Written by Mika Rautanen (M.D. specialising in forensic psychiatry, Helsinki University, Finland)
The COST Training School was comprised of two workshop days for selected participants and a general lecture day in the middle targeted for everyone interested in how modern forensic facilities should be designed today. Altogether, there were well over 70 professionals representing medical, psychological, nursing, juridical and architectural fields of expertise from various European countries.
A fruitful and open discussion was set as the leading principle through the Training School by Dr. Allan Seppänen, clinical director at Helsinki University Hospital and Finland’s COST- Action representative. He kept the content of the program open in the sense that instead of tight schedules we had time to tackle and discuss real-life problems presented by the trainers and us trainees. Due to great interest in participating, the lectures had to be moved to a larger venue which proved to be a necessary solution for the workgroup days too. Facilities and catering were just right for our purposes.
Do we need a wall?
Of course, according to Dr. Harry Kennedy, Clinical Professor of forensic psychiatry, Trinity College Dublin, Ireland. We started work by discussing what is needed to integrate the concepts of therapy and security and how this is currently implemented in different countries.
The wall around a high security hospital was seen as an inevitable and integral part of a safe facility. However, Christopher Shaw, Senior Director at Medical Architecture, London, reminded us that walls are only one expression of borders that divide space into different zones, and that this process of division can be achieved in multiple architectural ways.
We learned that the paraphrase ”people behind the bend” means not only mentally ill patients behind a curved wall but also expresses how the borders are felt by the surrounding public. Shaw showed us examples from various architectural sites where this combination of patient safety, privacy and public concerns was solved innovatively. One tip from him was to design the border as simple as possible, since unneeded details tend to psychologically enlarge the visual impact of a structure beyond its actual measures.
Safety lies in details
Small inventions in ways of building interiors, such as patient halls and rooms, are in a major role when planning safety in general. Simple places to sit down whenever and wherever one wants along the hospital corridors and in living areas can de-escalate potentially aggressive behavior. Possibilities to make choices, for instance which way to walk from one’s own room to the kitchen or how to avoid passing certain other people, help people feel more like capable, autonomous persons. Personalized colors at one’s door inset indicate that you are in your own, personal area and safe. Doors opening from bedrooms straight to common areas, such as a pool table hall, alerts the person to be ready for battle, instead of a relaxed transition from private to shared areas.
Without paying attention to details the hospital may become noisy, echoing, straight-forward and extremely boring for the patients and staff. Shaw encouraged us to be innovative in using modern possibilities such as robotics, IT and especially art to manage these pitfalls.
Dangerousness is a dangerous concept
There are no limits when trying to define exact measures in safety issues, such as the height of a wall. However, in order not to become outdated in a year or two, one should concentrate on continuous evaluation of different risks and the seriousness of these risks.
A hospital might find it helpful, for instance, to have regular evaluation teams for screening dangerous situations, patient leaves, coercive measures, and – why not? – teams checking whether the treatment plans are actually implemented or not.
Enough members of staff is vital for safe working conditions and for safe care. More staff- members are needed in the acute wards than later on the way to out-patient care.
Because in the field of psychiatry we don’t have a treatment-as-usual concept, we have to treat all the somatic problems of our patients and try to promote their mental wellbeing by an integrating, holistic approach. Concentrating only on small parts of the big picture – such as dangerousness – may mislead our focus from rehabilitation to isolation.
One of the main take-home points in the course was to understand the need for a long-term, well established and resourced multiprofessional planning team, when launching a forensic hospital design process. Accordingly, as a conclusion of the training school, we compiled a framework of all the initial steps in designing a forensic hospital. This 15-step template addresses the main issues to be taken into consideration and goes deep into details and suggested tasks and tools.
Need-based steps answer questions such as ”What is the facility’s role and profile in the overall organization of the forensic services, general psychiatric services and prison services?” and “Has the facility got a role as a university-affiliated research and teaching hospital?”
Policy issues cover regional, national and international legislation and attitudes, financial resources available and, for instance, patient advocacy.
The functional content step includes the role of the quality of design and materials. We also contemplated on growth and change related questions, such as ”What issues must be taken into consideration in order to ensure that designs have longevity and don’t become outdated too soon?” The detailed template can be obtained by asking Dr. Allan Seppänen.
The inspired general lectures and hands-on workgroups and the valuable short presentations by us trainees together with an open atmosphere generated a very successful Training School experience. By my knowledge, no such theme has been covered earlier with this kind of a multifaceted way. To promote mutual exchange of thoughts among nurses, psychologists, doctors, lawyers and architects when planning new safe and therapeutic facilities is exceptionally important.