A New Vision for Mental Health Infrastructure
Mental Health during the Global Covid-19 Pandemic
More than six months into the global Covid-19 pandemic in New York City the health crisis is temporarily at bay with numbers of Covid-19 cases eerily low and very slowly inching upwards. We wait for the case count to rise as the city resumes more activity daily and the cold and flu season starts. Every day we wake up to the reality of facing an indeterminate future at a global scale, months of social isolation, and an economic and social crisis reflecting grave inequities evidenced in increased homelessness and sky-high unemployment numbers– not only here in New York City, but nationwide. These realities leave us with a mental health crisis that cannot be overstated.
According to a Kaiser Family Foundation funded study in May one in three adults reported symptoms of anxiety or depressive disorder which is a three-fold increase from the year before when one in ten reported such symptoms. Mental health, defined by the World Health Organization as “… (the) state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community,” is an aspect of the human condition which architects and planners have forever sought to improve.
A Digital Model for a Mental Health Infrastructure
During the pandemic some states have contracted directly with digital applications like Headspace, What’s Up and Moodkit, to offer their citizens access to the applications for free, removing economic barriers to mental health services that frequently come with lack of financial resources and access to health insurance. This surge in mental health digital applications is a symptom of a pressing medical crisis that begs for a physical, relational, solution, rather than a virtual one. What the digital applications do offer, however is instant accessibility and an attractive interface. There is no structural reason that good environmental design paired with effective mental health services cannot do the same. While an application can provide tools for addressing stress and anxiety, studies show it is best when paired with in-person mental health treatment.
In Zimbabwe, Dixon Chibanda, one of only a dozen psychiatrists in the country, started a program in which grandmothers are trained in evidence-based talk therapy, supported by digital platforms. These grandmothers are then stationed at designated benches, as a resource to individual communities. By now over 30,000 people have received treatment from a grandmother and studies show that the grandmothers are able to more effectively treat depression than doctors. In Zimbabwe, a country that is far less regulated and less developed than the United States, this insertion of the bench represents innovation at an urban and even national scale, for the program has been wide-reaching, cost-efficient, and effective. A treatment solution was paired with a physical and spatial one, proving the power of form and space to make an impact. Availability, visibility, and accessibility is all part of the program’s success. Due to COVID-19 the program has been moved online.
WHO/ E. Rice
According to a Kaiser Family Foundation funded study in May one in three adults reported symptoms of anxiety or depressive disorder which is a three-fold increase from the year before when one in ten reported such symptoms. Mental health, defined by the World Health Organization as “… (the) state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community,” is an aspect of the human condition which architects and planners have forever sought to improve.
Long before this pandemic, in the United States, our efforts as architects - along with those of all the other professions charged with our collective well-being - were undermined by the systemic dysfunction of mental health care delivery. Despite the fact that U.S. spending on mental health care continues to rise and hit $201 billion in 2013, making it the single most expensive medical condition in the country, for the past 20 years on average 50% of people with severe psychiatric disorders have gone untreated according to policy research. Furthermore, emotional well-being correlates directly to proper neurological function and physical health, rendering good mental health care a critical component of any effective larger health care system.
As architects, New Yorkers, and global citizens, we consider the existing mental health services available and ask: are these services capable of addressing the ever-increasing mental health crisis that will last long after the Covid-19 pandemic has subsided?
Historical Context of Mental Health Services in the United States
Since the mid-1950s, due to policy changes, the number of state psychiatric hospital beds has plummeted from over 550,000 nationally to less than 40,000 (link to report). In a mental health crisis people are now more likely to interact with law enforcement than medical professionals. In the same time period that hospital facilities devoted to mental health have been so drastically reduced, the number of people imprisoned in the U.S. has quadrupled. In the United States, suicide rates and opioid related deaths have ballooned since 2000, and nearly half of Americans report feelings of loneliness. According to the Center for Disease Control (CDC), in 2013 among students in grades 9-12 in the U.S. “17% of students seriously considered attempting suicide.”
Pastor, Immanuel Lutheran Church, NYC
Precedents for a Physical Mental Health Infrastructure
A broad-based rethinking of the approach to mental health service delivery is clearly warranted, and architects, planners, and urbanists stand ready to contribute. What follows are examples of such rethinking.
Friendship Bench: bench for therapy, Zimbabwe
While this project in Zimbabwe was not conceived by an architect, there are lessons we can take from it. A bench became a visible symbol for mental health. Instead of sequestering the treatment, it was situated in plain sight. This concept is now being scaled up to a total of 72 clinics throughout Zimbabwe, and other countries are taking note and developing similar programs.
In recent years a handful of nonprofit organizations in the arts and architecture have been formed to address the intersection of design and mental health care. The Big Anxiety Festival, sponsored by the University of New South Wales in Sydney is a good example. The festival’s goal was to “reimagine the state of mental health in the 21st century” by bringing together artist, scientists, and communities. One initiative was a design competition “to design a pod to support good mental health, and calm, focused attention, for use in public schools” which was supported by the Minister of Health. Two pods were selected for construction, displayed during the festival, and subsequently installed in schools. In New York City, the NYC Department of Health and Mental Hygiene created the Mental Health by Design program, in which they partnered with architecture offices to transform15 classrooms in schools across the City into meditation rooms. Thoughtfully designed, these spaces make attention to mental hygiene both accessible and appealing.
The Van Alen Institute in New York City organized a flash competition in the Fall of 2017 and sought “proposals for an archetypal public mental health treatment center that will provide an imaginative street-level presence for a range of mental health services integrated within local communities to address the gap in access to mental healthcare, and help destigmatize mental illness.” There were several compelling responses. Two were given honorable mentions - one that elaborated on the idea of the friendship bench and located it in public libraries, and the other proposing a mental health truck, similar to the City’s ubiquitous food trucks.
Storefront Proposal, PSF Projects
Our firm, PSF Projects, produced the winning entry. In collaboration with a mental health clinician, we conceived a network of immediately identifiable, prefabricated wooden modules, to be deployed in hub and spoke configurations. The hubs would be set up to meet the pressing need for timely medication prescription and would contain six modules: two for medical exams with EKG equipment, two phlebotomy spaces, and two consulting rooms for psychiatry, all organized as a self-contained clinic within an existing commercial space. For the spokes we call for a number of neighborhood clinics to occupy empty storefront space. Each would have five modules, visible from the street, and serving as therapy rooms. They would be configured to define an additional larger multifunction area to serve community needs such as twelve-step programs or meditation classes. These clinics would be the primary initial point of contact with patients, with those in need of immediate medical intervention being sent to their associated medical hub. A third usage for the modules would be as kiosks for community outreach, located in public spaces in underserved communities. Our ambition is to provide a wide range of services in broadly distributed, de-stigmatized, self-supporting environments with the ultimate goal of improving care and reducing ER visits and psychiatric admissions. The tectonic and graphic identity of the treatment access points would be consistent and recognizable across the three scales of intervention. Employing biophilic design concepts, the material language and form of the modules utilizes natural materials and maximizes daylight to provide a calming environment for healing.
Creating a Healthier City
Collectively, the projects described above challenge the status quo and push for a future in which clinical treatment options and environments are visible, legible, and accessible. As the pandemic ticks on globally, we have seen a significant uptick in the need for mental health services. Add to that the need for temporary virus testing sites and treatment centers for Covid-19 patients and suddenly the need for a robust mental health infrastructure can also serve the dual purpose of a strong visible public health infrastructure. As our daily life, urban spaces, and economies are transformed by this pandemic, we see this as a chance to consider creating a future in which we can better address the problems of our society.
New York City is just one example of a city that has seen several disasters in the past 20 years: 9/11, Storm Sandy, and Covid-19. In each case, the presence of an easily identifiable, local network of disaster relief sites would have eased communication, outreach and recovery. Storefronts across the nation, in large and small cities alike, as well as in towns and villages, are vacated due to the inability of businesses to pay their rent as foot traffic is halted due to stay-at-home orders. These storefront vacancies are an opportunity to reinhabit them with more permanent public health service centers. Alternatively, stand-alone microunits can be integrated into our public parks and plazas which have provided refuge during the pandemic. The key - as the Zimbabwean grandmothers doubtlessly understand - is to transport the solution to the problem. In cities, that means that means proximity to the street, the fundamental locus of societal interaction. In the pandemic we have reinvented the shared outdoor spaces of the street, the plaza and the parking lot into places to teach our children and eat our meals safely. Now we can apply similar invention and vision to our healthcare and mental health infrastructure to create a stronger and healthier future for our cities.
by Barrett Feldman and Mark Sofield
Barrett and Mark are principals at PSF Projects, a NYC based architecture firm that thrives on transforming the expected into the unexpected by viewing challenges as opportunities to create thoughtful, innovative solutions that aim to improve the lives of people.