建筑如何帮助解决美国的精神保健危机

▲ 位于图森的亚利桑那大学行为健康馆和危机应对中心（2011年）将96张住院床位，一个县级法庭和一个危机应对中心整合到一个设施中。由Tim Hurlsey提供

 
入口对建筑师总有一种特殊的魅力。门廊，大厅或花园是两个空间状态之间过渡的空间表现形式，又可以使两者的体验完全不同。在精神保健空间的设计中，患者真的可能进入一种状态而退出另一种，这些入口处就显得尤为重要。
 
The threshold holds special fascination for architects. A doorway, hall, or garden is a spatial manifestation of transition between two phases and can make all the difference in the experience of both. In the design of mental-health-care spaces, where a patient may literally enter in one state and exit in another, the threshold is particularly important.
 
“当你从外面进来时，我们会观察测序。” CannonDesign行为心理健康工作室的首席架构师Stephanie Vito说。“我们确实花了大量时间研究细微差别。”
 
“We look at the sequencing as you move from the outside through the inside,” says Stephanie Vito, a lead architect in the behavioral-health studio at CannonDesign. “We really spend a lot of time looking at the nuances.”
 
该工作室有27名员工，包括建筑师，规划师，设计师，工程师，程序员和顾问，分布于公司在美国和加拿大的六个办事处，该工作室汇集了一批专家，负责领导高度专业性领域的项目——医疗保健设计，从石膏板到水龙头的所有事物都需要与其他医疗环境中不同的设计考量。
 
With 27 people—architects, planners, designers, engineers, programmers, and advisers—spread over six of the firm’s offices in the United States and Canada, the studio operates as a pool of experts tapped to helm projects in the highly specialized field of behavioral-healthcare design, in which everything from drywall to faucets requires consideration different from that in other health-care environments.
 

▲ 隆美尔（Rommel）在行为健康方面拥有超过25年的经验

CannonDesign过去三十年来一直在为创造心理保健空间不懈努力，因此它有足够的机会了解该领域的发展。当该公司的第一家行为心理健康保健机构——加拿大的“安大略海岸”（当时的惠特比精神病医院）于1996年开业时，这被认为是一个分水岭式的项目。“该医疗设施以帮助病人恢复健康为基础。”主导项目的行为心理健康建筑师Tim Rommel说。“在此之前，大多数这类医院都更像长期护理机构。患者的住院时间以年数来衡量，而不是月或天。”
 
CannonDesign has been creating behavioral-health-care spaces for three decades, so it has had ample opportunity to track the field’s evolution. When the firm’s first behavioral-healthcare facility, Canada’s Ontario Shores (then Whitby Psychiatric Hospital), opened in 1996, it was considered a watershed project. “The facility was based on wellness—helping patients get well,” says Tim Rommel, a behavioral-health architect who directs the studio. “Previous to that, most were more like long-term-care facilities. Patient lengths of stay were measured in years versus months or days.”
 

▲ 对于亚利桑那大学行为健康中心和危机应对中心，CannonDesign aslo在住院单元的各个级别提供了带阴影的室外花园，患者，访客和工作人员均可访问。图片由Bill Timmerman提供

 
在美国，对精神卫生保健的支持并不充分，该工作面临着从社会污名化，床位稀缺到保险范围不足等多个方面的挑战。五分之一的美国人患有某种形式的精神障碍，但不到一半的患病人群接收了治疗。儿童群体的情况尤其不令人乐观。CannonDesign儿科实践的负责人Diane Osan称其为“危机”，称儿童医院“在行为心理健康方面的科室，前所未有的人山人海。”她指出了一系列会影响儿童的公共精神健康创伤因素：学业压力，欺凌，对性少数或性取向的不宽容，家庭破裂，学校枪击事件，以及社区暴力和类鸦片药物的流行。
 
In the United States, mental-health care is under-delivered and faces challenges on multiple fronts, from social stigma to scarcity of beds to inadequate insurance coverage. One in five Americans experiences some form of mental disorder, but less than half of affected people receive treatment. The picture is especially dire for children. Diane Osan, the leader of CannonDesign’s pediatric practice, calls it a “crisis,” describing children’s hospitals as “being inundated in ways that they’ve never been before around behavioral health.” She points to a range of public-health traumas that affect children: academic stress, bullying, intolerance of gender nonconformity or sexual preference, separation of families, and school shootings, as well as violence in communities and the opioid epidemic.
 
行为心理健康建筑师比以往任何时候都必须考虑如何设计物理设计和医疗程序上的“进入空间”，以促进患者与护理人员，患者与研究人员，患者与社区或家庭之间的有效交流。这一个个空间不仅有利于护理环境的治疗功能，而且还可以对抗病耻感，并为治疗扫除障碍。“人们越来越认识到心理健康是整体健康的重要组成部分，”Rommel说：“就国内生产总值而言，精神健康问题的花费比排名前五种的生理疾病的总和还多，其中包括心血管疾病和癌症。我认为我们的社会正开始意识到这一点，并在采取相应措施。”
 
More than ever, behavioral-health architects must consider how to design physical and programmatic thresholds that facilitate productive exchange—between patient and caregiver, patient and researcher, patient and community or family. These thresholds not only support the therapeutic functions of care environments but also battle stigma and remove barriers to treatment. “There is a broader recognition that behavioral-health care is a vital part of overall health,” says Rommel. “Mental-health issues cost this country more in terms of GDP than the first five leading physical ailments combined, and that includes cardiovascular diseases and cancer. I think our society is starting to realize that and take steps.”
 

▲ 蒂姆·隆梅尔（Tim Rommel）（左）领导CannonDesign的行为健康工作室，该部门的首席建筑师斯蒂芬妮·维托（Stephanie Vito）（中）和戴维·萨斯（David Sass）（右）在公司波士顿办公室任职。该工作室位于布法罗，分布在六个地点。图片由Rachel Jerome Ferraro提供

 
对于许多人来说，治疗最开始的地方根本不是指定的行为心理保健空间，而是急诊室，即ED。为了提供一个更安静的环境并避免让那些可能不需要的人住院，许多公司被越来越多的要求将医疗单位设计成“混合区域”，以便对表现出精神和身体不适的患者进行评估治疗。Osan说，这种被称为“危机中心干预单位”的综合护理领域在儿童医院中变得越来越普遍，这些医院的设计者们认识到了良好的设计可以减轻员工和年轻患者的压力。
 
For many, the first threshold of treatment is not a designated behavioral-healthcare space at all, but the emergency department, or ED. To provide a calmer setting and avoid hospitalization for those who may not need it, firms like CannonDesign are increasingly asked to design hybrid areas where patients exhibiting both mental and physical distress can be assessed for treatment. Known as crisis-center intervention units, such integrated-care areas are becoming more common in children’s hospitals, which recognize that good design can alleviate the strain on staff and young patients, says Osan.
 

▲ 维托（Vito）和萨斯（Sass）在布法罗办公室的公共区域集中精力思考

在急诊室之外，CannonDesign使用“治疗平台”来描述将利于康复的环境组合在一起。设计师认为，这些日常的生活环境不应被视为奖励，而应成为治疗方案不可或缺的一部分。该治疗平台包括多个单元（视患者类型而定，除卧室外，还可以包括临床设施，活动空间和室外区域）以及单元之外的区域，例如用于娱乐和其他方面的共享和半公共区域。
 
Outside the ED, CannonDesign uses the term “therapeutic platform” to describe the combination of environments that supports healing. Rather than being thought of as bonuses, these environments of daily life, CannonDesign believes, should actually be integral to treatment protocols. The therapeutic platform comprises units—which, depending on the patient group, can include clinical settings, activity spaces, and outdoor areas in addition to bedrooms—and areas outside the units, such as shared and semipublic areas for recreation and other uses.
 
“治疗平台”成功的关键是患者的选择。私人房间有助于维护患者的尊严和正常感，这比带有多张床的宿舍式房间更受青睐，并且对于设计出性别特异性有额外优势，这对跨性别和非二元患者至关重要。也就是说，卧室的设计有意遵循“鼓励患者出门”的基本原则。在其他地方提供多种选择（较大的活动空间，较小的安静空间），使患者只要想要可以随时离开。
 
Key to a therapeutic platform’s success is patient choice. Private rooms, which help preserve patient dignity and a sense of normalcy, are now favored over dormitory-style rooms with multiple beds, and have the added advantage of designing out gender specificity—critical for transgender and nonbinary patients. That said, CannonDesign prefers that the bedrooms’ design intentionally hews to the basics to encourage patients to leave them. Providing variety elsewhere—larger spaces for active groups, smaller ones for quiet—allows patients to step away when they need to without retreating completely.
 
 

▲ 位于安大略省汉密尔顿的圣约瑟夫医疗保健学院汉密尔顿（2014）的玛格丽特和查尔斯·朱拉文斯基综合医疗保健中心公共区域旁的室外露台是可供患者使用的多种空间之一。由Bjorg Magnea提供

 
精神治疗领域正寻求替代物理和化学控制以使患者平静的方法，于是客户转向设计驱动的方法来降低高风险情况，或将其完全避免。位于加拿大安大略省汉密尔顿的圣约瑟夫医疗保健中心和查尔斯·朱拉文斯基综合医疗保健中心拥有一系列用于此目的的设计空间。该设施不仅可以治疗患有急性精神疾病的患者，还可以提供门诊医疗服务（这是与病耻感作斗争的另一项努力），该设施包括带健身空间的“治疗中心”，书店，台球，乒乓球，洗衣房和沙龙。当该公司的堪萨斯大学健康系统大学项目于2019年开放时，它还在其中央庭院中包括一个篮球场和野餐区。
 
As the field seeks alternatives to physical and chemical restraints for calming patients, clients are turning to design-driven ways to de-escalate high-risk situations or avoid them entirely. CannonDesign’s Margaret and Charles Juravinski Centre for Integrated Healthcare at St. Joseph’s Healthcare Hamilton in Hamilton, Ontario (2014), includes a range of spaces for just that purpose. The facility, which treats patients with acute mental illnesses and also offers medical outpatient services (another effort to battle stigma), has a “therapeutic mall” with fitness spaces, a bookstore, billiards and table tennis, a laundry, and a salon. When the firm’s University of Kansas Health System project opens in 2019, it will include a basketball court and cookout area in its central courtyard.
 
其他设施包括游泳池，瑜伽馆，行为心理健康工作室的首席架构师David Sass表示，条件允许的话还可以有保龄球馆。他说，虽然不是每个人都可以随时访问所有空间，但他的目标是开放“进入限制”并提供越来越多的自由。这并不是要取代治疗中心之外的生活，而是要帮助患者全心治疗。
 
Other facilities have had swimming pools, yoga studios, and in one instance a bowling alley, says David Sass, a lead architect in the behavioral-health studio. Though not everyone is permitted to visit all spaces at all times, the goal, he says, is to open thresholds and provide more and more freedom; not to replace life outside the center but to help patients return to it.
 

▲ 位于弗吉尼亚州里士满的VCU医疗中心（2018）的弗吉尼亚儿童治疗中心（VTCC）的景观图显示了该设施的室外空间和庭院

▲ VTCC的图解部分用于计划通过玻璃幕墙的自然光渗透
 


▲ 当参观者接近VTCC时，其自然前卫的设计已在美化环境和供阳光进入的大窗户墙中体现出来

为总体健康而设计对于保持心理健康特别有益，因为促进平静的外部条件可以减少对控制和监视的需求。大量研究表示，自然采光、接近自然对患者有益，体育活动也与心理健康密切相关。考虑到这一点，在里士满VCU医疗中心的弗吉尼亚儿童治疗中心，为患者提供了室内和室外活动区域，并利用玻璃窗墙带来自然光线和视野。
 
Designing for general well-being can have particular benefits in behavioral-health-care spaces, since facilities that foster calm can reduce the need for overt restraint and surveillance. A number of studies support the intuitive wisdom that natural light and access to nature are beneficial to patients, as well as the idea that physical activity and mental health are intimately connected. With this in mind, CannonDesign makes a point to provide access to exercise and the outdoors in all its facilities. At the Virginia Treatment Center for Children at VCU Medical Center in Richmond, this meant including indoor and outdoor activity areas for patients, and utilizing glazed window walls to bring in natural light and views. At Juravinski, which required tighter security, CannonDesign provided a “gradient” of outdoor spaces ranging from secure to fully public and situated inpatient areas toward the back of the building, where there are private views of the property.
 

▲ 同样在玛格丽特和查尔斯·朱拉文斯基综合医疗中心，CannonDesign的开放式室内区域具有充足自然采光的策略有助于在社区计划，住院单元和研究节点之间建立联系感，确保员工和患者对一个人可见另一个。由Bjorg Magnea提供

 
以兼顾自然的思路创造空间也带来了周到的治疗，通过庭院和心房将户外带入，有助于循环。Sheppard Pratt健康体系的新精神病医院计划于2020年在巴尔的摩开业，它围绕一个院子而建。Sass表示，除了以开放热情的入口吸引人们外，它还是一个“物理统一体”，建筑物的每一层都经过中央走廊。这种推行自然的方法还指导公司如何维护这个地方，最终形成轻微的调整，既可以保留现有坡度和树木，又能使患者，访客和工作人员都欣赏得到。Sass说：“整个医院的首要概念就是这种自然疗法，这是‘自然与治愈一体’观念的全部。”
 
Creating spaces with nature in mind has also yielded thoughtful threshold treatments, bringing the outdoors in through courtyards and atria that aid in circulation. Slated to open in 2020 in Baltimore, Sheppard Pratt Health System’s new psychiatric hospital is organized around a courtyard. Besides drawing people in through an open and welcoming entrance, it is, Sass says, a “physical unifier,” traversed by a central corridor at all levels of the building. The nature-forward approach has also guided how the firm treated the site, resulting in a light touch that will preserve the existing slope and trees for a landscape that patients, visitors, and staff can all enjoy. “The premier concept for the entire hospital is this idea of healing in nature,” says Sass. “It’s all part of the idea that nature and healing are one.”
 
随着当前对健康的全面思考，行为心理保健（根据定义，必须将心理和身体一起治疗）提醒人们“全人”设计如何能够极大地改善我们的整体健康和幸福感。CannonDesign的行为心理健康工作室的建筑师共同认为，设计决策会直接影响用户的生活——他们会通过事后研究定期评估这些内容。“对我和CannonDesign团队来说，这是一个很重的责任，” Rommel说，“但这却是让你早上迫不及待的想要起床那种。”
 
As current thinking about health and wellness becomes more holistic, behavioral-health-care facilities—which, by definition, must treat mind and body together—are a reminder of how design for the “whole person” can dramatically improve our overall health and happiness. The architects at CannonDesign’s behavioral-health studio are united in their conviction that design decisions directly affect users’ lives—something they evaluate regularly through postoccupancy studies. “To me and to the CannonDesign team, it’s a pretty big responsibility,” says Rommel, “but it’s something that really makes you want to get up in the morning.”
 
 

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