Perspectives on Behavioral Health: Learning from the CPR Experiment

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.

The greatest challenges to behavioral health for secure environments continue to be access to care and continuity of care. With the closing of mental hospitals as part of a “de-institutionalization,” program in the U.S., our corrections and detention facilities have often taken their place. This means those most at risk for behavioral health issues are often detained and confined. This in turn impacts operations and facility design for corrections and detention facilities.

We’re dedicated to championing healthy communities by helping our clients and partners plan, program and design their facilities to achieve their goals. This means we must first explore and understand what is happening in our communities, including the issues and challenges, effective and therapeutic design, and the evolving solutions.

In our first Q & A of the series, Greg Cook shared his informed perspective, based on his years of experience designing a broad range of facilities, with a specialty in justice. In the second of the series Brian Giebink, a project architect working primarily on healthcare projects, shares his perspective on behavioral health design within hospitals and heath facilities. Here we're featuring Paul Nagashima, an award-winning designer of both justice and health facilities, who shares how he became interested in behavioral health design and what he learned through the California Prison Receivership.

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

PN. I’ve worked on both health and detention/corrections and law enforcement facilities since 1984 and 1989, respectively. I became more focused on behavioral health design during the California Prison Receivership (CPR) project.

Q.  In 2010 you participated in the CPR Co-optition. What did you learn through that process that influenced your approach to planning behavioral health facilities for justice clients?

PN. CPR proved to be an incredible learning experience and It was a self-proclaimed “experiment” in social dynamics to learn how a large, diverse group of professionals from a wide range of disciplines: construction, engineering, design, healthcare clinicians and others, could come together, collaborate and at the same time, compete on such a large scale and ground-breaking endeavor. With all of us co-located in one big room, we learned a lot from each other, and how to work, outside our normal silos and comfort zones. Perhaps the most important thing I learned was the fluidity of the inmate-patients’ conditions and status, as far as medical and mental health and the different levels of acuity.

This meant that standardization, flexibility and adaptability were imperative to create a design that would remain operationally efficient and effective over time. The paradigm shift from acute care to long-term chronic care, particularly with the rapidly aging population, rampant drug abuse and mental illness, is more pronounced in jails and prisons than in our communities. The other key take-away is that most of these folks will be coming back to our communities. So often they are the forgotten segment of our population and not considered in our public health discussions and yet, they are the most at-risk segment of our community. 

Q. Lean Methodology was used to understand the treatment protocols in the Co-optition. What did we learn from that process that translated into physical plant design?

PN. I mentioned the fluid nature of inmate-patients’ conditions. It’s imperative to understand how different the nature of the problem is for most people involved with the criminal justice system. The conventional processes for delivery of care must be re-engineered for this population. Normally, in the free world, we would most likely have a general practitioner, who would address any general health needs and send us to see various specialists for acute and more specialized treatments and care. Delivery of care is separated into different silos. You get referred, then make other appointments to see the various specialists, and then perhaps seek second and third opinions, and beyond. There is a lot of running around among various providers.

In the world of correctional health that set of scenarios would require an enormous amount of inmate-patient movement, which is also very staff-intensive. And, because of the shift from acute care to long-term chronic care, we’ve found that having the various treatment disciplines co-located allows inmate-patients to more easily navigate the healthcare system and take greater responsibility for their own health. Unlike in the free-world, there is no competing amongst clinicians for market share. This is literally a captive market. In this realm, all the energy can be focused on the delivery of quality care in a safe, humane environment. The divisions between ambulatory and urgent care are more subtle and create a more holistic, integrated model of patient care. In most cases, the inmate-patients’ have severe medical and mental health issues due to years of neglect, and lack of access to care, along with the effects of the hard lifestyles many of them have led. Addressing the co-morbidity and acuity levels while the inmate-patient is incarcerated is challenging, considering the average length of stay. And once released, providing continuity of care can be equally challenging.

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

PN. I wouldn’t characterize it so much as a crossover, but more as an expansion of the definition of public health. Until we stop turning a blind eye to this segment of our population, we will never fully address public health or behavioral health.

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?

PN. Hopefully, we’ll see more compassionate responses, designs that are more therapeutic, and not punitive, supporting the patient’s dignity and allowing him/her to take greater responsibility for their own health and well-being. Correctional and detention facilities by nature require harder construction, and so do not lend themselves easily to renovation. When planning and designing facilities with standardized program components that can easily be re-purposed from, say medical to mental health; it provides greater flexibility as demographics and acuities change over time. As I mentioned above, the idea of a less siloed, more integrated delivery of care model, can translate into facility plans that provide more ‘one-stop-shopping’ using mainstreet concepts. This then translates into adjacencies of staff and support areas, in ways that provide convenient, safe and secure work environments. Of course, creating a normative environment must be balanced with safety and security.

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

PN. We have to be consummate listeners and test conventional thinking and long-standing perceptions about behavioral and mental health. We need to help facilitate process and programs that create better understanding and create meaningful environments that promote safe behavior, rather than just relying on the lowest common denominator which is simply physical separation or containment and control.

Q. How can we better address the continuum of care for these patients?

PN. We can be advocates for change, not just in the physical environments that we plan and create, but by helping to bring together public health, local government, law enforcement and community-based care, collaborating to create a fully integrated public health system which no longer ignores this segment of our population. We can develop new models of correctional healthcare that no longer stigmatize, but treat, rehabilitate and reduce recidivism.