In 1813, Samuel Tuke wrote the following in a description of York Retreat, an institution for insane people in York, England, that was founded by his grandfather William Tuke: “Many errors in the construction, as well as in the management, of asylums for the insane appear to arise from excessive attention to safety. … In the construction of such places, cure and comfort ought to be as much considered as security.”

It was true then, and it’s true today. A design approach for psychiatric facilities focused totally on the elimination of potential safety hazards for the patient will lead to an environment of care that is inhospitable, institutional, and unlivable. Designers must walk a tightrope between the ultimate safe environment and an environment that is therapeutic and fosters healing.

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The Facility Guidelines Institute’s 2010 Guidelines for Design and Construction of Health Care Facilities offers direction in the section “Environment of Care for Psychiatric Hospitals” by noting that a safe environment is critical; however, no environment can be entirely safe and free of risk. “Patients in inpatient psychiatric treatment facilities are considered at high risk for suicide; the environment should avoid physical hazards while maintaining a therapeutic environment. The built environment, no matter how well it’s designed and constructed, cannot be relied upon as an absolute preventive measure,” the guidelines state.

Certainly, the more comfortable and homelike the environment, the more problematic it becomes to make it entirely safe and free of risk. To overcome this challenge, designers and facilities must work in conjunction with the clinical staffers on these units and gather input from former patients, to address the issue of designing healthful, therapeutic spaces for patients with psychiatric disorders. Issues to discuss with staff include the safety of furniture items related to looping hazards, access to staff in the nurses’ station, and the  potential for self-harm when patients are in their rooms and alone.

It’s also helpful to have furniture items delivered to a site and assessed by clinical staff for safety and durability prior to purchase and installation. Items such as door hardware, plumbing fixtures, curtain attachments, and wardrobe construction should also be reviewed by members of the project team before being specified.

If the project timeline and budget allow, mockups are another option. At NewYork-Presbyterian Hospital/Westchester Division (White Plains, N.Y.), full-scale mockups of the proposed nurses’ station are being built prior to preparation of shop drawings and construction to allow clinical staff to see what’s planned.

Design considerations

During the design process, it’s important to weigh all the items that are part of the inpatient environment to determine if they’re safe and contribute to health and healing. This includes natural light, color, acoustics, furnishings, and artwork.

It’s also important for the design of these units to empower the patient, the visitor, and the caregiver. This means providing opportunities for patients to experience beauty and nature, and tailoring the therapeutic environment to foster patient autonomy and self-directed care.

At the child psychiatric clinic at NewYork-Presbyterian Hospital, a dreary corridor was turned into a cheerful, child-friendly outpatient suite with a new design that centers on a reception/waiting area defined by a curvilinear “play wall.” This area accommodates various functions, including seating at multiple levels, climbing areas, heat-sensitive touch walls, a fish tank, write-on/wipe-off surfaces, and storage for toys, books, and games.

Separate but connected waiting areas create flexibility for family members and children, while an adjacent, semiprivate space offers a respite for children who feel threatened, are acting out, or just need to be on their own for a while. The space was furnished with only soft floor pillows to reduce the chances of a child being injured when physically acting out.

In the public waiting areas, steel-framed furniture was selected for both durability and ease of maintenance, with upholstery that resists cutting or piecing. Still, the entire public space presents a playful, colorful, and friendly ambience upon entering.

In designing for caregivers, it’s important to remember that a visual connection must always be maintained between staff and patients. At a nurses’ station, which is typically the central point to control access to and egress from a psychiatric unit, the design should be open for general circulation and patients but also provide an enclosed area for staff to do paperwork and have private conversations.

The unit clerk has visual control of all circulation aisles as well as the major activity spaces such as dining, lounges, and living rooms. Since this can be a challenge in psychiatric units with more than 20 patients living in single or double bedrooms, one approach is to create an open area similar to a hotel concierge desk with high visibility and a private work area behind.

Providing privacy with security is another design key. Meeting areas for groups and dining rooms need to allow observation from the outside yet some privacy for the patients. For example, at NewYork-Presbyterian Hospital/Westchester Division, large polycarbonate vision panels were inserted into existing masonry walls to allow for visibility from the corridors into these spaces. In this way, the space can be used by patients and still be observable by staff without intruding into the room.

In a psychiatric emergency room where extreme behavior is the norm, electronically controlled glazing can be used from the corridor for observation while still providing some semblance of privacy to the patient. Here, a patient can be in the room yet the staff can switch the glass from translucent to transparent, then quickly switch it back.

At NewYork-Presbyterian/Weil Cornell Medical Center (New York), in the Greenberg Pavilion, this same material serves as partitions between activity areas and private consultation/family meeting rooms. The design feature allows staf
f to maintain observation of the patient while still allowing for a private visit.

These spaces become part of the visual field of the main activity areas and create a sense of openness within the closed psychiatric inpatient unit. Otherwise, without this type of architectural intervention, staff would have to open the door and interrupt activities on a regular basis.

Going forward

The challenge for design professionals is always to try to provide the most comfortable living environment possible in a setting where the patient is not really free to leave or be left alone. Accommodations for continual staff observation and intervention are major design factors, as is creating an environment that limits the ability for patients to harm themselves.

The more a psychiatric unit can be made to feel like home, the more likely it is that the environment will become a real “asylum” for the patient and a place for healing.

Jaques Black

Jaques Black, is principal/president at DaSilva Architects in New York. He can be reached at