DESIGN IN MENTAL HEALTH 2023
story today, and specifically to talk about the PICU environment.”
Giving the patient perspective Bernard Fox began by explaining – with some irony – that the title for his part of the presentation was ‘Bending corners and sucking eggs – a patient perspective on the design, build, and infrastructure, of mental health hospitals’. He said: “Let us always be mindful that the very foundations of our hospital settings are the clinicians and staff that ply their trade there. We are privileged, at NAPICU, to provide for, and improve, patients’ willingness to engage with these good people. Our quest is mentally unwell patients’ improved wellbeing and sustainability. I’d urge all involved in creating and maintaining mental healthcare environments to sense themselves both living, and working in them. It’s incumbent upon those working to calm our troubled minds to keep further ambiguity to a minimum.” Discussing a theme which was to recur several times in the presentation, he said that in his experience, ‘ambiguities’ in the context of mental healthcare settings were ‘mostly bad’. He elaborated: “Ambiguity leads to unfocused worry and confusion, paralysing choices and actions that would benefit the patient. Ambiguity also makes things seem different than they actually are, and instils a sense of discomfort and danger that further alters the perception of that person or situation. This is not helpful.”
Too much choice on offer? Dr Dye said these comments about ‘ambiguity’ were ‘interesting’, because the mental healthcare profession was currently striving to give patients ‘a lot of choice’. He said: “But then that somehow leads to some ambiguity, i.e. saying to patients: ‘You could do this; you could do that, or you could do this.’ As Bernard rightly says, there needs to be a clear path with both the process and the environment – from the latter standpoint you are talking about the physical, the psychological, and the social environment. I think that if all of these are clear to both patient and staff, you’re off on the right track.” Bernard Fox said his experience was
that when in a psychotic state, ‘one’s mind is awash with choices, many of which you don’t even recognise’. He said: “To further exacerbate this with external choices that don’t make sense is counterproductive.” He continued: “In your mind’s eye you will
Temple Grandin, whose innovations revolutionised practices in the humane handling of livestock.
find countless examples of that which is confusing or makes little sense. Let me share a few from my experience 20 years ago. For example – a perfectly sensible courtyard, paved ‘playground style’ with rubber tiles for protection, comfort, and ease of maintenance; a safe place for fresh air and exercise – you’d imagine – but with its access (to service-users) inexplicably barred, and – dead centre within it – the only occupant a decomposing pigeon, with corn from its last feed sprouting richly verdant from its rotten crop. This was the scene from both my room and the unit’s restaurant, that doubled up for supervised visits – a miracle sign from God just for me. It caused those locked doors to be opened in a trice; staff formerly engaged in avoidance now rushed to clear what they saw as a shameful mess.”
‘Not looking is no excuse’ ‘Like the patient suggestion box never opened’, Bernard Fox said, ‘not looking is no excuse’. Discussing some of his other experiences in PICU settings, he continued: “Previous occupants’ excrements were smeared illegibly on the wall of my allotted room in one facility; then there was the defective light that seemed to flash on and off ‘in sync’ with my troubled thoughts; shining domes in the corners of ceilings shielding all manner of observational devices. Ironically,” he added, “now these round mirrors have evolved into exactly that – cameras. How marvellous – as long
The definition of delusion is ‘a fixed false belief that is unamenable to reason’ – and when somebody is in that state, things need to be simple, and kept simple. When somebody is then gradually recovering from that state, they realise there are perhaps other choices, and this can then sometimes overwhelm people
THE NETWORK | AUGUST 2023
as the patient has such ‘tech’ knowledge- gathering devices explained to them.” He had also seen ‘unutilised spaces and equipment clearly inappropriate in short- term stabilising intensive care units’ – leading him to conclude: ‘If it’s unworkable, why not simply take it out or mend it?’ He continued, addressing mental healthcare providers as a whole: “It’s your innovations that simplify, modify, and re-design, any aggravations fuelling this uncertainty.” On recently visiting a new mental
healthcare facility, Bernard Fox explained that he had commented on ‘the very dilapidated state’ of the outside environment. He said: “There were thistles and nettles growing up wall boards, unmanaged weed and grass, and blocked drains. The stock answer I received from the staff there was: ‘This has nothing to do with us.’ However, we all know different, don’t we?” Stephen Dye said he believed the
examples Bernard Fox had just described highlighted both the importance of cleanliness and pride in a facility’s upkeep and appearance within the mental healthcare sphere, and that ‘everything in such environments has a function, but that sometimes it’s not understood by the inpatients’. It was key, he believed, to ensure that the purpose of components such as the domed CCTV cameras Bernard Fox had alluded to was clear. He said: “No matter how wonderful the physical environment, things can be taken in a different ‘context’ when you are mentally unwell. I think this goes back to the ambiguity Bernard alluded to. He is now going to talk a little about the similarities of what he sees in his farming life day-to- day, and good practice in a psychiatric environment.”
Dr Stephen Dye
Relevance of building and design to farming career Bernard Fox said: “Working with animals has perhaps given me a more sensitive
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Rosalie Winard
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