Why We Need a Psychiatric Museum of Psychological Engineering
The people designing inpatient psychiatric units are not inconvenienced by their designs
In a memorable post on
, asks: Why doesn’t good design replicate and dominate? Why does bad design persist?“… bad design is everywhere. Norman Doors—the kind that fool you into pulling when you should push or pushing when you should pull—are still common nearly thirty years after a bestselling book pointed out their stupidity. My microwave beeps very loudly every 15 seconds once it finishes cooking; there’s no way to turn this feature off. Clothing tags tell you how to care for your garments in inscrutable hieroglyphics… it is a grim indication that we live in a world where good ideas lose. Some problems—like cold fusion—persist because we haven’t figured out the solutions yet. Some problems—like racism—persist because there are bad people. But some problems seem to persist for no good reason, which should make us all very worried.”
In answering this question, Mastroianni focuses on the difference between technological and psychological engineering. While technological engineering problems are easy to identify and fix, psychological engineering issues, such as unintuitive doors, are harder to spot and solve. This is because psychological engineering deals with human behavior and perception, which vary widely, making it challenging to design universally intuitive solutions.
Technological advances tend to spread quickly—better phones, faster cars—because they are measurable and can be optimized. However, psychological engineering improvements, such as better door design or more user-friendly public restrooms, often go unnoticed because people only recognize bad design when it inconveniences them. Even when good psychological design exists, it tends to “melt into the background,” offering no measurable advantage that can be marketed or hyped.
proposes a “Museum of Psychological Engineering” (MuPE) to raise awareness of good design by allowing people to experience both bad and improved designs firsthand. By immersing visitors in thoughtfully designed spaces, MuPE would exhibit the value of good psychological engineering.“… taking one perspective is hard enough, but psychological engineering requires you to take several. Bathrooms should be wheelchair accessible and easy to clean, but designers are probably not going to invite people who use wheelchairs to test out their bathrooms, nor are they going to try scrubbing behind the toilets. Anyone who can overcome these challenges is rewarded with indifference. Psychological engineering problems are hard to spot in the first place, so people rarely notice when you solve them.”
“[G]ood design can’t be explained; it must be experienced. That’s why what we really need is a Museum of Psychological Engineering where people could immerse themselves in the delicious joy of good design… In the MuPE, every door shows you exactly how you should interact with it. Queues are perfectly designed so waiting in line is painless. You get to interact with tons of bad designs—remote controls, office chairs, moving vans—and then you get to see the versions that have solved the psychological engineering problems and go “ahh that’s so much better.””
Every since reading that post, I’ve been thinking about the degree to which crappy, and at times outright traumatic, experiences of inpatient psychiatric care are problems of psychological engineering.
Mastroianni focuses on psychological engineering because he doesn’t think that bad design is merely a problem of incentives. I agree with that. However, inpatient psychiatric care is one of those situations where there is a clear problem of incentives in addition to everything else. Current incentives are almost entirely focused on risk reduction and safety optimization (and that too in a rather bizarre, bureaucratic manner that is disconnected from empirical evidence).
AMA Journal of Ethics recently devoted a whole issue to “Psychiatric Inpatient Environmental Architecture” (edited by Rebecca Grossman-Kahn). A running theme in the issue is that psychiatric units are often designed with stringent safety protocols, such as limiting access to personal items with ligature risk to prevent possible harm, but these measures frequently lead to dehumanizing conditions, undermining the therapeutic goals of the space. I relate to this very strongly. I worked for many years in an inpatient psychiatric setting, and I was constantly aware of the trade-offs between patient safety and patient comfort and dignity.
Edwards and Morris write in their article in the issue:
“Adverse event frequency in inpatient psychiatric settings, combined with the threat of punitive actions (eg, regulatory sanctions, litigation), places pressure on inpatient psychiatric staff and administrators to prioritize managing risks of dangerousness over other therapeutic needs of patients (ie, characteristics and features of treatment that promote healing and recovery). For example, because hospitalized patients have attempted or completed suicide with shoelaces or belts in the past, inpatient psychiatric facilities may then develop policies restricting all patients from having these items. In response to patients drinking hand sanitizer to become intoxicated, staff members have restricted access to or removed hand sanitizer in psychiatric units to prevent further ingestion of these products. After investigating a psychiatric facility in Colorado for assaults on staff, among other unsafe work conditions, the Occupational Safety and Health Administration cited several workplace hazards in 2019 and suggested abatement methods, including redesigning nursing stations so that patients cannot access these workstations or items for weapons, such as “hole punchers, staplers, telephones, cords, pens, computers, computer peripherals, and other items.” Due to security and legal concerns, psychiatric units around the world have installed video surveillance to monitor or record patients and staff on these units. As one article about nursing in these environments noted: “Safety is not merely a consideration or goal, but the highest value.”
Clinical staff and administrators in these settings should remain aware of the need to balance the risks of dangerousness in inpatient psychiatric facilities with the risks of creating dehumanizing and sterile environments that do not support recovery for patients with severe psychiatric needs. For instance, if a patient attempts strangulation with a privacy curtain in a shared room with a roommate, removing all curtains from shared patient rooms without any sort of replacement would entail considerable privacy drawbacks for patients sharing rooms; nevertheless, it is difficult to measure loss of privacy associated with these types of changes. Similarly, if a patient uses exercise equipment to assault a peer or staff, removing all exercise equipment from patients could have deleterious effects on patients who rely on exercise for their mental and broader well-being.” (Edwards & Morris, 2024; references removed from the quotes)
In an excellent article (my favorite in this issue), Liu et al. discuss the role the Joint Commission (TJC) has played in making environmental threats to patient safety a focus on psychiatric inpatient environments to the detriment of patient comfort:
“While the general rekindled interest in the relationship between hospital design and patient outcomes is encouraging, with respect to the design of psychiatric facilities, there is a tug of war between proponents of creating a healing environment and proponents of minimizing suicide risk. It is difficult to discern whether these 2 priorities are mutually exclusive or can be equally, effectively, and concomitantly addressed with thoughtful design. Given that hanging is the predominant method of suicide in the inpatient setting, TJC has prioritized mitigating ligature risk in its suicide safety standards. However, there has been widespread uncertainty regarding the implementation of these vague guidelines and the cost of renovations. The requirement for hospitals to be as ligature free as possible has been accompanied by minimal instruction from TJC on how to implement this standard in the physical space, and implementation has been further impeded by a limited number of design furniture vendors for behavioral wards… While there have been attempts to reduce suicide rates using mental health checklists, the impact of these checklists is unclear, given the small number of completed suicides on inpatient psychiatric units. As such, it has become common practice for medical directors of psychiatric facilities to hire consultants to inspect hospitals before official TJC surveys to interpret how these ambiguous guidelines apply to their physical spaces. An example of one such consultation occurred on our adult inpatient psychiatric unit, where a piano and uncaulked paintings in the common space were identified as potential ligature risks.”
“In addition to implementing design elements to mitigate suicide risk in inpatient psychiatric units, organizations (both health care and accreditation), researchers, and clinicians should also keep in mind the potential of architectural design to create healing spaces. TJC guidelines have largely narrowed the focus to interventions on the built environment that theoretically minimize acute suicide risk. However, these interventions not only lack empirical support but also prioritize risk management over healing.”
“We must remember that treating patients’ underlying mental illness and providing them with tools to cope with distressing emotions and adverse circumstances are the most effective methods in suicide prevention. Health care organizations contemplating restructuring of their behavioral unit should consider incorporating known therapeutic design elements—privacy, sound reduction, daylight, environmental complexity, ventilation, color, and nature—while also incorporating opportunities for clinicians to observe patients (eg, open nursing units) to help maintain patient autonomy.” (Liu, et al. 2024; references removed.)
Tamarelli et al. make the case that boredom in locked inpatient psychiatric units should be considered an iatrogenic harm. I was really glad to see this article because one of the things almost everyone, even those with relatively positive experiences of inpatient psychiatric care, complains of is extreme and maddening boredom.
Shields et al. offer a very helpful summary of patient-centered design features for psychiatric units (see table in the article).
Slemon & Dhari discuss the scenario of a patient who feels distressed about not having access to fresh air. The psychiatrist makes a case for having a staff member accompany the patient to the hospital garden, and the risk manager responds: “I’m sorry; we just can’t. Two years ago, a patient eloped after being allowed to walk in that garden.”
A series of digital drawings by Srinivasan considers how design influences patients’ experiences (check them out!).
There is a clear problem of incentives when it comes to inpatient psychiatric care—an imprudent emphasis on safety at the cost of patient comfort, dignity, and autonomy, driven by regulatory requirements—but there is also a notable component of psychological engineering. The people who are designing inpatient psychiatric units are terrible at anticipating the needs of individuals who will end up using these spaces, patients as well as healthcare professionals. Just as most people designing bathrooms are not scrubbing behind the toilets they have designed (I’m taking Mastroianni’s word on this!), people designing inpatient psychiatric units are not going to spend any meaningful amount of time on the unit.1
Plunkett and Kelly discuss the following clinical case in the AMA Journal of Ethics issue:
“BL is a 48-year-old woman suffering an initial episode of severe depression. She has been contemplating ending her life and, at her sister’s urging, agrees to voluntary inpatient admission to be treated for depression. To her horror, she is asked to remove and relinquish her bra, her drawstring sweatpants, and her shoelaces, since straps and strings are viewed as a ligature risk. She is admitted, alone, and feels stripped and ashamed. Wearing no bra and ill-fitting hospital-issued clothing and footwear, she meets Dr Psych for the first time.”
The people designing suicide risk policies never get to experience the implementation of those policies. In their minds, they are keeping people safe… what’s the big deal?
I have worked in many inpatient settings, including many years in a state psychiatric hospital with forensic patients, and I got to see first-hand all the ways in which patients push the limits of hospital design and policies: patients trying to cut themselves or strangle themselves with the most unlikely objects; patients attempting to elope; patients receiving drugs in mail in postage stamps; patients fermenting fruit juices to make alcohol; patients harassing people at odd hours using the hospital phone, etc. I know how difficult it is to deal with these challenges. I also know that in the process of cracking down on these problems, hospitals have created such controlling and austere environments that I have had some patients beg me to send them back to the jail since the jail offered them more autonomy and flexibility than the forensic hospital.
People tend to recognize bad design when it inconveniences them. The people designing inpatient psychiatric units are not inconvenienced by them, and the people inconvenienced have no power to change the design.
People who overcome problems of psychological engineering are rewarded with indifference. This is particularly true when it comes to inpatient psychiatric units. There are units out there that have addressed issues of patient comfort and dignity; they are sometimes not even rewarded with indifference but punished; they face greater financial pressures because they are paying more for a higher staff-to-patient ratio, and they face greater risk of liability in case of a negative outcome (“We told you to get rid of that piano!”). Patient satisfaction in the inpatient psychiatric context isn’t really tracked, publicly reported, or monitored. And there is such a shortage of inpatient beds that patients in an emergency situation don’t have much of a choice in which psychiatric unit they’ll be admitted to; they’ll be sent to wherever a bed is available.
During my psychiatry residency, as part of our consultation-liaison training, we had to undergo an exercise. With a small group of residents, a nurse would simulate what putting a patient on “suicide precautions” on the medical floor entails; you would get to see first-hand what personal belongings have restricted because they entail some sort of hypothetical risk and how onerous these restrictions are. To this day I am grateful that we got to participate in something like that.
The idea of a “Psychiatric Museum of Psychological Engineering,” impractical and idealistic as it is, is attractive to me. A place where you get to experience bad inpatient psychiatric design and then get to immerse yourself in good designs that find a variety of optimal solutions to the safety-comfort trade-off. Wouldn’t that be something? It won’t solve many of the problems that we face—skewed incentives, limited funding and resources, liability concerns, and shortage of beds—but it will increase the likelihood that people making these decisions are not doing so from a place of psychological ignorance.
We don’t really have a psychiatric museum of psychological engineering, but meaningful involvement of people with lived experience, their families, and clinical professionals in the design and implementation of psychiatric architecture and policies is well within our means. Our collective failure to do so speaks to the degree to which individuals with psychiatric problems are still alien to our affections.
See also:
George Dawson. The problem with inpatient units… Real Psychiatry
Martin Greenwald. Improving Inpatient Psychiatry. Socratic Psychiatrist
Awais Aftab. Asking better questions about involuntary psychiatric care. Psychiatry at the Margins
The inpatient psychiatric unit with the best design where I’ve personally worked is the geriatric psychiatry unit at the University of California San Diego (UCSD), where I did my fellowship. From what I know, the medical director—Dan Sewell, a brilliant psychiatrist and a very patient-oriented clinician—had been closely involved in the design and creation of the unit, and a lot of thought went into things like the design of corridors, room windows, placement of lights, the degree of illumination, the exact shade of paint color on the walls, the selection of art works on the unit and in patient rooms, privacy, and access to internet.
I am struck by the insistence on safety manifesting as stripping people of all physical objects that they could use to harm themselves. What about increasing safety by emphasizing the emotional connection that a patient has with staff members, so that they feel free to tell staff how they are feeling, and then navigate through those feelings without fear? Instead, the physical environment mitigates against emotional connection (i.e. the nursing station is often glassed off from the general hallway.)
Forgive me if I've already said this in a previous post: a long time ago, before I became a dr, I read an article about a med school program where students were required to spend a week in a hospital. I have not since been able to find this citation. It seemed to me like a brilliant idea.
Would that more programs did what yours did in terms of trainees having the experience of being dehumanized in the process of turning into a patient. I would advocate for a mandatory experience on a psych unit or in the ER!
If anyone is interested in finding a way to turn this idea into actually policy, please lmk.
I have to believe that valid research involving patient feedback on emergency room and hospital protocols would be feasible. Few people who actually want to harm themselves would take the time to cooperate in research to improve hospital policies- people don't go to the hospital to harm themselves. They harm themselves in hospitals because of pre-existing illness and inadequate care.