, I’m sure you have a list that’s at least an arm’s length of wishes and needs and have to’s. And do you spend a lot of time trying to connect the dots? Or do things fit together somehow naturally? What’s your process? I guess.

Meredith: (Laughs). Oh…

Janet: How long do we have?

Meredith: laughs.

Janet: (Laughs). Is it one of those, okay. It was a loaded question, but if you can break it down. I mean, because as designers, right, even in the best circumstances, you usually get like a wish list, right? (M: sure). I mean, you get some sort of something like, this is what we would really like to have in some of the things they might not have even thought of. (M: yeah).

But when you’re dealing with so many different components, yet although trying to provide the same service for the same individual, (M: yeah). How does that work? Like any tips or I guess maybe that’s a better way to look at it at the moment… (M: yeah). We can have Meredith come back for a whole new series just on her methodology.

Meredith: Absolutely. I’d love to, um, so. Oh, gosh.

So first I’ll just say like, these projects are my favorite because they’re new models of care. And so they’re new building typologies. We don’t have precedents that we can turn to. And so we get to be really innovative, which is fun. And so kind of to your point of like, well, where do you start?

So sort of from the human factors perspective, we embrace evidence-based design processes, but we also include experience-based design. And this goes back to a point Davis was making about that lived experience and the importance of lived experience and cultivating empathy.

So I don’t have a prescriptive approach, but I do like to sort of start with the experience which recognizes, you know, that every person’s experience is a very valuable data point. Which is different than evidence-based design, which is like, you know, we need robust evidence and large sample sizes in order to sort of show this as true. And experienced design is like, no, every person’s experience is, is a very valuable data point that we need to consider.

So I like to start with that. I like to sort of start with the stories. And for behavioral health, this can be challenging because their behavioral health patients are considered a protected class. They’re a vulnerable population. And if you’re working with, you know, pediatric behavioral health, they’re kind of twice protected, so it can be really, really challenging.

So some of the ways we’ve sort of gathered their experience is by, accessing family advisory groups that are attached to the organization. So if we can’t go to the children, we can ask their parents and their caregivers to share their experience. Or if they’re adults, we can ask past former patient volunteers who give their time and share their experience in these advisory groups to participate.

I like to do whenever possible sort of walking interviews where you’re walking, and talking because there’s, I don’t know if this is the right use of the word, but there’s like this artifactual memory, or sort of like seeing different artifacts that triggers like ‘oh, you know…’

Janet: ‘oh, that’s right, oh by the way, can you do something with this?’ Right, exactly.

Meredith: Yeah. So we do a lot of that with staff, kind of these walking interviews with staff to talk about what’s working or what’s challenging in certain environments.

So I like to start with kind of that experience. And right away, I think we kind of learn, you know, what’s important, such as, you know: dignity; or reducing stigma; protecting privacy; giving control. Those things kind of bubble up right away and help create targets or goals.

And then we can issue things like surveys to get kind of that larger sample size. But now at least we know the questions to ask from kind of having those stories and learned those experiences.

Janet: Right, yeah. Davis?

Davis: I love talking methods to an ethic approval. Ah, yes, it’s a tricky, it’s a tricky thing to get access to people who are so-called vulnerable, because they’re the ones that we need to study the most. (M: Yeah).

And I love hearing about the walking interviews. It reminded me right away of a different time frame, but a similar approach perhaps, is video reflexive ethnography. (M: hmm). So that’s the work that I was involved with, videotaping an experience, something occurring, and then watching that video with the participants themselves.

And while they’re watching their own selves, they’re recognizing all that was going on, on a subconscious level that they’re now aware of now that they’re sitting and viewing it and having a chance to pause it, and interview and ask what’s coming to the surface for them.

Meredith: Oh, wow. I love that.

Davis: it’s so interesting.

Janet: That’s a great example Davis, right, because that might be something that could, you know it’s technology.

Davis: But another thought I had around getting somebody who you don’t have access to. So we want to design for particular folks and they’re not, we can’t approach them, we can’t talk to them because of privacy concerns and their vulnerable status. (J: Right). So this is where being creative and imaginative and knowing how to be, you know, like having more actors and actresses come into the design world would be amazing because they can become and personify other people role playing.

I did a lot of work when I worked at— and there’s a podcast episode from early on of me speaking about the ABC House— where I worked with folks to design an abuse intervention center. And I wasn’t, I had no intention to talk to any of the people who would be coming to that space, aside from the staff and the clients.

And there, we didn’t have advisory groups like Meredith does, but that would be fruitful. And we, I think we were doing it ad hoc. We were pulling that together and I was finding my nearest children and saying, would you mind coming with me and just giving me your opinion about how this is going to look, because I needed it from your perspective and your angle. And I would put myself on my knees and get to that height so I could see what people are seeing. (M: hmm). So, it’s just fascinating, fascinating work. (J: Yeah).

Meredith: Yeah. What you just described, it, we call those empathetic observations. So the scenario I’m thinking of, we were designing this eating recovery center. It was what they call their spa bath. So it’s the space where patients with eating disorders get ready in the morning. So they shower, they brush their teeth, they get ready, but it’s also where they have weight check-ins and vital check-ins in the morning. So, they’re in a very vulnerable state and it would never be appropriate for us to kind of go and observe this in real life.

So I played the role of a patient, just so we could document the processes in the spaces and really get an understanding— not to say that I would ever understand what it’s like to be a person with an eating disorder, or to sort of be in this inpatient eating recovery center— but reenacting the processes they were going through in the morning. And then there was another researcher with me who was kind of writing everything down and doing spaghetti diagrams and that sort of thing, really helped us with some process improvement for the space and then ultimately the design of the space as well.

Janet: Yeah. I think that this is a really fascinating part that you did in your methodology for this particular type of a vulnerable group. And it’s probably one of the more challenging populations to design for and your methodology to go through all of that. And to Davis’ point, you’re putting in sort of an actor into that role, because you’re also trying to have some sort of privacy for those that go through it.

At some point I have gone and taken my students around and they have them in wheelchairs or I have them sort of blindfolded. There’s definitely like you even said, I’m not trying to pretend to know what it’s like to go through it, but, but there’s certain things that I think you can get out of that.

And I guess my, my question is… Did you have an ‘aha’ moment when you were walking through and you were doing your own acting role within this? Did you think it was a good thing to do it that way, I mean obviously we would like to have those that go through it but is there something else that you would preferred? Did it work?

I guess I have a hundred questions, so I don’t know which ones to ask first, (M: laughs). I think that that’s what it comes down to. So if you want to expand a little bit more on, on your experience with that, that would be great…

Meredith: Sure, sure, sure. So, there’s not like a prescriptive sort of methods I roll out for every project, it’s really kind of matching the right tools and techniques to whatever it is we’re trying to address. For that particular space, there was an issue of sort of, of waiting in line in order to have weight and vitals checked. And these patients are in a really vulnerable state they’re sort of in a gown, besides just the ‘waiting is waste’ sort of thing.

And so our objective was, you know, how do we get rid of that waiting experience, and then also just create sort of more dignity around what’s happening during their morning routine. So the empathetic observation was one piece to really capture the processes. And there were some also, some things that I experienced just, different proximity to other people, that felt very uncomfortable, again, when I was in that vulnerable state and I did put on the gown and all of that.

Janet: Wow. So you really are a method actor, as they would say. So it’s sort of like what we do with my students. Right.

Meredith: Yeah. So right, even though I don’t have that eating disorder, there were still environmental elements that I was very hyper aware of, that I would imagine sort of would translate. So we can check our assumptions on that by issuing a patient survey, which we did to former patient. They have a whole alumni group of volunteers who took the survey and did respond to some of the assumptions that I had so that those were validated in the survey.

The other thing we did is we did some simulation testing using a digital software program called ‘FlexSim’ which you can set up the architecture, you know, floor plan or a 3d model. And then if you have the processes correct, and sort of timestamped, you can actually run these fake patients through and understand sort of where the bottlenecks are.

And then, you know, you can figure out, do I need to add another staff member? Is this an operational thing? Do I need to cut out one of the process steps? Or is it a design thing? Do I need to add another shower? Do I need to add another exam room? And so you can quickly change these different variables and then run patients through as a simulation and see if wait time is reduced, if sort of the bottlenecks go away.

I think that testing during design is really, really important, so we’re not waiting until the project’s built and we can’t do anything about it. (J: about it, Right). Yeah.

Janet: Yeah. That’s an important piece. So, yeah, but I just think it was such an interesting project that you did and I think there was probably more challenges than other projects. Did I understand that correctly?

Meredith: So again, this is kind of one of those new ways of delivering care, so kind of specific to an eating disorder population. Even though anorexia is the most— gosh, I feel like I need to get my words correct— but I want to say anorexia is the most fatal psychiatric disorder. There’s not a lot of funding to support treatment. It’s getting better, like they’re passing legislation to recognize it as a disorder and then sort of provide insurance treatment. But historically it’s been really difficult. (J: right). So without the insurance to sort of fund treatment, there haven’t been facilities to have the treatment, which is, I mean, it’s sort of mind-blowing.

Sometimes these patients go into traditional behavioral health care settings, but eating disorders are really different. And the, what the patients are experiencing and their treatment programs are very, very different from sort of, (J: just like, alcoholism…) sure, yeah. Any of those sorts of things. (J: right) And so, again, this is an opportunity with the rise of these eating recovery centers, which are now all over the country to say, well, what is the right design to support the care that they’re giving.

One of the things that came up was proxemics, comfortable proxemics. So sort of part of eating disorders diagnosis is a misperception of your body, the kind of the space your body is taking up. And related to that, sort of a misjudgment of maybe body to body distances; or body to wall distance; or body to furniture distance. That perception is often, that judgment is sort of off.

So like in the dining area, which is a really stressful part of treatment, you know, we heard from the patients that they felt cramped or crowded. And so we created smaller dining cafes, so there weren’t as many patients in the dining space together. And then we created— and I forget what sort of the recommendation is between, diner to diner— but we almost doubled that to give them more space and more comfortable proxemics there.

Janet: I mean, I find that fascinating you know, that there’s some sort of body dysmorphic anyways, but that they are also reading the built environment incorrectly in terms of their body. Am I understanding that correctly? (M: yeah).

And then I start to wonder who, those others, like psychological issues that I think would probably also have that same sort of thought processes— like maybe people who have schizophrenia— in terms of themselves versus the built environment. (M: hmm). But in terms of eating disorders, I mean that’s pretty incredible. And I’ve got to think that there’s, I mean, we talk about it anyways, right, to a certain degree, but this is, I feel like it’s more tangible and more understandable.

Davis:  It might even be more or, or even less than the thought process, because that’s putting it on the individual that they’re thinking or not thinking correctly, but really what we’re talking about is it is a circuitry… (J: misfire). Yeah, you know, neural connection, (J: right), uh that, that can be altered. And once the chemistry of the body is, is shifting. And in addition to the thinking training along with the, you know, the spaces is therapeutically supporting that process. Right?

Meredith: Yeah, absolutely. Right. And another thing with persons with eating disorder is they have dis-regulated circadian rhythms because eating and regular meals is a regulator of our circadian system.

So, you know, I think that’s where daylight becomes really, really important in their recovery process as we’re, you know, trying to retrain the circadian systems. And that’s hard for behavioral health because by code you’re required to have patient rooms have windows and that’s a code requirement. But often patients aren’t using their rooms during the day. So all of the spaces that could have daylight are often kind of moved to the core. and that’s just, that’s not good for their, their recovery process.

Janet: You learn something new every day, Meredith. (M: laughs). That’s an interesting point, but it’s, it’s a really good point, right? I mean, you don’t spend all that time and if you do it’s mostly at night.

Well, there’s that, ah I’m not going to remember the name. They just did a whole thing. Some very wealthy donor gave a lot of money. It was for a dormitory….

Meredith:  … oh yes, at “USC” Santa Barbara.

Janet: Yes. So just for our listeners, in case you don’t know, they put all the dorm rooms on the interior, right? And they put all of the public spaces on the outside. And there’s been a lot of outcry from the design and architecture community that this is probably not a good thing. And they are sticking to their guns. They are sticking to their guns. Any thoughts on, on that…

Davis: Well doesn’t it bring up that we need more good science and good evidence because, well, you know, you’re manipulating the experiences of thousands and thousands of people without necessarily the logical evidence that can create that… you know, tossing hypotheses at a construction plan that will become an actual building and a place where a person will live for long time, not the length of a cruise.

You know, but what is it when you get back to the evidence part of it? Well is it the photons of light coming through the window that are helping people feel better, or is it the gaze of the eye that’s connecting to the brain that’s helping people feel better. We just don’t know, do we. (J: right). I mean, it’s bringing to the front a complex matter that needs a lot of good smart people coming together and talking to each other, just like we’re doing.

Janet: I was going to say just like Meredith and Davis… it’s all good…

Meredith: (laugh). It certainly is a move that does not seem supported by any evidence that I’m aware of. (J: Right). And, when we did a project for Boulder Community Health. This was an adult inpatient behavioral health unit. And the design team included tune-able lighting throughout the whole unit. And it’s the first that we’re aware of that the inpatient behavioral health that had tune-ables throughout the whole units, even in the patient bathrooms, for example.

So the tune-able changes over 24-hours to mimic changes in, in natural daylight. And, you know, you have higher intensity blue light in the morning to suppress your melatonin and keep you awake and alert, and then kind of eliminating that blue light spectrum in the evening to allow melatonin and support sleep.

Now, because this had never been done, our lighting designer really struggled with: “what time do I make the shifts?” “What should be the light intensity at four o’clock versus nine o’clock?” “What should be the color spectrum at, you know, 11 o’clock at night versus 8:00 AM in the morning?”

So she made use the best use of the evidence, but I remember having many conversations with her about, ‘we don’t know, what if we are doing harm here, because we don’t know.’ And, but certainly, you know, we made really the best decisions we possibly could make using the evidence we had available. (J: right).

The great thing about tune-able is you can change it and, and we’ve collected data and we have gone back and changed it. So, that’s great. It’s not sort of like a traditional lighting system where you got to change out all the fixtures in order to make a difference.

But this question of designing when you don’t have the evidence, it does become sort of a little bit of an ethical responsibility to consider. (J: right). But UCSB, I don’t see any evidence supporting what they’re doing at all. (laughs).

Janet: No. Well I think that’s why it made the news. (M: yeah). I think that’s why everybody was sort of up in arms about it. I kind of didn’t mean to go off topic, but again, it was, you know, again, it goes back to this sort of like what kind of evidence that we have, and, you know, in much like the lighting that you’re talking about, we will always have to kind of keep tuning those pieces of evidence because things will come out and things will change. And who knows, even with some of the stuff that we’re dealing with the pandemic will change sort of how we also live, and how we, maybe inherently biologically like it’s still, a lot of this stuff is still the same, but maybe things will change just a little bit that again, just need to be finely tuned.

Meredith: Yeah, I think this is a really interesting time we’re in, because evidence-based processes are great when we’re in stable systems. And when I think about the pandemic, we’re in this time of great disruption. And the evidence keeps changing, and policy keeps changing every single day, right?

Janet: And we’re getting used to the uncertainty…

Meredith: We’re getting used to the uncertainty and those who have relied on evidence-based medicine or evidence-based processes to make decisions, I think they’re really struggling right now. sort of what is best practice. Even for our designs, you know, they’re supposed to last at least 40 years. And we don’t quite understand ‘what is best practice now’ considering this pandemic and transmission and all of those things. So…

Janet: Right. Going back to what you were talking about in terms of the neuroscience of it. (M: yeah). Is any of this, you know, again, back to trauma, is some of this trauma also changing some of the wiring in our brains? Is that going to be some sort of factor? is the 40-year time span really relevant?

I find this kind of stuff fascinating. I think it’s going to, you’re right, this is a destructor, right. So, but we get an opportunity to kind of maybe look at things (M: yeah) and, maybe it is that we will have things that we have already known to be true, but maybe we will also pivot.

I know Davis and I have both talked about how like a lot of people are like, ‘oh, I haven’t done anything by make bread for the last two years’. (M: laughs). Davis and I both though, have— I don’t know about you— have found that this is a very busy time for us. It’s been very, very busy. And because I think people were trying to figure things out and, and we’re trying to all kind of, I think, maybe help each other.

Meredith: Yeah, I think, you know, Davis made a point about healthcare, well specifically to healthcare being risk averse. And absolutely, we see most healthcare organizations being risk averse. But because of the pandemic, I think there’s a real opportunity rather than just using evidence to inform design— they like to use evidence that can validate this model that’s been used 50 times is the best nurse station or patient program or that sort of thing— now we can use evidence to transform design. So to me, that’s really exciting because we weren’t able to sort of take those innovative leaps with a lot of healthcare clients today. And, because we have this great disruptor, now we can.

Janet: We have an opportunity for change, right? I agree with you, mentioned it to my students recently as well. (M: Yeah.). That’s great. Meredith.

So what do you think about going forward? What do you think about the future, about methodology? What do you think about, in terms of some of the things that we might be seeing? Because we’re now just talked about the pandemic and how things are disruptors. Like, so what do you see as our future? What are your hopes and what are your thoughts about that?

Meredith: Okay. So from the research perspective, I see sort of this move into data. I’ve heard others kind of describe that data, not drawings, is our new currency. I think it’s probably data in drawings, because drawings are the way that we communicate. So how do we infuse data into the drawings? So I’ve been— even as Director of Research— I’m increasingly uncomfortable with kind of this post-occupancy evaluation, which is sort of what we’re trained as design researchers is the gold standard.

Janet: You might not be able to see me, but my eyes just went “what?” …

Meredith: (Laughs). Don’t throw rotten fruit at me, please, please. They’re going to take away my title as researcher. But hear me out first for a second. Because post-occupancy— so here’s my issues is that— it looks at a facility at one point in time. And I think that we need to realize that certainly people are dynamic. We get that. We change. And also groups of people and, uh, sort of staffs can have turnovers or different cultures. And those change too.

I don’t know that we think enough about how dynamic environments are. And I’m not just talking about sort of longitudinal change that happens over a building’s life cycle. Like, okay, now this storage closet becomes a break room. I mean, that is important to consider as well, but I’m thinking of just the short-term dynamic changes that happen in our environment.

So if you’re in an environment with windows, you’re exposed to different light levels and color spectrums of light throughout, you know, almost minute by minute. If you’re in a room with a lot of people, you have different noise levels and those can change, again within a day. Your air quality. Again, if you have a room full of people, you might have higher CO2 levels, which can really affect your cognition and your alertness. So those kind of environmental variables are constantly changing and affect our performance in those environments. (J: right).

So I think that we need to think about continuous monitoring of both the environmental and human parts of that ecosystem. Going back to the ecosystem model, in order to sort of understand this as a complex interacting system. So, our methods, instead of post-occupancy, I might offer, you know, can we move into continuous occupancy evaluation? Instead of looking at just one project, can we look at portfolios of projects?

So we’re really lucky because we have repeat clients who, like ‘Eating Recovery Center’ who I mentioned earlier, who have multiple facilities and sites that offer the same programs.

So, when I’m doing a study, I never just look at one project. I always look at sort of their whole portfolio. Right now, we’re looking at eight different programs sites for them in order to sort of understand what’s best moving forward.

So it’s sort of this big data approach and taking multiple streams of data. And then, you know, maybe looking for outliers of, ‘oh, this facility is really doing something great, what can we learn from them on this dimension’ versus ‘this facility isn’t working at all’.

So in terms of technology, we’re starting to introduce sensors and wearables. Like a ring measuring stress. We have not used it in a healthcare setting yet. We’ve sort of just set up a system using volunteers from our own staff to do sort of an office worker study, just so we can kind of get the components in the system set up.

We have done a study where we had inpatient behavioral health staff wear light sensors to understand their lighting exposures. This was under the tune-able system which was really important.

But any time you have a sensor— whether it’s an environmental sensor or a biometric sensor— that’s timestamped, you can bring all of this data into the same spreadsheet and then look at interactions between them and really start to understand the system as this ecosystem

Davis: That is so fascinating. Being a lifelong, um, sensor wearer due to— which I’m also forthright about sharing my lived experience— of having type one diabetes. It was only recently that they’ve developed a continuous glucose monitor sensor. So to know that information for me on an ongoing constant evaluation is fruitful and helpful, and I can see patterns and trends.

And one moment in time with a blood sugar test is useless. (M: yes). So having something that’s responsive to the immediate needs is much, much more helpful. So I really love your evolution of post-occupancy evaluation. In fact, I was just speaking with Mardelle Shepley yesterday, because she said that also— something she was hedging in that direction I believe, I might be putting words in her mouth— but it’s a little too broad. The POE, it’s, it’s a broad ‘here let’s just plunk it into the building and take advantage of this’, not knowing what the actual specific typology is; what the actual population needs are. It’s not able to be nuanced and fine-grained enough. So the ‘Continuous Occupancy Evaluation’ – Meredith Banasiak, C-O-E. I’ve got a termed here now, it’s a thing. (laughs).

Meredith: Sweet! Yeah, I love, I love the analogy you shared Davis about your monitoring your diabetes. I might have to borrow that one as well. I think that makes a strong case. And I also think it’s setting us up as designers for creating kind of feedback loops.

So not just the monitoring of this human environment system, but adaptive environments. And that sounds really sci-fi, but it’s really possible with the tune-able lighting. I mean, we’re almost there. We don’t have the AI built into the tune-able system, but we’re not that far away that it could respond to different occupant measures and automatically adapt.

Davis: Right. And once we get sleep under control individually and as a collective community, we’re all going to just start feeling much, much better. And getting a handle on our lighting needs, will feed, it’s that feedback loop, its, it’s just perfect. And then the sensors and the lighting and the battery life is just eclipsing each other, the competition is amazing. I wear my aura ring here and can track my sleep measures quite well. So, I’m excited to hear about the future of technology and how we can integrate and incorporate these new streams of data. (M: hmm). It’s Fantastic. (M: Yes).

Janet: Right. So before we go, any last thoughts from your perspective, meaning like what do you want designers to take away or know on neuroscience and designing for behavioral facilities? Is there anything else we should know?

Meredith: So, when the Academy of Neuroscience for Architecture was just emerging, it aimed to bring together neuroscientists and architects, because that’s all we had as our starting point. But, you know, fast forward almost two decades later, we have bridges. We have, like you, like Davis, like Janet. We have bridges in this field who are bilingual in the sciences or in evidence-based and in design.

And those bridges are really critical to help making the translation between the evidence. And also for conducting practice-based research which is absolutely a necessary part of this research spectrum.

We absolutely want to make use of the findings coming out of the lab, but we also need to do research in naturalistic settings which is very different from the way they do research in the lab and the findings they’re getting in the lab. So, I would just say, we need more bridges in this field in order to advance the field.

Davis: Well, thank you so much. This is such a treat and, I love the emergence of a new job description, the design bridges of the world. So, I look forward to speaking with you more personally, but I also would invite you to share how folks who are listening, who would like to hear more about your work or learn more about what you’re up to, how they can be in touch with you.

Meredith: Oh, I’m happy to share anything. It’s great, I love connecting with people who are interested in this stuff. So I’ll provide a link to our site at BA Science. And I can also be found on Twitter and LinkedIn and look forward to connecting.

Janet: Meredith, thank you so much for this time. This has been a fantastic episode and there is so much more to discuss. Maybe we can continue this conversation in a future episode…

Meredith: Yeah, absolutely. Thank you so much for the opportunity to be a guest on your show. I have such respect for the work you’re doing and the resources that you’re sharing with our design community so we can help move the culture forward.

Janet: Yeah, I know I’m excited about it too.

Davis:  and I look forward to more conversations with you Meredith, thank you.

Janet: Thank you Meredith, Thank you Davis.

Outro- Section 3

Janet: Boy, Meredith really knows her stuff. I am so impressed with her and the work that she is doing in this area of behavioral health facilities. One thing that really stayed with me was the use of Tunable lighting. Although Carolyn I got to tell you, my cat was just a little disappointed, she thought it was tuna-able lighting. Get it?

Carolyn: (laughs) I do get it… I think my sense of humor is rubbing off on you.

Janet: But in all seriousness, daylight is so important to recovery, and to be able to adjust the lighting is huge. I also love how Meredith stresses the use of research evidence and scientific knowledge together to inform real projects. This optimizes the design for health, performance and access.

Carolyn: From what she said and the examples she gave, these methods have proven to help the staff at the facilities, as well as the patients and their families. Meredith is very forward thinking and to quote from her bio, she ‘supports a transformational shift in design towards an evidence-based, and person-centered culture.’

Janet: With that we’d like to thank both her and Dr. Harte for this inspiring, empathetic and scientifically considered talk today. I cannot thank them enough. As Dr. Harte said, this was a gift for us to have this type of conversation with Meredith.

Carolyn: And I can see us bringing Meredith back to dig into these topics even more in the future.

Janet: I’m nodding my head, absolutely, but getting back to this episode… we will also share the links for Meredith; Davis; Trauma Informed Design; and of course, the many more things mentioned during this discussion… all on our website at:…

Carolyn: That’s:…

Janet: Thank you to Meredith & Davis. And thank you all as well for listening.

Carolyn: Along with all the regular places you get your podcasts, you can also find us on YouTube as, you guessed it, Inclusive Designers Podcast. 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: And, as we say around here: ’Stay Well…and, Stay Well Informed’.

Thank you as always for stopping by. We’ll see you next time.

Carolyn: Yes, thanks again.

– music up

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