Episode 50

The Changing Landscape of Behavioral Health

There’s a growing mental health crisis in the US, and a growing need for behavioral health resources. Listen in to this fact and experience filled conversation with a provider, Charity Holmes from the University of Washington Behavioral Health Services and a behavioral health designer/planner, Lori Epler from SRG Partnership. Learn with us more about their challenges, their successes and their hopes for the future of behavioral health resources.

Featured on the Show
“I think it's interesting because the models, the treatment models for mental health are changing so rapidly right now that each project really has a different set of rules for a set of flows, a set of spaces. A set of rules as to how spaces should be connected or not connected. And I think each client has a very different perspective on this.”


CCB: [00:00:00] Welcome to the ONEder podcast. This is your host, CCB. And we have a topic today that we're going to have a conversation around which touches many of us. And we know from statistics that the “many” is gigantic, I want to say the many is GIGANTIC. We're talking about behavioral health and behavioral health design. And we know that 25% of us adults are diagnosable for at least one mental health disorder in any given year. Okay, think about that, twenty five percent, and 1 in 25 Americans suffer from a debilitating mental illness. That's 1 in 25. And then half of all Americans will experience some type of mental health problem in their lifetime.
Coming off of the pandemic, you just imagine how much more anxiety there is that we've all been facing. And so, we know how huge the problem is and how giant the challenges are. And we love to celebrate people that are working to overcome challenges. So, today's guests, and I'm going have them introduce themselves, but we have Charity Holmes from the University of Washington Medical Center, and Lori Epler, who's a principal at SRG Partnership in Seattle. So welcome, ladies. Charity, Introduce yourself.

Charity: [00:01:29] Hi, I'm Charity Holmes. I'm the Assistant Administrator for Behavioral Health Services for the University of Washington. I've been in health care for over 20 years. I'm an RN by trade, and I've been in behavioral health for over 15 of those 20 years. And I'm specializing right now in reconstruction and building of behavioral health spaces to make them safe and do program planning for behavioral health patients.

CCB: [00:01:55] And I'm sure we're keeping you very busy. Yes. And Lori, tell us a little bit about yourself.

Lori: [00:02:03] Hi, I'm Lori Epler. I'm a medical planner, architect, and a principal here at SRG Partnership. I've been working with mental health for a while, health care for about more years than I'd want to mention, but 25 or so years. But mental health in the last five, ten years. There's a lot of reasons for that. There's a lot of demand. There's a lot of need in the community for mental health. But there's also, like personal reasons why people get into this. A while back, I found out, I got approached, I was doing some genealogy, and I was approached by someone from the Oregon State Hospital, which is the psychiatric state hospital in Oregon, saying, “hey, are you a relative of this person? He died here. We have his ashes, and we'd like someone to take them home”. And I started digging into this with my family and realized that this is my, my great-great uncle. And he had left home when he was about 18 and no one ever knew where he went. And he spent over 50 years in the Oregon State Hospital before he passed away. We shouldn't be doing that. We shouldn't be keeping people in hospitals for that long. If there's anything that we can do about it. And so, it became apparent that there was something important that I could do in this space about creating the right environments for healing, instead of putting people away. Um, and so that's my personal story. Yeah.

CCB: [00:03:36] Lori, thanks a bunch. Because the big question that we'd like to tackle is how, how does design impact patient recovery? So you both have come at it from your perspectives. And we are going to be, you know, just enormously grateful for the stories that you have to tell because you're doing it every single day. So, Charity, how about you start with, because you're talking about, you know, creating the facilities, being responsible for them. How, what's been your learning curve in what are the, you know, the factors, the elements that need to be incorporated in the behavioral health spaces?

Charity: [00:04:22] Uh, it's been a huge learning curve. So, my, my experience with designing behavioral health spaces started back in California. When CMS and Joint Commission started doing a lot of their citations for the ligature requirements in behavioral health spaces, that started about 12 years ago. It was one of the lucky first units to get cited for the ligature requirements when those, when they started really doing the citations on those, for which very good surveys started happening around that. And so it was very interesting working with the architects and the construction entities around trying to figure out how to do that, because most of these spaces in hospitals are retrofitted spaces. They're MedSurg units that were retrofitted to be behavioral health units now. Right? And so, trying to figure out how to make those even safer for ligature requirements, was a very interesting space.

Luckily, I was working for an organization at that time that was really an advocate of involving patients and families. And so, I was really fortunate to be able to work with a Patient Family Advisory Council at the beginning of my career and working in this. So having that experience and working with that Patient Family Advisory Council really helped me in my foundation in this space. Involving that and I think that's part of the most important aspects of this.

Charity: [00:05:54] And so throughout my career and throughout my development in all of these spaces, it's really important to make sure that you're involving those elements when you're planning any kind of space, because those are your experts, right? Your patients and your families are really the people experiencing these spaces and these therapeutic actions as you're trying to get them healed, you know, and on to the next level of care. And so, if you can involve them into everything from not only the way the room is designed, but just the type of seating you're using. And so as one of the projects I'm working on now is the Behavioral Health Teaching facility for the University of Washington that's going to be on the Northwest campus. And so that's actually the exercise that we just went through a couple of weeks ago as we brought in chairs for patients and families and staff to sit in, and say, these are the chairs that are going to be in your therapy rooms. Are they comfortable? Do you like the seats? Do you like the armrests? You know, so we had all these questions for them to actually answer and try out these chairs. And even to those kinds of details, and the color samples.

CCB: [00:06:58] So it's fascinating that you bring in obviously the users of the, of the spaces too, because they are the experts, if you will, in the functional use of them. But I'm going to turn it to Lori and say there's a whole expertise in translating those needs into actual design. So, so Lori, Charity just unpacked an enormous amount of, you know, kind of tracking through the process. But from the standpoint of doing a programming exercise in the very beginning, how does how does that, does it look any different than any other design programming exercise?

Lori: [00:07:40] Oh, boy. Yes, it does look different. I think it's interesting because the models, the treatment models for mental health are changing so rapidly right now that each project really has a different set of rules for a set of flows, a set of spaces. A set of rules as to how spaces should be connected or not connected. And so, I think each client has a very different perspective on this. So, when we started working with Charity and her team on the project, you know, there was already a program established in the State Pre-design process. It's a long story the way that gets developed, but we received a program, and it didn't really match the model of care that the University of Washington and Charity and her team were actually planning on achieving. And so, in the process of design, we ended up changing the program, having more, more larger group therapy spaces, more open space per person, per patient, so that there was more space, less density of, of people in the space, which allows people that breathing room to heal. We changed the model of nursing. And just so that the nursing staff would be more distributed from the way it had originally been planned, instead of having a centralized nurse station, we then had distributed nursing out in the in the milieu of the patient. So, a lot of those things are just super dependent on who's operating it, who's building it and who the space is for. I think it's interesting because one of the things that they don't teach you in architecture school or design school, you learn all kinds of things about creating beautiful space. They don't teach you about how to make a safe space. Mm. And so for me, that was the biggest learning curve moving into mental health because with, with health care spaces, you're looking at efficiency. You're looking at durability. You're looking at performance, right? Those are the things you're looking at when you're thinking about mental health. The first consideration has to be is this safe? The second concern.

CCB: [00:10:02] For any of the users. So that could be the providers. That's the patients. That's the families. That's.

Lori: [00:10:07] Yeah, correct. Could this be used in a way that could hurt someone, whether it's themselves or someone else within the space? And so that's the first consideration. You know, my first mental health project was actually an evaluation of, as Charity was talking about, an old medical surgical unit that had sort of been changed to become a mental health facility. And they knew that they were about to get hit by all kinds of regulatory things. And so, we did a study and we identified over 100 items that needed to be changed in order to be safe, and then had to go through a phased renovation project for that. But it's a huge mindset change to think about. How could I hurt myself here? You know, you walk into a room and say, what? What isn't right? It's just not the way designers typically think.

CCB: [00:10:59] Not the way that they think. And Charity, you also bring up and you're both talking about this - if you're reusing a space or, you know, redesigning a space to to be able to do these kinds of things, how much flexibility can be built into any space to also incorporate all the needs that, you know, each iteration, you know, of, of care is, you know, requires. That's just fascinating to think about.

Charity: [00:11:30] Yeah, that's actually one of the things as we built the new tower that we were actually looking at. How much flexibility can we build into that space for any changes that may be coming forward, right? Because we've learned throughout the years with behavioral health that it's changed. And as we come up with new regulations and new safety measures or new models of care, we want to be able to change with it. And so, we've done things innovative with Lori and her team to help facilitate those changes. And so, even within the nursing station component, we worked really closely with Lori to figure out….we have a very high acuity population that's going to be coming into this this space. And there's kind of a dichotomy of theories on whether you want an enclosed nursing station or an open nursing station right now in a behavioral health space. And so, we decided to go with an enclosed nursing station. But we worked really closely with Lori's team to figure out how can we build this with the flexibility to make it open if we decide to open it later. And so, we came up with a really cool design that's enclosed right now with the ability to take off the plexiglass and still have a beautiful counter and an open area if we move into it. And a year after moving into it with this patient population decide that we can actually open it, and it's going to be more therapeutic to this patient population to open it or open half of it, you know, and be able to do that. And we actually did design it to be able to open half of it if we need to and so both of those are options and flexibility. And so, those are really cool partnerships to be able to do that with the architects. And we did that with several spaces. A lot of our stuff is modular and so we don't have to make sure that it's permanent or built in or things like that. It is flexible design. We can do that.

CCB: [00:13:26] Okay. That's going to open the door to another piece of this, that the question about how do providers and designers and the ecosystem of support work together to make this happen. So, you can have the need, Charity, and explain the requirements. And Lori, you can come up with the design, but there are suppliers and vendors and, you know, any other number of folks that are involved in the, the final delivery, And how, uh, it's almost like is there a group of usual suspects that you work with, or are there are there folks that are, that stand out because they've spent so much time in the industry, but your needs are changing so rapidly. It's just interesting to think about.

Charity: [00:14:13] There are a couple, there are a couple of usual suspects because there's the Behavioral Health Build Guide, right. That has the usual suspects on the end of it. There's the New York Guide that has the more usual suspects in it. And so, you go to those first because those are, those are your normal ones. And then you go outside of it because those don't always have all of them. And so, Google's been a good friend, honestly. Um, I mean, just really and then there's some things you have to manufacture. You have to go to people and say, “this is what we think we need, can you make it?” And so, they manufacture it. And, and one of the favorite parts of my job right now is to work with the architects where they come in and they say, “hey, we made this really cool bench and it's got this built in light and we think it worked. Can you come look at it and test it?” I'm like, Sure, and go look at it and I break the light because my patients are going to break the light, right? Yeah.

Lori: [00:15:07] We had fun sending her like, ceiling grid, like vent covers and seeing how she could destroy them or how she could hook something into it to make sure that it was going to be safe for her patients. And so, we have this relationship where we go back and forth. Charity knows how people can damage things. Good job, Charity, without a baseball bat. She's very good at destroying things. And we go back and forth until we get it right.

CCB: [00:15:36] That that's a great relationship. But it also is, it's fascinating to think that the way that you folks work together, you know, with the need that's out there, there are massive needs for square footage of behavioral health. And what do you see, you know, outside of your own kind of ecosystem? Like how much hope do you have for what's taking place in other parts of Washington? You know, in other parts of the United States, I see faces that are grimacing just slightly.

Lori: [00:16:14] No, I'm just trying to figure out how to answer that, to be honest. Okay. It's a very broad question. It is great.

Charity: [00:16:21] But I am so hopeful, honestly, because I see things expanding like crisis centers that are being built and being funded. I see other like long term civil commitment beds that are being funded, like behavioral health has taken on such a wave of need and people are actually seeing the need to actually fund it and not just retrofit things. Right? Seeing the need to have it as a priority. Um, I for the first time like think, think people are actually seeing like this. This is a national need. And I think in the last like 8 to 10 years like people are actually standing behind it, right? And so it gives me a wave of hope that we're actually getting to where we need to be and we're destigmatizing it for the first time. Um, which is, you know, it's one of the things, foundations for our building is to destigmatize behavioral health. We put the cafeteria for the campus in the bottom of this building, like the first floor of this building so that people come into this building just naturally, um, for everything. Because we wanted to make this not just the building that had the psych patients, right? Um, and so I think that people are starting to see that across the nation too. You don't just have this freestanding psych building that's in the corner of the bottom of your county, you know, Um, so it is becoming part of the natural culture and I really actually appreciate that. So for me, it gives me hope. And I think that, um, having more of these conversations and having more architects that are familiar with it, being able to have more providers that are familiar with it, I think for me it gives me hope.

Lori: [00:18:04] I agree. It definitely it's much more hopeful than it was even five years ago. Right. And it's interesting that the pandemic somehow in all of us becoming more anxious and more depressed has caused us to talk about it more. And it's come to light, right? Everyone is much more comfortable talking about mental health needs than they were five years ago. Um, and that conversation has continued all the way to the governor's mansions and all of our states, right? So we have offices in Portland and Seattle, so we're, we're closely following Washington and Oregon. And both governors have a huge, huge priority placed on funding mental health. So this year, I believe the number in Washington, they just passed over $1 billion again for mental health, including some additional funding for the University of Washington project. But there are other things like expanding the workforce and increasing pay for the workforce and mental health and things that are being prioritized in our state. There's not enough. I don't think that there's enough focus on prevention yet with the way our dollars are being spent. We're doing a pretty good job of thinking about ways that we are going to build beds and crisis centers, not as much on how we're going to catch cases early, you know? You know, I know things like that.

CCB: [00:19:30] In the state of California also, our governor has, you know, has put a spotlight on it and recognizing and what we're seeing in California is a great deal of housing for, you know, for the unhoused and, you know, the whole Housing First and get people and, you know, knowledge that people on the street, it doesn't take long. If you didn't have a mental health issue to develop a mental health issue. So if we can you know, if we can kind of short circuit that. To your point, though, obviously there's so much more to do. But in the in the area of what we can do, one of the other things that I kind of wanted to have you guys, you folks talk about is the way that spaces are becoming more human. And you've talked about the functional need. But I've also heard you talk about some of the other considerations that are being made relative to design or materials or….

Lori: [00:20:28] Yeah, I think there's a lot of things, right? We're trying to make things less institutional. I mean, the whole purpose, the whole design from parameter or the design.

CCB: [00:20:41] Oh, you're just going out there for a minute? Uh oh. Oh, there. You're back.

Lori: [00:20:45] I'll say it again. Sorry. The whole design premise behind or the concept behind the University of Washington Behavioral Health Teaching facility was that it's an institution. Yes, but it shouldn't feel institutional. In other words, it's not going to feel like your bedroom at home. But could it have the influences more of like a hotel or something that has more of an appealing and soothing setting than your typical. You know, with the doors, with the little tiny panels and, you know, the old school design that you might have seen in the old state hospitals. So, we're really looking at things that are more tactile, you know, more comfortable, that more resemble things that you would see out in the rest of the world. Charity, you can probably weigh in there as well.

Charity: [00:21:39] Yeah. I mean, we don't want you walking in and feeling like you're in a jail, and we don't want you walking in and feeling like you're walking into a kindergarten setting. because a lot of the psych facilities, when they had to do quick retrofits, had to buy what was out there, which is a lot of the hard plastic blue furniture, right? Um, and so we really wanted to figure out how to do more modern type of furniture, how to do more home type furniture and to the point that we, for the bathroom doors in the patient rooms, we did sliding barn doors. And so, it's very homelike, right? And we still found a way to do them. So, they’re ligature resistant. Um, and to that aspect, the things that we did on these, these units are on the fourth, fifth and sixth floors of the building. But we did find a way to do patios on each of the, each of the floors so they have access to fresh air, outdoor air. And on the fourth level we found a way to do an actual atrium where they can actually go outside and have a garden space and actually be able to sit outside or do yoga outside. And it's actually a pretty big space. Um, then when you look up at the fence that surrounds that space, it's a no climb fence. But when you look up at it, it's a, it's one of those fences that has an optical illusion where you don't really see the fence. And when you look down from the patient's perspective, you don't really see the fence. You see the beautiful view. And so, the architects were very intentional about finding that material, which was very cool.

Lori: [00:23:16] We worked really hard to find something that didn't, wasn't reminiscent. Most of the climb-free mesh sort of things, they look, they make it look like prison bars. And that is the opposite of what you want, right? There's nothing about the law enforcement and jail system that we want to reference here. We want people to feel comfortable and in a healing environment. And so, we went through I don't even know how many samples of things before we settled on what we did, but I think it turned out beautifully. Um, and it was great.

Charity: [00:23:49] And it turned out great. And then the other things we did were we hired artists and photographers to help decorate this facility. And so, um, the photographer that we hired, actually printed the photography on Acrovyn, so it could be non-destructible on the psychiatric unit. And it's beautiful photography. It's of the area, different versions of Washington. So, you have the desert scape and you have the ocean and all the different areas so very much outdoors. So, they don't feel like they're enclosed. Um, and you know, things like that that just add to the atmosphere, so the patients don't feel like they're there. We also built in a sensory room on each of the units, and so the patients that can be able to access that type of room, that are safe can have access to a room that has like a vibrating chair and a 3D projector, and they can feel like they're actually at the ocean and hear the sounds and things like that. And so very much working with the architects. and then to think of the staff perspective versus just the patient perspective. Um, we put in a respite room in the staff lounge and so looking at things like that that were, that are not just, not just normal, typical psych things.

CCB: [00:25:06] Think we're seeing also so many more, more offerings from a lot of the material makers and the furniture makers that are, because there's such a such a move towards hospitality in almost every aspect of place today making people feel more comfortable, that it has bled into all the different suppliers in a in a very I'm going to say heartwarming way because you just see lots and lots of choices.

Charity: [00:25:41] Yeah, yeah. And we did things to help with the safety aspects as well. So we did the sally ports off the visitor elevators. We made sure that the, the elevators come up to actually a stop-accessible hallway that has all the staff support areas. Nutritional care doesn't necessarily have to come on to the unit. All of their stuff can be dropped off into an alcove and then staff can access it from the other side. So, all of those kind of features were actually very intentional and very included in the design process, which is very nice.

Lori: [00:26:11] And then also thinking about staff safety, the back way out of the nurse station so that if someone did, if we opened up the nurse station and someone was able to jump over, then there's another way out so that you're not barricaded, and then really intentionally thinking through the safety of the staff as well as the patients.

CCB: [00:26:30] And I want to say thank you so very much for all the information that you're sharing, but the way that you're sharing it, like it's just it's what we do. It's, there's no special concern. I mean, you know, there are special concerns, but it's not like something that is out of our conversation, out of anyone's accessibility, which I think is really, really helpful again, to destigmatize, continue that movement. Um, we're actually close to time and I know it goes so quickly when people are, you know, talking about really, really interesting things. So, what we like to do on the ONEder podcast is allow each person to like share, either reinforce something that we've talked about that you think is incredibly important, or if there's something that we haven't talked about that you think would be great for people to hear, take a few minutes and share that with us. So, this time, I'm going to start with Lori.

Lori: [00:27:31] Oh, good. I've had so much time to prep. I don't know what I do every day.

CCB: [00:27:40] You know, it is.

Lori: [00:27:41] It is what I talk about all the time. This is what I do every day. It's true. And so, my brain is racking through the …should I talk about the shortage of providers? Should I talk about the gap? That's actually, um,.

CCB: [00:27:53] I do actually think that's interesting. We talked about it before we got on the on the podcast, but that that does another one of those framework contextual settings for everyone. Yeah.

Lori: [00:28:04] So in 2016, the estimated number of mental health workers that we would need to add to the system was over 250,000. Except that the pandemic happened. Right. And so, anxiety and depression reported cases have gone up by 400% since then. So that number is even very low. Right. So we're thinking, you know, maybe double that, I don't know, in a shortage of mental health care workers, at the same time, you know, 78% of psychiatrists report experiencing burnout symptoms, the ones that are already in practice. So, we really need to find ways to support the people that are in practice and just make it more either more attractive or something. There's got to be a way to attract more mental health workers, whether it's higher pay, which is one of the things that's going on in our state, trying to create new roles with different levels of education. But we have a big problem, um, the way the US identifies a mental health professional shortage area is, are you ready for this, less than one provider for 30,000 people? And if you think back to what I said at the very beginning, where maybe 25% of adults have a mental health issue, that's like 7500 people, that that person would need to have to help at the same time. But they can't. Like that's it's way above that capacity. So, if you think about that, that threshold is just wrong.

CCB: [00:29:43] Right., and that's one of the reasons why I wanted you to say it. If we're sitting here talking about it and having people understand more, more effectively what the challenge is, you know that. So, then we have more empathy for, you know, the providers as well as the patients, as we're destigmatizing all of this. The more that we talk about it, I think the better off we all are, because it does. And people don't always understand or know what the opportunities are, What, where might I go? There was one other thing that you mentioned, Lori, that I would love for you to talk about, and that was the, um, the if you can't see it, you can't be it…. if you don't.

Lori: [00:30:27] Yeah. So we have all these conversations because this is what we talk about all day, about, um, disparities in our communities, about not, um, communities of color. LGBTQIA+ had to say, of all communities, we have this lovely number that was created for us, this nine, eight, eight number where you can call nationally and receive someone on the other line that should be able to help you. And it's not always plugged in properly, but that's okay. The number exists, but communities of color, people that are marginalized, are are less likely to call this number and actually seek help. Number one, because law enforcement is probably the one that's going to be dispatched right now instead of a crisis response team. And those communities are more likely to be harmed by law enforcement. So there's one thing, and the other reason is it's hard to ask for help when you know that the person that is going to be assigned to help you isn't necessarily like you. They may not come from your culture. They may not look like you. They may not understand where you're coming from, what your cultural values are. And so it becomes much more difficult to want to seek that care. So until we can I don't know the answer to this, by the way. Wish I did. Until we can sort of expand our mental health, the pool of people that are going into the mental health field, that's going to continue to be a big problem.

CCB: [00:32:03] Yeah, I mean, again, I think the more we talk about it, the more that people understand what is available. You know, the folks that tramp, that walk through the, you know, Charity's facilities, you know, and start to get the better feeling because, you know, that's what will help others that will help people understand. And experience and the more positive experiences that people have, the more that that gets communicated. And I can't begin to tell you how many young people I've heard saying I want to be a ____ because someone in my family had this issue and I want to be able to be the provider that helps. So I do think that, you know, there's that's the positive spin to it but we then can end with Charity and you know the representative of the provider and and what would your last your last comment be?

Charity: [00:33:00] Well I think to piggyback on what Lori's saying, that's one of the things that truly excites me and one of the reasons that I came to the University of Washington to help build this facility is because the behavioral health teaching facility will be the first facility dedicated to behavioral health teaching in the nation. And so it's really the first facility that was built with the intent to teach the next generation of behavioral health providers and providers of all type. That's not just MDs, that's the nurse practitioners, the social workers, the nurses, the psychologists, the occupational therapists, recreational therapists, the psych techs, everybody. And so, we are currently working on what that looks like and how to partner with all the different schools around us and figuring out what capacity we are going to have because we are only one location. But it is, it is truly exciting to be that and to figure out what that is.

CCB: [00:33:57] Yes, that's wonderful. And we will all look forward to learning more and seeing what happens as the school opens. And I'm going to say thank you again to Charity Holmes from the University of Washington Medical Center and Lori Epler from SRG Partnership in Seattle for a really powerful conversation about what our behavioral health needs are in the United States, what's happening in the state of Washington and what design can do to impact patient recovery. So, thanks so much for this. The ONEder podcast is available on all podcasting services, so if you'd like to sign up, you'll be able to get any ONEnder podcast. And on the website, there will be a ONEnder podcast page about this particular podcast where they're be links to Lori and Charity and all of the references that they've made. So, if you have more interest, you can get in touch with them. So thank you again

Lori: and thanks for having us.

CCB: You bet.