It is a generally accepted principle that patients need access to the outdoors. In some states, like California, it is a requirement. Parents often encourage their children to go out and get some “fresh air and exercise”. Health authorities recommend the same for healthy adults. The same advice applies to those who find themselves struggling with issues that have resulted in their being patients in behavioral health facilities.
One of my favorite quotes is from Swedish architect Stefan Lundin in his book “Architecture as Medicine”. This book provides a discussion of the design philosophy behind the new Ostra Hospital in Gotenborg, Sweden. It includes the following passage: “The patient’s self-esteem can be boosted by offering them dignified premises, premises signaling 'OK, so you’re ill and may not always be on your best behavior, but help and sympathy are forthcoming from those of us who, for the moment at least, are better off.'” (emphasis added)
If there can be agreement that it is desirable for behavioral healthcare patients to be allowed periods of time in the open air outside the unit, then the issue becomes: How do we define the space to which they are to have access? How do we protect against them leaving the area without authorization? What is included in these outdoor areas and how they are designed will be addressed in a future discussion. I will limit this blog to the perimeter enclosure.
If we subscribe to Mr. Lundin’s premise above, (and the general consensus of the clients I have worked with) the courtyard will be more therapeutic if it does not have an enclosure that makes it look like a prison yard. Therefore, a twelve foot high chain link fences topped with concertina wire is probably not an acceptable choice. So what is the perfect choice of material for the enclosure?
Like many issues in the design of these facilities, the “correct” answer may vary widely between different facilities.
Some of the variables are:
• Are the patients voluntary or involuntary admissions?
• What is the facility’s position on elopements?
• Is the courtyard located at ground level or a number of stories above ground level?
• Are views to the distance desirable?
• Is the courtyard intended to be for meditation and introspection?
• Is it intended to be used for physical activity and exercise?
The height of the enclosure is always a topic of discussion. With some adolescents and younger adults able to dunk basketballs in a goal that is ten feet high, it seems prudent to provide something taller. Patients have been known to work together to help each other get over enclosures which also tends to call for higher walls. The material of which the wall is constructed is also important. If it is smooth and without irregularities that provide opportunities for fingers or toes to gain traction, then a lower wall may be acceptable. This is very difficult to achieve if views beyond the walls are desired. If this is the case, perhaps glazed “windows” in the wall can be provided if appropriate break resistant materials are used and there are no horizontal framing members that will provide toe holds. Other commonly used fencing materials that allow vision through them are usually either climbable or overly prisonlike.
Possibly the most important aspect of the wall design is the top surface. The ability to get over the top of the wall is heavily dependent on getting a grip on the top surface. Since objects that could injure patients such as broken glass imbedded in the top of the wall are frowned on (for good reason), one hospital came up with an innovative solution. They anchored a 24-inch diameter plastic pipe to the top of a smooth wall. The pipe was painted to blend with the color scheme of the building and became an attractive feature that also made it VERY difficult for patients to get a grip and pull themselves over the wall.
Designing courtyards that are surrounded on all sides by the building can also be useful, especially if the building is more than one story above the level of the courtyard. Care should be taken with exposed downspouts and other items that may be used in climbing. Single story buildings may present opportunities to get onto the roof which is generally not a good idea. Also, it is suggested that care be taken with the glass in all windows that are accessible from patient courtyards to assure that the exterior pane of glass meets the same shatter and break resistance required for the interior pane of glass in patient accessible windows.
The “right” solution for any behavioral healthcare facility will depend entirely on the facility’s tolerance for elopements and the potential of harm to patients if they should get over the enclosing wall.