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The client experience: the most important aspect of MHF desi

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Jan Golembiewski

on 22 September 2014

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Transcript of The client experience: the most important aspect of MHF desi

The client experience: the most important aspect of MHF design.

The garden in a new MHF in Australia
A day room in a new MHF in USA
What is the 'patient journey' if not a narrative experience?

The patient Journey:
Design for de-escalation not to create a power dynamic

The paradigm of
management and control.
How does it perform?
The Panopticon prison, designed by Jeremy Bentham in the 1780’s “a new mode of obtaining power of mind over mind, in a quantity hitherto without example.”
Envisaged for use in education (to prevent chatter and distraction).
Effective for establishing the locus of control in centralised staff station.
Causes ‘total’ institutionalisation.
Highly controlled environments promote suicidal behaviour, especially just after discharge.
A prioritisation of staff control over all client amenity.

Newer designs follow the same principles as the panopticon in the patient areas, prioritising staff control over all amenity.

The staff are visualised as being static, and permanently watchful from inside a glass staff station.

Repeated evidence demonstrates that the removal of staff stations improves ward dynamics (between staff and patients and between patients) and also improves self-directed behaviour.

Patient to patient relationships are not fostered in modern plans, and nor are real life-skills.

The paradigm of management and control.
How have things moved on?

Care in for mental illness is not control.
Patient’s must find sufficient respite to enable natural recovery.

This means: Enriched spaces – lots of activities (structured and unstructured) good, wholesome things to do, see, smell, hear and touch. 24/7.

Removal of compromising elements (ugliness, semantically mixed messages etc.) and the removal of environmental demands that are likely to trigger automatic and unwanted responses. (And not just hiding them.)

Even the best psychopharmacology helps only by giving some relief from the most florid of symptoms.

Too few staff.
Most MHF’s have more staff (FTE’s) than patients. In ‘secure’ or ‘high dependency’ units there may be 3 times more staff. Shortage of staff is therefore not the problem. It’s that staff are too specialised to engage in other activities. The prevailing paradigm is that opening the ADL Kitchen or pottery room in the evening or weekend will mean another occupational therapist will be needed.

We want to calm the patients down, not excite them.
Symptoms can’t always be addressed directly. Especially with mania, to some degree patients have to get what they want before they will calm down. The trick here is to channel those desires through interesting things to do – 24/7.

Safety: Patients might eat the clay, hang themselves on a guitar string etc.
A one-size-fits-all approach serves nobody. There will be some patients who are confused and others who are suicidal. The environment in most MHF’s is stripped down to a very small set of controlled circumstances to restrict both kinds of danger. But to strip the environment back to the point where it cannot meet clinical needs for recovery is like banning medicines in a hospital. There’s also a correlation between stays in restrictive environments and increased suicidal ideation.

Security: Patients will escape.
Bizarrely, this concern is just as likely to be voiced for facilities where patients are self-admitted. The concern for security must always be risk managed alongside the knowledge that relational security isn’t the lines of sight in a facility. It’s the building of trusting relationships between staff and patients. Also a rewarding and healing environment doesn’t invite patients to escape.

Patients might be too happy.
They will fake mental illness to get in. Anyone who fakes mental illness with the objective to stay longer in a MHF has a mental disorder. Yes, stays my get longer, but the staff still have the power to discharge when it becomes appropriate. It’s worth noting that short stays (especially in highly restrictive facilities) have far higher suicide rates, both inside and within a month of leaving.

Giving patients what they want is just feeding their mania/delusions.
Delusions are a framework for dealing with life’s circumstances and complexity. Denying or removing this crutch is dangerous and counterproductive during a period of crisis. It’s like choosing to remove a security blanket from a child after a traumatic event.

Surveillance is democratised;
Privacy is graduated;
Flexible swing-zones;
Lots of outdoor space;
Standardised room sizes
means that functions can

A paradigm that fosters equality.

Much to be gained, nothing to be lost.
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