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Building a treatment mall

September 1, 2009
by Steven V. Riley, AIA, LEED AP
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Oregon State Hospital's new campus in Salem will employ this care model

A historic 1883 building is being incorporated into the new 620-bed oregon state hospital in salem. renderings
A historic 1883 building is being incorporated into the new 620-bed Oregon State Hospital in Salem. Renderings by Travis Schmiesing, HOK

In Milos Forman's 1975 screen adaptation of the Ken Kesey novel

One Flew Over the Cuckoo's Nest, the Oregon State Hospital (OSH) in Salem served as the stage for Jack Nicholson's Academy Award-winning performance. While the dramatic conditions depicted in the movie were fictional, the state has recognized the need to update and transform the aging OSH facilities. So in October 2007, the state commissioned architectural firm HOK, along with SRG Partnership, Inc., to guide a makeover of OSH that will include 620 beds in approximately 835,000 square feet of new and renovated buildings, along with 293,000 square feet of outdoor areas. The expansion and renovation, which began in spring of 2009 and is scheduled to be completed in the fall of 2011, will transform one of the oldest mental health hospitals on the West Coast to a “treatment mall” recovery-based model of care.

OSH's evolution

The Salem campus's first hospital building opened in 1883 and was designed in accordance with Dr. Thomas Kirkbride's writings, the era's widely accepted standards on the planning of mental health facilities. The “Kirkbride Plan,” described in Dr. Kirkbride's On the Construction, Organization and General Arrangements of Hospitals for the Insane, envisioned a central administration building with symmetrical wings consisting of staggered wards on either side. Male patients were housed in one wing and females in the other. A hierarchy was established within each wing by grouping patients according to their illness' severity: The most ill patients were placed in wards on the lower floors and farthest from the central administrative wing, while those with better behavior and more rational thought were placed on higher floors and closer to the center.

Dr. Kirkbride's recommendations are reflected not only in the 1883 hospital building, but also in the related support facilities, farm, and landscaped park. Dr. Kirkbride believed that the natural environment was crucial to patients' recovery. He advocated removing them from the ills associated with typical urban environments and exposing them to the natural beauty of landscaped parks to stimulate and calm the patients. Participating in grounds maintenance provided a sense of purpose while work on the farm made the institution more self-sufficient.

Over the years, several other building and site improvements were constructed to support the increasing demand for mental healthcare. The hospital experienced a great deal of growth until the late 1950s, when admission requirements changed to admit only those patients deemed to be a danger to themselves or others.

OSH's current care model is unit based: Patients live and receive care in the same location. While this care model may provide for easier logistics and a feeling of enhanced security, it has numerous challenges. In the unit-based care model, expanding treatment modalities and tailoring treatment to the individual are difficult because of the restricted space and available staffing. The boredom, dreariness, and lack of expectations characteristic of “ward life” destroy hope, which is indispensable in patients' recovery. Furthermore, a patient's isolation from society is worsened by the ward's isolation from the rest of the hospital community.

In 2005, the state commissioned a two-phase master planning study for OSH, which acknowledged that “consumers of mental health services in Oregon are often kept longer than is clinically necessary in hospital and extended care community settings.” The state articulated its goals in the

Oregon State Hospital Framework Master Plan Phase II Report: “Oregon is in the process of shifting to a ‘Recovery Model’ system of mental care…. This model, with its focus on self-determination, challenges the ‘traditional medical’ approach which has guided the treatment of mental illness in the past.” Regarding the existing hospital facilities in Salem, the report continued:

“The current Salem campus facilities are not appropriate for long-term continued use for the care and treatment of those with mental illness.

  • Patient rooms are overcrowded and undersized relative to Oregon Administrative Rules (OAR).
  • Patient and staff spaces are not well designed for treatment, safety, or security.
  • Patient wards are overcrowded.
  • Structural conditions of many buildings housing patients do not comply with current seismic requirements.
  • Buildings do not comply with current building or energy codes for secure psychiatric facilities.”

The new campus will include ample windows to let in natural light as well as have secure outdoor courtyards

The new campus will include ample windows to let in natural light as well as have secure outdoor courtyards.

The report also found that environmental hazards are present in a large number of the buildings.

Creating a treatment mall

The state is responding to these issues by pursuing the treatment mall recovery care model, which embraces the values of increasing self-determination, empowering relationships, developing meaningful roles, and eliminating stigma and discrimination. Although these values primarily drive organizational concepts and services, they also affect the built environment.