Across the United States, health systems are racing to expand behavioral health services to meet growing demand, yet entitlement and approvals obstacles continue to stall projects long before construction. Only about 20 percent of behavioral health projects are zoned “by right,” meaning development is automatically permitted under existing local zoning regulations without special permits or discretionary reviews, according to the article, “How SUD Providers Can Overcome Community Opposition to New Treatment Centers,” published in Behavioral Health Business in July 2024. The remaining 80 percent must navigate zoning variances and public hearings that can add months to schedules, inflate soft costs, or derail projects entirely.
When these obstacles disrupt critical behavioral health projects, the resulting strain on capacity directs patients to the next most accessible point of care: already overburdened emergency departments (EDs). This bottleneck will only worsen as the U.S. Health Resources and Services Administration projects a 50 percent rise in demand for behavioral health care by 2033, according to the article “The Road to Tomorrow” published in the American Counseling Association’s Counseling Today in January 2025.
In this context, project teams often view entitlements and approvals as bureaucratic hurdles. In reality, they are design challenges. Behavioral health facilities combine unfamiliar building types, high-stakes safety concerns, and persistent stigma. Projects succeed when teams treat approvals as an extension of design, requiring communication, visualization, and stakeholder alignment rather than documentation alone.
By following a five-step playbook, project teams can reframe zoning and permit approval for behavioral health facilities as an actively manageable design strategy that strengthens community trust and accelerates access to care.
1. Educate early to reduce stigma
Behavioral health approvals are driven as much by perception as by code. Community concerns typically center on safety, property values, police response, and proximity to schools. These fears often stem from a misunderstanding of who will be treated and how. Inpatient behavioral health patients are among the most supervised individuals in any community; without treatment, they pose a greater risk to themselves or others.
Preliminary meetings with planning staff allow teams to shift the approach from defense to proactive alignment, sharing early site and operational goals to surface concerns and identify stakeholders before a project is even submitted.
In public hearings, successful teams lead with a narrative, not a site plan. Clinical leaders are essential here, as a physician or administrator can translate operations into human terms. For example, high ED boarding rates are visible pain points for hospitals and first responders. Connecting a project to that relief reframes it as a community-oriented solution.
2. Supplement reviewer expertise
Local reviewers may have deep experience with residential construction but limited exposure to healthcare codes. Furthermore, behavioral health environments often require specialized safety detailing, such as antiligature hardware, secure yet code-compliant egress strategies, and tamper-resistant fixtures that reviewers are not likely to encounter in typical occupancies.
This expertise gap frequently triggers additional layers of review. Effective teams anticipate this by proactively providing a clear life safety narrative detailing the layers of occupant safety built into the design, including egress strategies and access control. External technical reviewers, such as national code organizations or consultants engaged by local authorities, can be allies, giving local reviewers confidence that complex projects meet appropriate safety standards.
Transparency is a schedule strategy. Teams should map all formal and informal reviews—including zoning, permitting, and those from third-party consultants—to identify where unfamiliarity is likely to slow decisions. Budgeting time and fees for supplemental review reduces schedule shock later on.
3. Engage informal stakeholders before they become critics
Formal approval bodies cast votes, but they rarely make decisions alone. Informal stakeholders, such as police and fire departments, school districts, and neighborhood associations, influence outcomes well before hearings occur. If their concerns go unaddressed, their skepticism can stall a project.
Project teams can take control of the narrative by scheduling voluntary briefings with these groups before major hearings. This means addressing their specific interests with tailored materials, such as security plans showing camera coverage to support police incident response or strategies for continuous, active staffing to assure neighborhood representatives of effective patient supervision.
By clearly explaining operational processes for admissions, observation, and discharge, project teams replace stakeholder uncertainty with concrete strategies for community safety, reducing the likelihood of last-minute objections that derail planning.
4. Run approvals and design in parallel
Behavioral health approvals routinely take longer than expected, often facing multiple reviews with their own meeting cycles. If design is held until each process is complete, months of idle time accumulate, prolonging community shortages and increasing costs. A parallel schedule that advances design while approvals progress can protect opening dates if executed strategically.
This approach comes with inherent financial risks. If critical approval is denied, design work will be lost. Teams must evaluate the owner’s tolerance of risk early to determine how far to move design in parallel.
Repeat developers with urgent capacity needs may accept a riskier approach, progressing all the way through design and documentation even as approvals are pending. First-time or resource-constrained owners may require a low-risk approach that pauses design at test-fits or schematic design until receiving favorable feedback from planning authorities.
When structured carefully, parallel work absorbs entitlement delays, preparing documentation for permit as soon as approvals are granted rather than months later.
5. Use architecture to reshape perception
Architecture can answer questions visually before a word of testimony is spoken at the first public hearing in the zoning approval process.
Behavioral health buildings must balance high safety and security with a welcoming, noninstitutional appearance. Design teams navigate this tension by integrating:
- Residential-scale massing rather than monolithic forms.
- Layered entries that signal supervision without visible barriers.
- Clear sightlines embedded within familiar architecture.
- Material palettes that evoke community centers instead of correctional facilities.
- Careful detailing of hardware and glazing rather than overt fortification.
Site planning is equally important. Embedding programs within larger healthcare campuses or civic contexts can normalize care and reduce perceived risk. A successful design not only reduces the institutionalization and stigma of behavioral health care but also gives neighbors and reviewers confidence that the facility prioritizes the safety of both patients and the community.
The framework in practice: Southwood Children’s Behavioral Health Hospital
Southwood Children’s Behavioral Health Hospital in Pittsburgh demonstrates this framework in action. The $37.8 million project, designed by IKM Architecture, introduced a 66,371-square-foot facility, adding 108 child and adolescent inpatient beds on an existing campus in a residential township. An initial meeting with local authorities outlined a six-month approval path, but the entitlement ultimately required nine months, driven by differently experienced reviewers and engineering verification.
Throughout four public hearings with the Upper St. Clair Township Planning Commission and three with the Upper St. Clair Township Board of Commissioners, the design team led with storytelling, partnering with the hospital’s passionate CEO to communicate the vital treatment this facility provides as a community asset. Visualizations of the colorful façade reinforced the welcoming character of the building while appealing to the young patients and families it serves. Each vote resulted in unanimous approval.
Local police requested a review despite having no formal role. The team presented detailed security plans showing camera placement and access control strategies, and the department ultimately raised no objections. To address the expertise gap, the team also complied with a request from the township’s engineering consultant for construction-level documentation of a retaining wall beside a neighboring apartment complex to verify safety.
Additionally, the local building official had limited experience with behavioral health occupancies and requested an external review to ensure the project met applicable building codes. While zoning approvals were still pending, the design team submitted a thorough life safety narrative to the International Code Council and responded to comments, enabling the permit to be issued with clarity immediately after approval.
Crucially, the owner allowed design to advance in parallel through construction documentation. While unexpected reviews added three months to the approvals process, the delay did not impact design progress or the construction start date. Southwood Children’s Behavioral Health Hospital opened in September 2024, preserving the owner’s speed-to-market goals.
Approvals as a core design competency
As long as behavioral facilities lag behind need, patients in crisis will continue boarding in emergency departments instead of receiving care in environments designed for their recovery.
Approvals determine whether that much-needed capacity reaches patients. When treated as a bureaucratic obstacle, entitlement remains unpredictable. When approached as a design process that demands communication, visualization, and risk planning, the process becomes something design teams can actively manage.
Roger Hartung, AIA, NCARB, is a principal at IKM Architecture (Pittsburgh) and can be reached at [email protected].
