David Cummins: G'day and welcome to the AHDC podcast series Health Design, the Go.

I'm your host David Cummins, and today we are speaking to Dr Gabrielle Jenkin who has over 20 years experience of research into investigating critical social and public health issues. Dr Jenkin's research has focused predominantly on suicide, mental health and wellbeing research with over 20 published papers and 15 reports in the field, which many have been presented at international conferences.

We welcome Dr Jenkin today to our podcast series to discuss mental health, and also as part of our RUOK Day series.

Welcome Dr. Jenkins. Thank you for your time to be here.

Gabrielle Jenkin: Thanks so much David for the opportunity and good morning.

David Cummins: It's a very interesting focus of architecture, mental health.

It's obviously something that's become way more prevalent over the years and the one thing that I'm very aware of with mental health design and mental health facilities is that there doesn't seem to be enough beds. They're not designed properly, and we are just not getting it.

That's pretty much all I know about it in reference to design. Is that a pretty fair assumption or am I completely wrong?

Gabrielle Jenkin: We definitely don't have enough beds. I also think we don't have the right type of facilities. And we also don't have much in the way of step-down facilities, like places where people might go before they get to that acute crisis.

So what we've got is people getting really mentally unwell and ending up in those acute units, which are completely not ideal for recovery. So we need actually, I think a whole range of options, but my focus and my research was on the modern day acute mental health facility.

David Cummins: Yeah, so with with modern day acute facilities, you've obviously got you've got males, you've got females, you've got young people, you've got old people.

And the interesting thing about mental health is that they seem to all be put into the one facility, even though the array of mental health issues, anything from a psychosis or anything from

schizophrenia and all their depression, like all these huge array of mental health issues, but they seem to be all located or co-located in one facility.

Is that a pro or a con?

Gabrielle Jenkin: Well in a small country like New Zealand, it would be difficult to probably have bespoke facilities for different mental illnesses, which might actually be a bit more ideal. But yeah, so you would have generally presentations like schizophrenia, bipolar disorder, major depression.

Sometimes people just having an absolute life crisis, so they might not actually have a diagnosed mental illness, quite often suicidal people and people who've made a suicide attempt.

So the key is to get people stable and keep them safe from themselves and keep the community safe as well.

David Cummins: Yeah.

When people generally do research into facilities like rehabilitation, you might speak to a patient about how hard it is to move with a four wheel frame. How hard was it to investigate and research these facilities, noting in their acute mental status?

Gabrielle Jenkin: I think the hardest thing was, actually even when I was right back at the beginning designing this research project before it got funding, I'm a social scientist so, I don't have a clinical background.

I didn't have the networks to go in and go and be allowed into such facilities. There was a lot of gatekeeping going on because it's considered a very highly vulnerable population. I did have a family member in an acute facility (my brother) so I had been in and out of one in Christchurch.

So I knew what that was like. But even trying to design, how am I going to do this research, how would it work in reality was really difficult until I actually had psychiatrists come on board who actually worked in that sector and said, "I'll get you in there so you can have a lock so you can help design your research better".

 And when we did get the funding for it, finally, the ethics process was really complex and it was the highest level ethical approval because you are basically going into an acute mental health facility where people were acutely unwell. And the ethics committee concern is always that "are people competent to consent and would I be safe interviewing people"?

And there was a lot of stereotypes and misunderstanding I think, even on ethics committee members about what it was trying to do and that actually people are probably quite competent to consent to talk about their environment.

I wasn't asking them really about their mental illness, I didn't even ever ask them about their mental illness, it came up, but I was just really interested in what does it feel like to be there, how do they experience the environment and how does that impact them, is it therapeutic or just how they felt about where they were.

David Cummins: I know you touched base on the therapeutic benefit of mental health facilities these days, but certainly the old movies and the old, the old facilities, from the seventies and eighties, they, it seemed very, very different from today where basically an old mental health facility.

An institution where you are pretty much locked away in some facility, but it does seem to have been a big shift in the last few decades where it is about more therapeutic but more about open spaces, more about group work.

That shift changed a few decades ago. But it sounds like there is need for more change in certainly changes in models of care as well, correct?

Gabrielle Jenkin: Well, I think the other major driver, going from the old style asylum to the acute mental health facility was the pharmaceuticals that came available and that's really the key therapeutic agent in these places, that's good and bad.

In the old days, people lived in these institutions and they were out in the country. When people were going visit them, they were a bit more functional, a bit more like rest homes, you're there permanently there was no hope for recovery.

And so, now a modern acute mental health facility in New Zealand has about a 14-day Key Performance Indicator.

The ideal is that you are in there stabilised quite quickly. You are only in there for a couple of weeks. They're not designed to be people living in these spaces. So they function like a hospital.

 It's mental health ED I guess. And then the idea is you get them back out as soon as you can, as soon as people are stable, as soon as they have a plan, as soon as they've got medication and a proper diagnosis, and then real care happens back in the community.

Or that's the idea anyway.

David Cummins: Yeah, I understand what you're talking about with that.

You talked briefly about the importance of design. How hard is it as a designer? To design for all the needs of complex cases and the caseload that is ever changing, and they're only there for a few weeks.

So how hard is that to achieve that goal?

Gabrielle Jenkin: Well I think it should be a lot less hard than people imagine, but because we haven't really had the evidence base, I think it's really hard for people to understand and architects in particular, it's just people we're talking about people in various stages of unwellness.

They need the same as any other people who are in a space for a couple of weeks. They need access to outdoor space, ideally they need their own bedroom and bathroom. They need somewhere where they can have privacy, but they also need somewhere where they can connect with other people.

These facilities do have certain medical requirements but that's pretty standard. So there are other things that they need to design for now, I think is really the other therapeutic option so that people aren't just given medication as the only choice.

Most of these wards had a social worker, a psychiatrist and nursing staff, but there was no psychologist. So there's no talking therapy, there's no group therapy, there was no real organisation around introducing someone onto the ward, "This is what life is like. This is where you get this, this is how you do that".

From my point of view, it should operate a bit more like a guest house where people are treated with that real care. And people really just need respite and sleep and peace and care.

I don't think it's rocket science, but yes, you do have some people who might have psychosis and there are spatial things. I understand with schizophrenia that you need wider, more open spaces for people. Some people, at the moment, the model is that we have these seclusion units for people when they really are a danger to themselves, and you need good surveillance across the whole facility so that you can actually see what people are doing.

There are those requirements, but they're still quite institutional buildings, the courtyards are still full of concrete and either fake grass or no grass or no nature. There's just a lot of improvements that could occur, but what's really required is the resource to be put into it.

I mean, architects can design for that, but there's got to be the money too, and they have to have anti-ligature fittings and things like that in these places as well. So there is design for safety and security, but a lot of that can be through surveillance and through relationships between staff.

So if you've got a ward that's got a much more open environment where the staff and mulling around with the service users rather than hiding behind nurses station, there can be a lot more of that sort of therapeutic relationship and trust-building that can go on.

 One of the wards that I looked at had that very open design and it was completely different environment and feel to one where the staff are all hiding in this glass bubble, and service users are knocking on the door, can I get my phone charged, can I get this, can I get that?

And then feeling really completely ignored because the staff are really busy because they have to write and document everything that's going on all the time. Those things of design, opening Flexi-Wards and things like that is becoming much more important.

So you could actually say, if you could have a pod of three or four beds with their own courtyard in their own lounge and things like that is probably much more appropriate because then you can have people who you want to put together, and you might not know, it might not be by specific type of illness, but it might be by just their vulnerability.

They might be vulnerable, it might be transgender person, it might be a much older person, it could be quite a much younger person, it could be a really disinhibited person.

So I think if you've got flexibility and you can, instead of close off other books, these Flexi-Wards are really good because you can, they have their own staff and you're caring for people on small pockets of the building, I think that's the way that they're going to go and, the internal courtyards as well.

David Cummins: So, obviously some of the main principles you've talked about there is importance of nature, open spaces, group work, and some models of care for the relationship between staff and patients.

How important is it to get the detail right, the architectural detail, especially with ligature points in that design because, some architects say you can't it's impossible to design.

Some architects say, oh, it's possible, but there is some risk.

How important is it to get that balance of detail?

Gabrielle Jenkin: The layout is really important because the geography of space and the social relations that facilitates and the surveillance, that's really important I think in terms of the nature, it's not just views of nature people need, ideally they have views from their bedrooms, but it's not just views of nature that are important, it's actually interaction with.

 It's not so good to just be able to see something and not touch and feel. Some of the old wards had courtyards around the outside, which is not an ideal situation.

They were talking about contraband coming in through the the courtyard fences and stuff like that. And also then you've got a public view of people in an acute mental health facility which can be highly stigmatising when you actually look at the materials that they're using to make these external courtyards.

They're wire cages, and of course, when you are inside there and you talk to service users, they will tell you that they feel like a tiger in a cage. One of the facilities we studied, you could see those cages from the road. So they look very prison-like, they feel prison, like you don't want it to feel like that.

So they've gone more towards the, the internal courtyard model so that people can have their own privacy. But with that, there's the constraints of space on a hospital campus where you've got much smaller courtyards and then, they're not really nature based. They might have, well, I think I saw some spiky flaxes in the newest one.

It's not a feeling of nature, it's a institutional requirement to have access to sunshine and fresh air, and that's what it provides.

The details of surveillance are pretty important. The things about nature are pretty important. Allowing service users to have autonomy, so some things that they can do themselves.

So I think it's really important that service users can lock and unlock their own door. And a lot of facilities, they were too old and they couldn't do that. Those locks need to be overridden by staff on emergencies.

But to have some autonomy for service use is much more empowering to say, "well, you can bring in your own quilts, you can control the window, the light in your room, you can control your door, here's a locker to put your valuables in".

A lot of them don't have lockers for people to be able to lock your room when you walk out and know that your things are safe. I mean, these are basic simple things, but at the same time we have to provide for surveillance.

So they do have windows on the doors. They had special shower doors and the brand new facility, which actually just were velcroed on so that the staff could see what was going on but they were still afforded privacy. So you could see below the knee, and the height of a person and you could adjust them.

So designing for surveillance and privacy at the same time is a bit of an art and it required quite a lot of mockups. So they did mockups in the basement of what that would look like and how would you help someone in the shower and still give them privacy.

So it's all those things about keeping people's dignity, yet still being able to have your eye on everybody at the same time. And, things like a lot of the time, what service users go to the nurses station for, they end up congregating around this nurse station like it's a bar, really and that's where people hang out.

They go there because they don't have any way of charging their phone, they're not allowed razors or anything to have a shave. So being able to keep themselves clean and looking okay. I don't think they have hair dryers in the bedroom.

So there's lots of things that people are not allowed to have, but some of those things could have been really quite easily addressed by having sockets in the bedroom to charge your phone if you want to. You don't have to have cords, you know, there are some easy fixes for quite a lot of these things.

But they just need to be thought about. But the other complexity with those things is, because people are at varying stages of unwellness, it might be that, that person's care plan doesn't allow them to use a phone on the ward because they may be bullied on social media or there may be something going on there that's not helpful for their mental health at that point so, you've then got different care plans for different people.

And from a service user point of view, it has tended to look like some people were favoured over others and are allowed more opportunities and advantages than others. But it gets interpreted as a sense of injustice. So it's just understanding those human aspects of how can we talk.

You've got to talk to the people in the building, right? That use the building, the staff, the services, and the family who visit. So families need spaces now, especially in New Zealand, we're saying we want family involved in people's recovery. One of the wards that we looked at the room was so small, it was the size of an office, and that was for a 64-bed facility.

And so the family can't visit and there's lots of issues to consider. Do you want family members going on the ward or not on the ward? A lot of service users don't want other people coming on the ward because they're embarrassed of being in the facility. They don't want people to find out that they're there.

So that's another whole issue about should they be visible at the front of the hospital? Yes, I think so, but they also need the option of private entry and things like that because some people, quite rightly, want the privacy, but at the same time, family members want to go and visit their kids in these places, like teenagers in these places.

There's nowhere for family to sit and be normal and have a normal meal and environment. The newest one did design a Chi Room where family was supposed to be able to go and sit with service users but kitchens have a lot of things that are kind of not very safe, and so there's always concern there that knives aren't safe and other things aren't safe.

So that room never really got used for family members to go and eat with their loved ones but I don't see why you can't have a cafe public part of these places. In a lot of wards they're also separated by gender, so they have like a female corridor and a male corridor, and that's becoming a little bit outdated, but it's quite controversial.

Do you have males and females separated, because we know now we don't have two genders. There are multiple genders and this is what comes back to Flexi-Wards. It's much better to design them so you can modify them depending on the clients or the services you've got, the population you've got at the time.

Then they would say, "okay, so the men aren't allowed down the female corridors", well, that becomes a real problem if you're a father wanting to go and visit your daughter.

You can't, where are you going to go and visit? So they're going to have to go on the ward and sit on the bed in the bedroom and there's no comfortable chair, some of this is even about furniture.

But there's just no proper space. That, hasn't been thought about how do we care for family when they come in here and a lot of family members, I talk to.

To families, place is really difficult to find, so they're down the back rabbit warren of a hospital, you're going down corridors and you just keep on going and then you go drop down a floor and then you basically feel like you're going right down to the bottom of the basement.

And it's really, really stressful because you can imagine, if you're a parent with a suicidal young person that you've been caring for and you are distressed yourself and trying to go and connect with your family member, not even being able to find the front door of these places is really problematic.

Yeah, so a lot of what I did was try and get those kind of stories and just talking to people about, the issues that they faced. I'm not an architect, I'm a social scientist, so I have to work with the architects to then translate that into, okay, so what would be the design look like?

So we're still really working on that and we have some students at Vic Uni using VR and stuff like that to reimagine how it could be different. I think it's really hard for people who work in these systems to imagine what what it could look like. So they know what the problems are, but they don't seem to know so much what the solutions are.

And that's where I think architects are really good, they're very solution focused and they're like, well, how would you translate that into design, what would that look like? What does it look like to have a lounge, for example, where people can connect, but can also have privacy?

And how do you design that? You have half partitions and things like that, you can have hubs because you still need to be able to have surveillance over the whole lot.

So, I just think it just takes a lot of people's heads together to try and think how to make these places.

David Cummins: Yeah, it is a complicated beast, but through strong communication, it certainly can be achieved, and I certainly have seen some phenomenal mental health facilities in Australia.

One of the new models of care that's coming out here, I'm not too sure in New Zealand, is vertical mental health facilities where it's basically a building, obviously it's got a lot of advantages for space, but a lot of disadvantages for that connection to nature.

So I don't know if you've tackled that challenge over there where you've got more of a two or three floor mental health facility now which makes sense in the sense of space, but I just don't know how they connected nature as much as they need to.

Gabrielle Jenkin: Yeah, well I'd be interested to see how that works out. I know that they do overseas have them vertical.

My understanding when they were designing some of the new ones was the ideal was single floor. But I know of some that are like two floors and they have the staff area upstairs and then the service user area downstairs, I think it's quite good to have some separate space for the staff.

And having different floors is quite a good way of doing that. The connection with nature is really hard to design for if space is a premium, I don't know, they would still be doing internal courtyards. So I imagine an atrium switch, then again, you have to be a little bit concerned about the safety aspect of that.

David Cummins: Yeah, especially in the urbanisation of somewhere like Sydney or Melbourne where space is a premium. It is that challenge to try and get that model of care right but also the therapeutic benefits for patients.

But I just wanted to say thank you so much for your time today. It's been absolutely phenomenal.

It does sound like a lot of challenges there, a lot of opportunities, but certainly it's people with you in your research who are asking the tough questions, interviewing those people, doing the research.

That's certainly helping a lot of people with mental health conditions, but also people who are treating mental health facilities. So I think your research is paramount and certainly, I know it's gone around the world and I know a lot of people have appreciated the hard work you put into mental health and mental health facilities.

So thank you very much.

Gabrielle Jenkin: Thank you so much.

You have been listening to the Australian Health Design Council podcast series, Health Design on the Go.

If you'd like to learn more about the AHDC, please connect with us on our website or LinkedIn. Thank you for listening.