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The Bethlem Hospital, also known as Bedlam.

Wellcome Library, London

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The Bethlem Hospital, also known as Bedlam.

Wellcome Library, London

Clinical psychologist Lucy Maddox asks: how can we move away from mental health clinics that are dark, sad and scary?

The first psychology training placement I ever had was treating adults who had depression and anxiety. The building I worked in was in Archway, north London, near the notorious ‘suicide bridge’. The clinic was based in an old hospital and the service was due to be moved. It was one of the most depressing and anxiety-provoking environments I have worked in, which, given that I’ve been working in often underfunded NHS mental health settings for nearly ten years, is saying quite a lot.

As trainees, eight of us shared a room with two desks, one filing cabinet and three chairs. The secretaries didn’t learn our names, or if they did they didn’t let on. They referred to us as ‘Baldricks’. They knew our place.

Like most services, we needed to book rooms in advance to see people in. It was hard to book the same room each time, so we took pot luck. Some were nicer than others: if a room had a little lamp or a piece of art on the wall it was prized. Most did not. Grey carpets, uncomfortable institutional chairs, low laminate wood tables and the occasional spider plant was the best you got in most of them. Some of the blinds were broken, bunched up at the edges or buckled in the middle. The walls were often dirty.

The best-case scenario was drab, the worst was claustrophobic and unhygienic. Not ideal for clients with phobias or obsessive–compulsive disorder, unless you were a fan of ‘flooding’, a seldom-used behavioural technique where someone is exposed to their worst fear without any graded steps of exposure.

I felt bleak going to work there. It was hard to feel hopeful about what we could do for our clients in a place that made me feel sad when I walked through the door.

This experience is not universal to every mental health setting, but it certainly isn’t uncommon. The well-designed or more comfortable facilities stand out in my mind as the exceptions. Children’s services are often much cheerier, with bright colours and toys and garden spaces. In the adult services I’ve worked in, the generic, depressing clinic room has more often been the norm.

In mental health hospitals there is the additional added chaos of alarms going off unexpectedly. The soundscape in hospital wards is often noisy and echoey anyway, where corridors bounce sound around instead of absorbing it. The alarms add an additional stress that can’t be overestimated, for both staff and patients. It’s bad enough when you’re a psychiatric nurse who has spent an eight-hour shift being unsure when the next piercing alarm is going to go off. But when you are suffering from post-traumatic stress disorder and heightened anxiety, and living on the ward 24/7, it must be nearly intolerable.

I’m lucky enough now to work in a ward that is light and airy. There is a frieze of beautiful translucent bubbles on the glass around the stairwell, and a vibrant mural of a beach scene in the ward garden. But even the building where our ward is based is not perfect. It was the best option available when a ward move was deemed necessary, so the space isn’t purpose-built. The ward is split over two floors, separated by a floor that houses different services. This presents difficulties when young people are moving between the floors of our ward.

Why do we continue to use spaces that can be so dark, sad and scary to see people who are already inhabiting dark, sad and scary places in their own minds? The answer seems to come down to a combination of cost and a lack of consideration. Healthcare renovations are often done relatively quickly, in order to use up a financial year’s budget before the deadline to spend it has passed. The decisions are taken by busy teams of clinicians and managers who lack the time and design experience to consider the brief fully.

Several organisations are devoting time and thought to mental healthcare design in the UK, including Star Wards and the Design in Mental Health Network, but what can be achieved is often limited by funding. In NHS mental health settings, the financial pressures have been great for years, and are only increasing. Despite the government’s discussions around reaching parity of care for mental health and physical health, we are far from parity of financial provision. Partnerships like the Dyson Centre for Neonatal Care in Bath (funded partly by the NHS and partly by charitable donations) might be one way to achieve high-quality design for mental health spaces.

Old models of psychiatric care used the idea of asylum. Although asylums were often scary and stigmatising, the idea of being outside of the city, surrounded by green spaces, is not a bad one. The wards at the Bethlem Hospital (previously known as Bedlam), for example, are surrounded by grass, flowerbeds, beautiful old trees and the occasional sculpture.

While reverting to the old idea of sending people away to recover from mental health difficulties is not ideal, we can definitely borrow something from the true meaning of the word ‘asylum’ as a place of refuge. The more we can make our mental healthcare buildings places where people feel a sense of relaxation and safety, the better. 

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