Design for people with mental illness

by John Van der Have

John Van der Have is the principal of Bio-Building Design Pty Ltd - Architects and Access Consultants, based in the City of Blue Mountains, NSW. He is a member of ACAA, and also a member of the Australian Institute of Architects. He has served as access consultant on several hospital projects, including psychiatric wards.

The Premises Standards Review Consultation Paper issued in February 2021 by the Commonwealth Department of Industry, Science, Energy and Resources (1) flagged an issue that has not so far been included in the Access-to-Premises Standards. That issue was referred to as ‘Environmental sensitivities’. The paper elaborated: ‘Some reported how buildings or building designs interacted with people’s extreme sensitivity to noise, psychosocial disabilities, anxiety issues …’ (2).

The Consultation Paper reported that individuals affected by ‘environmental sensitivities’ experience symptoms that impact their health and wellbeing. As an example, one person commented: ‘Carpet and flooring patterns should be considered in the designing process as this may cause the perception/illusions for those with … anxiety’ (3).

How do we go about designing for people who experience anxiety or other mental health conditions? What is the extent of mental illness in Australia, and can it be addressed in the Premises Standards, the Building Code of Australia or Australian Standards?

At present, AS 1428 - Design for access and mobility - makes detailed provisions for design for people with mobility impairments, and also for people with some sensory impairments. The AS 1428 series of standards, however, makes no provision for people with impairment or disability associated with mental illness. The Premises Standards 2010 likewise currently contain no explicit mention of design for people with issues relating to mental illness.

The National Construction Code (NCC) does contain a few scattered references to the diverse needs of people with mental health conditions. For example, Clause D2.21 makes special allowances for door latches in mental health facilities (4).

We can conclude that the regulatory documents that govern much of what access consultants do on a day-to-day basis contain little prescriptive information regarding design for people with impairment or disability related to mental ill-health.

However, the over-riding legal document in this area is the Disability Discrimination Act 1992 (DDA). Under the DDA, disability is defined as:

‘(a) total or partial loss of the person’s bodily or mental functions; or …

(g) a disorder … that affects a person’s thought processes, perception of reality, emotions or judgment or that results in disturbed behaviour’.(5)

Under the DDA it is unlawful for anyone to discriminate against a person with a disability, including a mental disability, in the provision of access to public buildings. So, notwithstanding that Australian Standards, the Premises Standards and the BCA have little to say on the topic, those who design and construct buildings have a responsibility, under the over-arching provisions of the DDA, not to discriminate against people with mental illness or disability. How big is the issue that we are talking about? Let’s look at a few statistics, to get a perspective on how big this issue is.

The following statistics are taken from the Productivity Commission Inquiry Report into Mental Health (6):

• Approximately one in five people in our country will experience mental illness this year.

• Almost half of all Australians will be diagnosed with a mental health condition in their lifetime.

• Poor mental health and self-harm cost Australia $200 billion a year. To put that in context, this is just over one-tenth of the size of Australia’s entire economic production in 2019.

• Just over 3000 people are lost to suicide each year in Australia, an average of more than 8 people per day. Two thirds of people who die by suicide had a reported mental illness.

• Suicide has been the leading cause of premature death in Australia’s young adults, accounting for around one-third of deaths among people aged 15-24.

• Suicide rates of Aboriginal and Torres Strait Islander people are more than double those of non-Indigenous Australians.

A graph describing the prevalence of mental illness in Australia follows:

Distribution of mental health among the Australian population (Source: Productivity Commission, Mental Health, Inquiry Report, Volume 1, June 2020)

What do we mean by the term mental illness or disability? A mental illness is ‘a health problem that significantly affects how a person feels, thinks, behaves, and interacts with other people.’ (7) The terms ‘mental disorder’ or ‘mental disability’ can also be used. There are many other forms of mental illness or disability, varying in degrees of severity.

Some of the common groups of mental health conditions include:

• mood disorders (such as depression or bipolar disorder)

• anxiety disorders (including panic disorder, obsessive-compulsive disorder, and phobias)

• personality disorders

• psychotic disorders (such as schizophrenia)

• eating disorders

• trauma-related disorders (such as post-traumatic stress).

Buildings can be designed to meet the specific needs of people with mental illness. For example, for the benefit of those who have claustrophobia - a type of anxiety disorder - a wide open stairway or ramp can be installed as an alternative to a lift. For the benefit of those who have agoraphobia - another form of anxiety disorder - large public spaces can include secluded sheltered areas, where people can take refuge.

People with the most serious of mental health disorders, that may result in self-harm, require a distinct response in building design terms. Decision makers within hospital management systems are doctors, all of whom are bound by the Hippocratic Oath, the principal tenet of which is ‘Do no harm’. Based on that tenet, clinicians who lead hospitals that include psychiatric wards are ethically bound to not allow those within their jurisdiction to cause harm, including self harm. As a result, they regularly decide to overrule adherence to prescriptive deemed-to-satisfy regulations, rather than to allow patients to self-harm.

In practice, this means that no ligature points can be included within in-patient areas of psychiatric or forensic hospitals. This entails departures from the prescriptive Deemed-to-Satisfy provisions of the regulations when it comes to details such as grab rails, shower roses, tap sets, door handles, etc. Special thought needs to be given to curtain rails. Such requirements are applicable also to other premises where there may be high concentrations of people with mental illness or disability, such as prisons and detention centres.

In dealing with patients or clients who may have distorted views of reality, careful consideration needs to be given also to workplace health and safety. Emergency call buttons and dual withdrawal pathways for staff may be appropriate in facilities such as community health centres.

The prospects of reform of the Premises Standards to accommodate the needs of people with mental illness or disability are bleak. Given the complexity of the issues involved, the potential of conflict between the needs of people with mental illness and those with physical disabilities, and the painfully cumbersome and slow pace of regulatory reform, it is unlikely that reform to meet the needs of those with mental illness will take place at any time in the near future. The Consultation Paper implied as much, suggesting that there may be other ways to address this issue (8).

Notwithstanding this, the requirements of the DDA remain. Under this over-arching legislation it is an offence to discriminate against people with disabilities, including people with mental disabilities, in the provision of access to premises.

Beyond the bleak prospects of regulatory reform to address the needs of people with mental illness, as described above, there is good news. The good news is that architects today can avail themselves of techniques and strategies in the design of buildings that will foster positive mental health outcomes. These approaches to architectural design are proven palliatives that alleviate the symptoms of people actively experiencing mental illness. Such techniques and strategies are beyond the scope of this brief introductory article.

1. Department of Industry, Science, Energy and Resources, February 2021 - Premises Standards Review Consultation Paper - 2020 Review of the Disability (Access to Premises - Building) Standards 2010

2. Ibid p 14

3. Ibid p 14

4. Building Code of Australia, Volume One, 2019: Clause D2.21(b)(iii)(B).

5. Disability Discrimination Act 1992 Clause 4 - Interpretation

6. Productivity Commission 2020, Mental Health, Report no. 95, Canberra

7. Commonwealth Department of Health website <www1.health.gov.au> accessed 04.04.21

8. Department of Industry, Science, Energy and Resources, February 2021 - Premises Standards Review Consultation Paper - 2020 Review of the Disability (Access to Premises - Building) Standards 2010 p 14