We do not have to sacrifice a therapeutic environment in the name of safety. Additionally, I would argue that a well-designed therapeutic environment is a safety feature.
What does that mean? It means that safety is complicated.
When we talk about safety in behavioral healthcare, we are talking about minimizing the impact of aggressive behavior whether that behavior is aimed at self, others or the environment. Most safety features are meant to absorb the impact of an aggressive act. The physical environment can reduce aggressive acts. In simple terms: A wall that isn’t hit, isn’t broken.
When we think of safety, we generally understand that some patients are inherently going to be aggressive. Some diagnoses lead to this type of behavior. That is why we pay attention to ligature points and durability—we all get that. But to design a truly safe environment, we need to look at group dynamics.
In my house, it is hard to get four people to share a room and agree on a TV show without someone getting upset. I’m a pretty easy going guy, but if you put me in a room with 16 other people, one TV and no other options, there is a strong likelihood that I will exhibit aggressive behavior, even if I do not have a condition that might affect my behavior.
Remember, these patients are ambulatory and move about somewhat freely in a space. One of the things I find interesting is the rule of thumb for group space that says to allow 35 square feet per patient. I would bet your average Starbucks is more crowded than that, but they have designed an environment where people are happy to be in an energetic shared space.
So, how do we apply those principals to behavioral healthcare? Imagine a psychiatric unit that was so well designed, we all wish we could spend a week there. If we can create an environment in which people feel comfortable, we can reduce aggressive acts. And in case it isn’t intuitively obvious, reducing the level of aggression on a unit is directly tied to improved outcomes and shorter lengths of stay.