Perspectives on Behavioral Health: Complexities in Care within the Prison Environment

Welcome to a new Q & A series designed to uncover what behavioral health really means within secure justice facilities, including the current and future trends in design, the crossover with the healthcare, the shared focus we have with our clients and partners, and the best way forward.

This is the fourth installment in our Q & A of the series which has previously featured Brian Giebink and Paul Nagashima. Here we’re featuring Health Planning Principal Dave Redemske, an expert in the design and planning of correctional health facilities. Dave was a recipient of an HDR Fellowship and spent a year examining healthcare in the U.S. prison system. His research focused on the complexity of the environments in which healthcare is delivered to U.S. prison inmates, including the prison clinic or infirmary, regional correctional medical facilities, and community hospitals.

Q: How long have you been a planner for both health and correctional facilities, and when did you become focused on behavioral health design? What do you find most interesting about behavioral health projects?

DR: I’ve been working in healthcare design for 28 years. I started working on correctional health projects about 10 years ago and have found it to be a fascinating building type. My experience in behavioral health design started around the time I began focusing on correctional health. While I had designed behavioral health units in community hospitals, it wasn’t until I started working in correctional health that I really began to take a deep-dive into behavioral health design.

I find the complex balance between therapeutic treatment needs with safety and security requirements to be the most interesting challenge surrounding behavioral health projects. I make it a point to ask a client in the initial stages of a project if they want a hospital that has security, or a prison that has healthcare. While this question might sound like a simple difference in semantics, each approach would result in vastly different types of facilities.

Q: How would you characterize the crossover with health and justice relating to behavioral health?

DR: The deinstitutionalization movement of the 1960s, along with our mass-incarceration policies, have created the crossover of health and justice relating to behavioral health. Research shows there are many people incarcerated for crimes they likely wouldn’t have committed had there been community-based mental health treatment options available. It can cost up to three times as much to provide mental healthcare in a correctional facility versus in a community-based facility. Because of this, many jurisdictions are now implementing diversion policies, where law enforcement brings people to treatment facilities rather than jail. These diversion policies help provide access to much needed treatment in addition to keeping them out of the criminal justice system. Many people working within this crossover area are working hard to provide the best in therapeutic treatment, which not only improves patient outcomes in the most cost effective manner, but does so without negatively impacting public safety.

Q: What design trends do you see developing in the design response for behavioral health within both secure facilities and in hospital / health facility environments? How do you see that translating into physical plant design?

DR: In regards to design, there are in fact some common elements found in both community-based and corrections-based facilities. Research consistently supports that normative environments and access to nature have positive effects on behavioral health treatment. Providing a normative environment in a facility designed for punishment can be challenging, particularly from a safety and security standpoint — large expanses of glass often prove difficult to incorporate and access to nature can often only be provided through the use of murals.

Some corrections officials in the U.S. are realizing that the approach to mental healthcare within corrections is not sustainable. They are looking overseas for successful examples of inmate mental health treatment. Some of those examples have proven that their facility design, integrated normative environments and the inmate’s access to programming, results in patient outcomes and recidivism rates that are much more positive than the U.S. statistics.

Q: How can we, as designers, support the mission and the focus of a facility designed around behavioral health or mental health?

DR: For the most part, designers are great advocates for the mission of mental health providers and administrators. We understand the importance of therapeutic and normative spaces and how the design of those spaces can directly influence patient outcomes. We know that what we’ve been doing in the U.S. isn’t sustainable and that there needs to be a paradigm shift in both the correctional mental health facilities being constructed and the conversation we’re having around incarceration of the mentally ill. Design thinking could go a long way in helping politicians, administrators, health providers, and law enforcement reframe the public discourse on this complex issue.

Principal Health Planner