Modern forensic psychiatric hospital design: clinical, legal and structural aspects

Forensic psychiatric care aims to improve the mental health and reduce the risk of recidivism of mentally disordered offenders, and other patients with similar complex needs. This must be achieved within the least restrictive setting possible, and with a view to eventual community reintegration, whilst simultaneously maintaining a secure treatment environment [1‐3]. However, forensic psychiatric services and the facilities in which they are provided are defined and governed in different ways across the world: some countries have issued detailed criteria for different levels of secure care, including building design and material specifications [4‐6], whereas in other countries, security is much more loosely defined, and has essentially developed over time along with clinical practices [7‐9]. This is mainly due to variation in the specifics of legislation and the particular ways in which forensic mental health systems are operationalized in different countries, as the underlying clinical issues and principles remain relatively similar across countries [10‐13].

Accordingly, the placement and treatment of the forensic patient population has been an issue of debate within the criminal justice systems in Western Europe [14, 15]. In addition to dedicated forensic hospitals and units, mentally disordered offenders may be placed in general psychiatric hospitals, prison hospitals and, less commonly, psychiatric wards in general hospitals. In some EU member states, not only mentally disordered offenders, but other aggressive, violent or otherwise high-risk patients referred from general psychiatric facilities may be admitted to forensic facilities [12, 14]. This can cause strain between services, as general psychiatry may develop a tendency towards outsourcing to forensic psychiatry the treatment—particularly coercive interventions—of patients viewed as somehow troublesome [16] and, on the other hand, forensic patients may be seen to block beds needed for patients with more acute presentations [17]. In any case, interaction between general psychiatric services and forensic psychiatry is essential, and inevitable: the majority of patients in forensic units have had previous contact with general psychiatric services and will require transfer back to communal care at some point in their psychiatric treatment [18].

Deinstitutionalization, particularly in Western Europe and the United States, has gradually reformed psychiatric health care; many large, institution-like hospitals have been withdrawn from use or modified since the 1950s [19] and many units face continual pressure to decrease the number of remaining beds. The trend is being reinforced by developments in information technology, which are continually offering new treatment possibilities and environments for psychiatric care [20]. Arguably, the trend towards deinstitutionalization of general psychiatric patients has contributed to increasing the number of placements in forensic psychiatric facilities and raising the demand for supported housing, in a process of re- or trans-institutionalization [17, 19, 21, 22]. This is not a new area of enquiry; the relationship between the decrease in general psychiatric bed numbers and the expansion of the prison population suffering from mental health issues has been a focus of intense research and debate since the 1930’s, when Penrose introduced his “Law”, according to which the size of the prison population is inversely related to the available number of psychiatric hospital beds [23]. Some studies have indeed found a correlation between the decrease in psychiatric bed numbers and an increase in mentally ill prisoners [24] but further research is needed to establish causality [25, 26]. It has been suggested, for instance, that other societal factors in the USA and Western Europe, rather than deinstitutionalization in itself, are responsible for the rising number of prisoners with psychiatric problems. Significant contributory factors may be the increase in homelessness, illegal drug use, changes in mental healthcare funding [24], and decreased numbers of forensic psychiatric pre-sentence examinations [27]. Furthermore, a cross-sectional study by Large and Nielssen [28] found no association between the size of the prison population and psychiatric hospital bed numbers in high-income countries, whereas positive correlations were found in low- and middle-income countries.

However, while ongoing trends in psychiatric service systems indeed stress deinstitutionalization and out-patient care, for some patients a restricted and safe environment is an essential feature of their mental health care regime, at least at certain stages of their illness, in order to maintain both their own and public safety. Here, we review the current literature on what aspects of forensic psychiatric facilities best serve the needs of those patients who still need to rely on them, and we attempt to define a structured way of approaching the complex and costly challenge of forensic psychiatric facility design. For the purpose of this review, we define a forensic psychiatric facility as a healthcare institution into which patients have been diverted from either correctional services, typically due to criminal irresponsibility issues or enduring post-sentencing mental illness, or general psychiatric services, typically due to serious risk of inter- or intrapersonal violence.

According to Horsburgh [29], the architectural design of psychiatric facilities and the quality of living space are essential aspects of the healing process, and thus affect the outcome of medical care. Previous studies have highlighted the importance of a safe physical environment that enables intensive, stabilizing treatment together with reasonable privacy and observability [30]. Dijkstra, Pieterse [31] conclude that while the general notion of the healthcare environment affecting the well-being of patients is supported by the literature, conclusive evidence is still limited as to specific environmental factors. Others argue that research findings and clinical conjecture have consistently supported the idea of the environment playing a significant role in patient and staff functioning in psychiatric hospital settings, but that this fact has even yet to be fully recognized and implemented in hospital design. Indeed, the development of psychiatric institutions has been characterised as coercive, confining and their buildings as the embodyment of discipline and control, the exercise of power over the socially deviant [32]. Yet modern design of built environments can create an engineered sense of shared safety and ownership of one’s living space [33, 34] and even the earliest hospitals for the mentally ill were established with caring and compassionate ideals [35]. Typically, the various designers and theorists placed great emphasis on the same elements of architecture, staffing and activities: physical, relational and procedural safety and security as described below, with an organisational and managerial vision and overview [36, 37]. In what may be a series of historical cycles, these elements became subsequently victims of the social processes that supported them [38]: a growing awareness of the social context of mental illness [39] led on to a recognition of the anthropological micro-cultures of closed institutions [40, 41] and the policy decision to close the asylums on the grounds that they were inherently harmful and community care would prevent ‘institutionalisation’ followed [42]. In practice, it was evident from an early stage that this was not a coherent theory or policy, and the practice of decarceration was not equal to a liberation or an improvement in quality of life [19, 43]. As the historical cycle has continued to turn, there has been first a new interest in reform and attention to therapeutic environment and regime [44, 45], a review of the culture and exercise of ‘power and praxis’ in psychiatric wards and hospitals [46] and a late, but welcome, interest in the primary therapeutic power of the hospital environment itself [29, 31, 47‐52], in which nature and art play an important part [53].

All in all, one of the most consistent recommendations in the body of literature on psychiatric hospital design is to reduce the institutional feel of the facility, and instead create a more homelike environment [54]. This must be taken into consideration from the earliest stages of the design process, as architectural features, such as the layout or physical plan, size and shape of rooms, and the placement of windows, are relatively immutable aspects of the hospital building [50]. In contrast, interior design features are less fixed; furnishings, basic consumer appliances (e.g. televisions, telephones, computers), colors, artwork and the décor of patient rooms [50] are easily modifiable according to purpose and individual choice. Also ambient features, such as sunlight, views of nature and reduction in noise, have been shown to be helpful in psychiatric recovery [31, 55]. Also, fresh air, good ventilation, neutral odours, and natural daylight in patient rooms can promote the recovery of psychiatric patients with severe depression; in general, soft, indirect and pervasive lighting should be provided [54]. Providing outdoor gardens and rooms with views of nature might shorten recovery times, reduce need for pain medication, and mitigate patients’ psychological distress by serving as positive distractions [47, 54]. These findings are consistent with research indicating that views of nature produce higher levels of relaxation as compared with urban scenes [48]. According to Edgerton, Ritchie [33], colour selection, live plants, floor space, and furniture arrangement can foster social interaction, but at the same time help maintain privacy. This is an important point, as patients should be able to regulate their own level of social contact while in psychiatric care [52, 54].

Thus, although the trend towards deinstitutionalizing psychiatric patients remains strong, the modern psychiatric unit continues to have an important role to play as a stable and secure centre for treatment, research, and rehabilitation [51]. This is particularly true of forensic psychiatric units.

In the UK, as an example, the current forensic psychiatric services began to form and diverge from earlier settings in the early 1960s. Regional secure units were set up within general psychiatric hospitals from the 1980s onwards, further stimulating debate about how health and social services should provide for mentally ill offenders and non-offenders with similar needs. The Reed Report [56] made hundreds of recommendations for streamlining forensic service provision, including that security measures should be no stricter than warranted by the risk posed by patients to themselves or to others. Accordingly, Eggert, Kelly [49] emphasize that the cardinal principle in the design of psychiatric facilities is the mitigation of the risk of self-harm or harm to others. Nowhere is this more true than in forensic psychiatric facilities.

Indeed, risk issues lie at the very core of forensic psychiatric practice, as the environment must be safe and stable before any real treatment progress can take place [57]. In a forensic facility, various forms of treatment- and safety-compromising risks are present which require correlative management strategies. For instance, the risk of violence and self-harm requires adequate numbers of well-trained clinical staff [58] and a culture of fluent communication of risk observation [59]. Also, the treatment facilities must be designed in a way that enables staff to observe all activity that occurs in the interior areas, except, for reasons of privacy, the patients’ rooms [30], which in turn must be designed to minimize ligature risk [60]. The risk of escape, on the other hand, requires a well designed perimeter and well thought-out procedures regarding passage in and out of the secure facility [2]. An unsuitable physical environment can severely impair care quality and the feeling of safety, and might damage the person-centered therapeutic process [45, 61].

Taking into consideration the myriad clinical, legal and architectural considerations, planning a new forensic hospital is a highly complex process. However, as an integral part of a well-functioning forensic service, it is a clinical and ethical necessity in any society. Despite variability in national legislation and socio-demographic factors affecting various national forensic patient populations, in the following design template we attempt to capture general, internationally applicable design principles (Table 1).

The process of deinstitutionalization of psychiatric care in many Western nations is coming to be understood, rather, as a more complex process of trans- or reinstitutionalization from traditional psychiatric hospitals to supported housing, prisons and, not least, forensic psychiatric units [19, 22, 27]. As a result, authorities in many countries have come under increased pressure to both expand and update their forensic psychiatric services [17, 90‐93], so as to respond more effectively to the needs of mentally ill offenders and other psychiatric patients with similar needs. Simultaneously, an increased focus on patient and carer rights and involvement has emerged throughout the development and implementation of healthcare services [94, 95], as have international monitoring standards to uphold human rights within psychiatric institutions [68]. Thus, it is becoming less acceptable to operate national forensic services without reference to international standards or without knowing what practices are employed elsewhere in the world [11, 96].

Developments in international trends, societal attitudes towards mental health issues, and the design of psychiatric care environments are closely intertwined. This is reflected in modern evidence-based architectural hospital design, which is founded on research into the link between characteristics of the care environment and patient recuperation and well-being [97]. Also, the way in which society defines its basic ethical principles changes over time, and it is a matter of continual ethical, clinical and legal debate where the line between security and therapy should be drawn at any given time. Thus, changing views on treatment must be matched by changes in the operational models of healthcare services, which are themselves bound up with the design of hospital buildings [51].

Forensic psychiatric hospitals are high-cost, low-volume medical institutions, which are required to provide both therapeutic and safe and secure material environments [2, 4, 6, 59, 68]; thus they are at the very forefront in implementing the latest developments in medical architecture. Although the evidence base for many interventions within forensic psychiatry is still weak, these hospitals do provide an essential, specialized service for mentally disordered offenders and others with similar needs, both in terms of healthcare and decreasing the risk of re-offending [15, 98]. Only by entering into an open, yet structured and coherent, international research-driven discussion with clinicians, scientists, architects, policy-makers and medico-legal authorities, can we continue to raise the standard of our services, and the facilities in which they are provided.