Strengthening the Public Mental Health Addictions Safety Net

Much needs to be done to ensure that national healthcare reform and parity live up to their promise for persons with mental illness and addiction disorders, Congressmen and advocates pointed out during a recent policy briefing on mental health.

There is an unfortunate dual crisis of increased demand and service reduction. Coverage expansion under healthcare reform will result in 1.5 million new patients entering the public safety net for mental health and addictions treatment, which already struggles to care for 8 million+ children and adults. Approximately 2.5 million people with serious mental disorders, individuals with major addiction disorders and homeless persons will remain uninsured, relying on services delivered by the safety net. The economic recession has resulted in over $2 billion in cuts to public mental health services -with more cuts on the horizon – leading to the elimination of services for the uninsured.

Another public health emergency was highlighted during the policy briefing: Persons with schizophrenia, bipolar disorder and major depression die, on average, at the age of 53 -the highest death rate among any population served by any agency of the United States Public Health Service. Co-occurring chronic illnesses -asthma, diabetes, cancer, heart disease and cardio-pulmonary conditions -and lack of access to primary care and specialty medicine is a critical factor in these tragic outcomes.

The time has come for parity between community behavioral health and other parts of America’s safety net including public hospitals and Community Health Centers. All of us (including Congress and regulators) must pay attention to three issues critical to the success of parity and healthcare reform:

  • Passage of HR 5636, the Community Mental Health and Addiction Safety Net Equity Act, that offers a new definition for Federally Qualified Behavioral Health Centers and identifies core services, creates nationwide cost based reimbursement, and establishes clearly-defined national accountability and reporting requirements.
  • Regulations to ensure that the healthcare reform’s new Medicaid Health Home State Option requires mandatory subcontracts with behavioral health; and that behavioral health organizations serve as medical homes for people with serious mental illnesses and addictions to advance this population’s overall health and improve life expectancy.
  • Passage of the HR 5040, the Health Information Technology Extension for Behavioral Health Services Act, to support the use of technology to create treatment transparency, eliminate errors and better coordinate care to improve the health outcomes of persons with serious mental illness.
  • Rep. Paul Tonko (D-NY), said there were four keys to a successful implementation of healthcare reform for people with mental and addiction disorders -a vigorous outreach and enrollment program by the Centers for Medicare and Medicaid Services; regulations that ensure parity in Medicaid state exchanges and parity in Medicare managed care plans, inclusion of intensive community based services and residential addiction services in the mandatory minimum benefits package offered through the new state exchanges, and inclusion of community mental health centers in every medical home funded via the law’s Health Home State Option.
  • Rep. Tim Murphy (R-PA), pressed for passage of legislation that would extend federal health information technology incentives to behavioral health services. The legislation, introduced by Rep. Patrick Kennedy (D-RI), would make behavioral and mental health providers eligible for federal grants to acquire electronic health records that are interoperable, integrated, intelligent and easy to use. But bills improving access to mental health services “only matter if we make sure we integrate care together,” Murphy said. “Mental health services are not stand-alone and that is something we need to continue to educate the community around.”

One Consumer’s Observations of the Mental Health Care System in America

The mental health system is a unique culture. Psychiatry itself is, unlike any other medical specialty. Mental health is an enclosed system. That means it is a world within a world. The doctors, therapists, patients, and support workers play roles. It’s a reciprocal environment. Each player in the system allows the other person the opportunity to act out his or her role. For example, the psychiatrist gives you a diagnosis that has no basis (Yes this does happen from time to time). You, the patient, having complete faith in the powers of the behavioral health system, accept this diagnosis as the gospel truth. In time, you begin to notice certain behaviors and thoughts that you believe may be a sign of your supposed illness. You return to your doctor and report these symptoms. Your psychiatrist agrees with your observations and writes them down in your medical record. He also inserts his authoritative comments to support his opinion. Therefore, both parties in the relationship are mutually validated in their roles.

When one has been playing the patient role for so long, a person begins to identify himself or herself as a “psych patient.” That’s who you are. This is the term that defines your very existence. You belong to the mental health system. Soon enough you find that every activity you engage yourself in is related to your disorder and the medication your doctor prescribed to suppress it. It’s a sad commentary indeed. It’s sadder still for the person who needlessly struggles against an undefinable defect in his or her character as if the diagnosis were the irrefutable truth. I acknowledge the fact that the unsettling scenario I am painting here is not true for every psychiatric patient.

At some point, the psychiatric patient discovers the benefits of being labeled mentally ill. There are mental health workers, such as case managers who assist the “consumer” in obtaining a free living allowance from the Federal government in the form of Social Security Disability Income or Supplemental Security Income in whatever minimal amount it may be. I will add for comfort that social security disability benefits are reported (by the government) to run dry in 2016. A consumer is often entitled to free housing, health care, food assistance, and much more. The mentally ill person may even have the right under certain disability laws to bring a pit-bull into a no-pet residential community. Technically speaking, you could even take it on a commercial airliner. The reason is simply because your therapist deemed it necessary that you have an emotional support animal (oops was that a secret?). Don’t get me wrong. I’m sure there are people who require a companion animal for their emotional health. I’m not trying to be disrespectful to those who are struggling. What I’m saying that there are incentives built into the system for many people to accept their diagnosis and play out their role.

There are case managers and outreach workers that will go to court with you, and advocate on your behalf before the judge when you run afoul of the law. They will help the mentally ill with all of their personal affairs. What a bargain! Run out and tell all of your friends about it. Let the government take care of you. It makes being a psychiatric patient seem so much more attractive. Why wouldn’t anyone want a psychiatrist label to them disabled? Again, I’m being sarcastic to make my point that people, who are improperly labeled with a DSM V diagnosis, run the risk of becoming dependent on the mental health system for their needs.

This kind of social welfare encourages people to give up their ambition and motivation. It instills the idea that living a marginal existence is sufficient. I, for one, believe in the greatness people can achieve for themselves and the world by applying themselves.

Remember this. Once you get into the mental health system your chances of getting out are slim. There are a number of reasons for this. Primarily because the psychiatrist or psychologist has you convinced that you have a serious medical problem, which you can’t handle yourself. We all know that’s ridiculous. Many people manage their depression and anxiety remarkably well without the use of psychiatric medications. If Ativan calms your nerves and helps you function, then that’s great. On the other hand, I have seen plenty of people become addicted to sedatives. These drugs are unsafe. I wouldn’t put your faith in the safety of the anti-depressants either. I think the pharmaceutical giants are quick to point that out as a result of the numerous class action lawsuits filed against them.

Some blame can be placed on the pharmaceutical companies for this unnatural drug dependence. As I was writing this article, I surfed NAMI’s website (National Alliance for Mental Illness) and noticed “In Our Own Voice,” a public education program, is funded by a grant from Eli Lily. This is the pharmaceutical giant that manufactures psychiatric drugs like Prozac, Zyprexa, and Cymbalta. I gather (without too much mental effort) that Eli Lily’s generosity is a publicity campaign to make them look like one of the good guys in the mental field, and as a result, boost sales. As I surfaced the Internet, I found that NAMI has been receiving their fair share of criticism for their questionable association with pharmaceutical companies. I will not say NAMI is immoral or unethical. That would be too easy. If Ely Lily offered me thousands of dollars, I would have to seriously consider taking it. Sometimes the decision to cross the line depends on one’s real life needs. Other times it just has to do with making a buck. There is no denying that this kind of corporate misconduct adversely affects the mental health system and exacerbates the suffering of its consumers. Again, I know some people require the assistance of the pharmaceutical companies and the psychiatric community. The screening process for prescribing these medications is a big part of the problem. That’s because there is no adequate process in place for dispensing these potentially dangerous drugs.

Society itself contributes to this dysfunctional culture. The general attitude of the public is “As long as they are not bothering us you can do what you please with them.” This gives the mental health providers even more authority to do as they please. And so the psychiatric patient is stripped of his or her rights. As I see it, a psychiatric patient is a human being without respect or dignity. You can call my words dramatic if you like.

It may seem as I am playing the blame game and the taking on the victim role. Allow to clarify the role of the patient in the mental health system (those like myself). I will be the first to admit that the informed psychiatric patient is the one who is primarily responsible for his or her unfortunate situation. We have to accept our role in the system. No one can twist your arm behind your back, and say, “Go see a therapist about your anxiety.” At least that’s true in most cases. When you reflect on why you did it, you will say, “It seemed like a good idea at the time.”

The worst thing a mentally ill person could ever do, is telling someone about his or her condition. As soon as you do, the other person looks at you differently. An automatic flash goes off in the person’s brain, “Oh God. Here we go. His illness is acting up.” This attitude is especially noticeable in the face of a mental health professional, your family members, and closest friends. It’s a universal reaction. From the moment you reveal your secret, everything you do will be blamed on your illness. The ways in which you express yourself as a normal human being will be measured against your supposed disorder. If you are frustrated about something, the people in your life will conclude, “His meds aren’t working.” When people think you cannot hear them, they will gossip amongst themselves, “Oh he’s a psych patient. That’s why he looks agitated. That’s part of his illness.” This attitude is quite common. It comes from a lack of understanding. How could a person know, unless he or she has personally experienced it.

If you should attempt to verbalize your rights as a human being, the mental health provider will proceed to have you committed to a psychiatric hospital against your will. The patient can be held for an indefinite period of time until a clinician decides the person has come to his or her senses. The mental health professionals can essentially do whatever they want with you because no one is going to speak out against them. In Massachusetts, psychiatric patients must retain a specially trained lawyer to represent them before a mental health court in order to be released. This is where we are in 2013. I’ll bet most of you reading this article didn’t know how our behavioral health system works. We are still in the dark ages.

The only time the state of the mental health system is brought to light is when a patient commits suicide or kills someone. Then there is a public uproar and the psychiatrist or therapist are blamed or in some cases sued. In their defense, no doctor can control the behavior of their patient in society. That is not their job as I see it. The mental health professional cannot be held responsible for the actions of their patients, unless they were grossly negligent in some way. We are free and sovereign human beings. In the United States, people are generally allowed to operate freely without undue interference from others. The American attitude is “No one has the right to tell me what to do.” It’s a slightly different story if the patient states that he or she intends to commit suicide or kill someone. Then the call to duty is activated.

Planning and Design of Behavioral Healthcare Facilities

Behavioral Healthcare Facilities: The Current State of Design

In keeping with most districts of healthcare, the marketplace has seen a boom in the construction of Behavioral Healthcare facilities. Contributing to this increase is the paradigm shift in the way society views mental illness. Society is placing a heavier value on the need to treat people with serious addictions such as alcohol, prescription and elicit drugs. A large percentage of people suffering from behavioral disorders are afflicted with both mental and addictive behaviors, and most will re-enter communities and either become contributors or violators.

These very specialized facilities do not typically yield the attention from today’s top healthcare designers and their quantity accounts for a small fraction of healthcare construction. However, Behavioral Healthcare projects are increasing in number and are being designed by some very prominent architectural firms such as Cannon Design and Architecture Plus. Many are creating state-of-the-art, award-winning contemporary facilities that defy what most of us believe Behavioral Healthcare design to be.

Changing the Way We Design Behavioral Healthcare Facilities

As with all good planners and designers, A+D (along with facility experts) are reviewing the direct needs of patient and staff while reflecting on how new medicine and modern design can foster patient healing rates, reduce environmental stress, and increase safety. This is changing the face of treatment and outcome by giving the practitioner more time to treat because they require less time and resources to “manage” disruptive patient populations.

The face of Behavioral Healthcare is quickly changing. No longer are these facilities designed to warehouse patients indefinitely. And society’s expectations have changed. Patients are often treated with the belief that they can return to their community and be a contributor to society. According to the National Association of Psychiatric Health Systems (NAPHS), depending on the severity of illness, the average length of stay in a Behavioral Healthcare facility is only 9.6 days.

What has changed?

Jaques Laurence Black, AIA, president and principal of New York City-based daSILVA Architects, states that there are two primary reasons for the shortened admission period:

1. Introduction of modern psychotropic drugs that greatly speed recovery

2. Pressures from insurance companies to get patients out of expensive modes of care

To meet these challenges, healthcare professionals are finding it very difficult to effectively treat patients within the walls of antiquated, rapidly deteriorating mental facilities. A great percentage of these facilities were built between 1908 and 1928 and were designed for psychiatric needs that were principled in the belief to “store” not to “rehabilitate.”

Also impacting the need for Behavioral Healthcare construction is the reluctance of acute-care facilities to provide mental health level services for psychiatric or addiction patients. They recognize that patient groups suffering from behavioral disorders have unique health needs, all of which need to be handled and treated only by very experienced healthcare professionals. This patient population also requires a heightened level of security. Self-harm and injuring staff and other patients are major concerns.

The Report of the Surgeon General: “Epidemiology of Mental Illness” also reports that within a given year about 20% of Americans suffer from a diagnosable mental disorder and 5.4% suffer from a serious mental illness (SMI ) – defined as bipolar, panic, obsessive-compulsive, personality, and depression disorders and schizophrenia. It is also believed 6% of Americans suffer from addiction disorders, a statistic that is separate from individuals who suffer from both mental and addiction disorders. Within a given year it is believed that over one-quarter of America’s population warrants levels of mental clinical care. Even if these statistics were cut in half, it cannot be denied as a serious societal issue.

With a growing population, effectively designing in accordance with such measures is at the heart of public health.

Understanding the Complexity of Behavioral Healthcare Design

Therefore, like Corrections, leading planners and designers specializing in Behavioral Healthcare are delving deeper to better understand the complexity of issues and to be the activist to design facilities that promote treatment and healing – and a safer community.

The following is a list of key design variables that are being studied and implemented:

1. Right Sizing

2. Humanizing Materials and Color

3. Staff-Focused Amneties and Happiness

4. Security and Safety

5. Therapeutic Design Tenants


Today’s Behavioral Healthcare facilities are often one-story single buildings within a campus size. Often debated by Clients due to costs, this design preference is driven by the demand for natural light, window views to nature for all patient areas, and outdoor open-air gardens “wrapped” within. All of this provides soothing qualities to the patient, reduces their anxieties, counteracts disruptive conduct and helps to reduce staff stress.

“When you look at the program mix in these buildings, there’s a high demand for perimeter because there are a lot of rooms that need natural light. Offices, classrooms, dining areas, community rooms, and patient rooms all demand natural light, so you end up with a tremendous amount of exterior wall, and it forces the building to have a very large footprint.” – James Kent Muirhead, AIA, associate principal at Cannon Design in Baltimore

These design principles are also believed to improve staff work conditions. Unlike a multi-story complex, at any moment staff can walk outdoors and access nature, free from visual barriers, and within a building that more accurately reflects building types that both patients and staff would encounter in their communities.

In addition to right-sizing for the overall building footprint, is right-sizing for internal patient and staff support area. Similar to the move we have seen in Corrections to de-centralize support spaces, Behavioral Healthcare is moving to decentralized nursing/patient units called “neighborhoods.” With mental health facilities there is a large concern with distances and space adjacencies in relation to the patient room and patient support areas such as treatment and social spaces. Frank Pitts, AIA, FACHA, OAA president of Architecture Plus, Troy, NY, advocates neighborhoods that average 24-30 beds arranged in sub-clusters, called “houses”, of 8-10 beds. Thus, each neighborhood consists of three houses. Often these layouts will include a common area where patients congregate and socialize, with a separate quiet room so patients can elect to avoid active, crowded areas. In addition Pitts states, “There’s a move away from central dining facilities. So, while facilities will still have a central kitchen, it’s a whole lot easier moving food than it is patients.” However, it is important for the facility to mimic normal outside daily life routines, so patients are encouraged to frequently leave their neighborhoods to attend treatment sessions, and outdoor courtyards.

Humanizing Materials & Color

In all facilities that play a role in rehabilitation, design strives to create spaces that humanize, calm, and relax. Behavioral Healthcare patients need to feel that they are in familiar surroundings; therefore, the architectural vocabulary should feel comfortable and normal. Since these facilities are about rehabilitation (when possible) and encouraging patients to merge back into society, the facility should feel like an extension of the community. Their spaces should reflect the nature and architecture of the surrounding region and thus so, no two facilities should look too much alike.

“Our approach to designing these facilities is to view the facility as an extension of the community where patients will end up when they’re released. Interior finishes also depend on geography because you want to replicate the environment patients are used to. You want to de-stigmatize the facility as much as possible.” – Tim Rommel, AIA, ACHA, OAA, principal with Cannon Design in Buffalo, NY.

Therefore, materials and colors within these spaces want to feel familiar to one’s region and everyday life. To soothe the psyche and rehabilitate, they want to feel soft and comfortable, yet visually stimulating. An interior that is overly neutral or hard in appearance is not appropriate. Materials should reduce noise, and colors should lift the spirit. This can help to create an environment in which the patient can learn, socialize, and be productive while easing anxieties, delivering dignity, and modifying behavior. As stated previously, behavioral studies advise the use of softer interior materials-like carpeting, wood doors and tile. Doing so translates directly to both patient and staff well-being, particularly staff safety, and makes for a nicer place to work. In addition, staff have more resources to “treat” instead of manage heated situations. When staff experiences are eased and satisfied, morale is boosted and life-saving rules and policies are more likely to be enforced.

Staff-Focused Amenities & Happiness

While reducing staff stress and fatigue through a healing supportive environment seems like an obvious goal, there are relatively few studies that have dealt with this issue in any detail. More attention has been given to patient outcomes. However, many leading hospitals that have adopted therapeutic tenants into their newly built environments have seen vast improvement through their “business matrixes” and financial reporting.

In one example, the Mayo Clinic, a national leader in implementing healing design in its facilities, has reported a reduction of nursing turnover from a national annual average of 20% to an annual 3%-4%. In another example, when Bronson Methodist Hospital incorporated evidence-based design into its new 343-bed hospital, they cited their 19%-20% nurse turnover rate dramatically dropped to 5%.

Now, both the Mayo Clinic and Bronson Methodist Hospital have had to initiate a waiting list for nursing staff seeking positions. This converts to better-trained and qualified staff, and a reduced error rate. Therefore, more health facilities are investing in staff support areas such as lounges, changing rooms, and temporary sleep rooms. Within these staff spaces and in the hospital throughout, facilities are also recognizing the need for upgrade materials, better day lighting, and an interesting use of color: One soon realizes that the need of patients and staff are interwoven, each impacting positively or negatively the other.

Security & Safety

Without debate, self harm and harm to staff is one of the biggest concerns mental health facilities manage. Often the biggest safety and security concern is the damage patients can do to themselves. “There are three rules I had drummed in me,” says Mark Hanchar; Director of Preconstruction Services for Gilbane Building Company, Providence, R.I. “First, there can’t be any way for people to hang themselves. Second, there can be no way for them to create weapons. Third, you must eliminate things that can be thrown.” Hanchar says that the typical facility is, “a hospital with medium-security prison construction.” This means shatter proof glass, solid surface countertops (laminate can be peeled apart), stainless steel toilets and sinks (porcelain can shatter), push pull door latches and furniture that cannot be pulled apart and used as a weapon. These are just to name a few.

Additionally, removing barriers between patients and nursing staff is a safety consideration. Frank Pitts, AIA, FACHA, OAA president of Architecture Plus, says what may be counter-intuitive for safety precautions, “Glass walls around nursing stations just aggravate the patients.” Removing glass or lowering it at nursing stations so patients can feel a more human connection to nurses often calms patients. There is also discussion of removing nursing stations altogether; decentralizing and placing these care needs directly into the clinical neighborhoods and community spaces. Pitt says, “The view is that [nursing staff] need to be out there treating their patients.”

Therapeutic Design Tenants

As medicine is increasingly moving towards “evidence-based” medicine, where clinical choices are informed by research, healthcare design is increasingly guided by research linking the physical environment directly to patient and staff outcomes. Research teams from Texas A&M and Georgia Tech sifted through thousands of scientific articles and identified more than 600 – most from top peer-reviewed journals – to quantify how hospital design can play a direct role in clinical outcomes.

The research teams uncovered a large body of evidence that demonstrates design features such as increased day-lighting, access to nature, reduced noise and increased patient control helped reduce stress, improve sleep, and increase staff effectiveness – all of which promote healing rates and save facilities cost. Therefore, improving physical settings can be a critical tool in making hospitals more safe, more healing, and better places to work.

Today’s therapeutic spaces have been defined to excel in 3 categories:

1. Provide clinical excellence in the treatment of the body

2. Meet the psycho-social needs of patients, families, and staff

3. Produce measurable positive patient outcomes and staff effectiveness

Considering the cost of treating mental illness, which is exceedingly high, and wanting facilities to have effective outcomes, a further practice of incorporating therapeutic design is increasing. The National Institute of Mental Health (NIM H) approximated in 2008 that serious mental illnesses (SMI ), costs the nation $193 billion annually in lost wages. The indirect costs are impossible to estimate.

The estimated direct cost to clinically treat is approximately $70 billion annually and another $12 billion spent towards substance abuse disorders. In addition to the increased need of care and the boom in Behavioral Healthcare construction, it becomes an obligation to make certain that we as facility managers, architects, designers and manufacturers therapeutically plan and design these facilities.

Notably, in 2004, “The Role of the Physical Environment in the Hospital for the 21st Century: A Once-in-a-Lifetime Opportunity,” published by Roger Ulrich P.H.D., of Texas A&M University, was released. In a culmination of evidence-based research, research teams found five design principles that contributed significantly to achieving therapeutic design goals.

The report indicates five key factors that are essential for the psychological well-being of patients, families and staff, including:

1. Access to Nature

2. Provide Positive Distractions

3. Provide Social Support Spaces

4. Give a Sense of Control

5. Reduce or eliminate environmental stress

Access to Nature

Studies indicate that nature might have the most powerful impact to help patient outcomes and staff effectiveness. Nature can be literal or figurative – natural light, water walls, views to nature, large prints of botanicals and geography, materials that indicate nature and most importantly, stimulating color that evokes nature. Several studies strongly support that access to nature such as day-lighting and appropriate colorations can improve health outcomes such as depression, agitation, sleep, circadian rest-activity rhythms, as well as length of stay in demented patients and persons with seasonal affective disorders (SAD).

These and related studies continue to affirm the powerful impact of natural elements on patient recovery and stress reduction. Thus, it is clear that interior designs which integrate natural elements can create a more relaxing, therapeutic environment that benefits both patients and staff.

Positive Distractions

These are a small set of environmental features that provide the patient and family a positive diversion from “the difficult” and, in doing so, also negate an institutional feel. These can be views to nature, water walls, artwork, super imposed graphics, sculpture, music – and ideally all of these want to be focused on nature and, when applicable, an interesting use of color. Therapeutic environments that provide such patient-centered features can empower patients and families, but also increase their confidence in the facility and staff. This helps with open lines of communication between patient and caregiver.

Social Support Spaces

These are spaces designed partially for the patient but mainly for the comfort and socialization of family members and friends of the patient; therefore, family lounges, resource libraries, chapels, sleep rooms and consult rooms all play a role. When family and friends play a key role in a patient’s healing, these spaces encourage families to play an active role in the rehabilitation process.

Sense of Control

In times when patients and family feel out of control, it is very healing for the facility design and staff to provide it back when appropriate. Although, this cannot always be done suitably in mental healthcare facilities. However, when applicable, these design features include optional lighting choices, architectural way-finding, resource libraries, enhanced food menus, private patient rooms and

optional areas to reside in. A few well-appointed studies in psychiatric wards and nursing homes have found that optional choices of moveable seating in dining areas enhanced social interaction and improved eating disorders. When patients feel partially in control of their healing program and that the building features are focused to them, an increased confidence of the quality of care enters and tensions lower.

As with all therapeutic design, this allows the caregiver to use their resources healing in lieu of “managing” patient populations.

Reduce or Eliminate Environmental Stress

Noise level measurements show that hospital wards can be excessively noisy places resulting in negative effects on patient outcomes. The continuous background noise produced by medical equipment and staff voices often exceeds the level of a busy restaurant. Peak noise periods (shift changes, equipment alarms, paging systems, telephones, bedrails, trolleys, and certain medical equipment like portable xray machines are comparable to walking next to a busy highway when a motorcycle or large truck passes.

Several studies have focused on infants in NIC Us, finding that higher noise levels, for example, decrease oxygen saturation (increasing need for oxygen support therapy), elevate blood pressure, increase heart and respiration rate, and worsen sleep. Research on adults and children show that noise is a major cause of awakening and sleep loss.

In addition to worsening sleep, there is strong evidence that noise increases stress in adult patients, for example, heightening blood pressure and heart rate. Environmental surfaces in hospitals are usually hard and sound-reflecting, not sound-absorbing causing noise to travel down corridors and into patient rooms. Sounds tend to echo, overlap and linger longer.

Interventions that reduce noise have been found to improve sleep and reduce patient stress. Of these, the environmental or design interventions such as changing to sound-absorbing ceiling tiles, are more successful than organizational interventions like establishing “quiet hours.”

Conclusion and Additional Information

The information contained in this excerpted report is intended as a guide for architects, specifiers, designers, facility planners, medical directors, procurers, psychologists and social workers which have a stake in providing improved facilities for behavioral healthcare patients. It is a portion of a report entitled “The Contributions of Color” authored by Tara Hill, of Little Fish Think Tank. Ms. Hill was commissioned by Norix Group Inc., in 2010 to research the role color plays in the safe operation of correctional facilities and behavioral health centers. More in-depth information specifically about the psychological influence of color and behavioral healthcare facility design can be found by reading the full report.

Energize Your Therapy Sessions – Seven Pearls For Cognitive Behavioral Therapy


Research has proven that by identifying our distorted thoughts and beliefs, we can have better control over thoughts, thus better control over our feelings. Having distorted thoughts or beliefs doesn’t mean that there is something wrong with us. We all have distorted thoughts and beliefs at different times in our lives. Some examples of distorted thoughts:

OVER-GENERALIZING: At times, we may see things as all-or-nothing. For example, if one thing goes wrong with a project, we may think that the entire project is a failure. Or, if there is one thing that upsets us about a person, we may decide we don’t care for that person at all.

MIND READING: We assume that we know what someone is thinking. We may tell ourselves that someone thinks we are “stupid” or does not like us even though there is no evidence that supports this thought. This is called mind reading.

CATASTROPHIZING: We exaggerate how “awful” something is or imagine the worst possible outcome. Perhaps our boss wants to speak with us and we catastrophize that we are going to be fired. Or, it rains on one of the days of a vacation and we think “this is the worst thing that could have happened”.

FORTUNE TELLING: We think we know for sure what is going to happen. For example, we tell ourselves, “I know I am not going to get that promotion” or “I won’t be able to handle that assignment”.

In addition, specific behaviors or skills are taught including social skills, assertiveness, organizational skills, and relaxation techniques. These are taught during and between sessions.

Below, are seven pearls that I will share with you that I have found helpful over the years in my practice:


During the initial assessment phase, it is important to collaborate on the goals of treatment. This helps keep the treatment focused and productive. Without goals, therapy can end up focusing on whatever problem is coming up that week and can interfere with progress of the original presenting problems. Sometimes, the patient may not be able to specifically describe a goal except a vague “I want to be less anxious” or “I want to feel happier”. This is fine at the beginning. However, over the first couple of months, you should return to this discussion about goals to see if they can be described in more specific terms.

For example, if someone presents with depression, the goals may include the following: Finding a more fulfilling job, returning to college, exercising three times a week, making two new friends, and stopping the use of marijuana.


Every session should start with an agenda that is discussed collaboratively between the therapist and the patient. Again, this helps to keep the session focused and more effective. The agenda should include following up on homework from the previous session, a check-in about the mood and week, bridging or reviewing the topics and progress from the previous session, and topics related to discuss in the current session that is related to a specific goal.


Most therapy goals will have several components including distorted thoughts, beliefs or behaviors. Thus, during the session, collaboratively decide on which level to address the goals. If you are working on distorted thoughts, it is important to elicit what thoughts or images occur that are leading to the distress, such as anxiety, low mood, or blocking a certain behavior. If you are working on certain behaviors such as social skills or relationship issues, it is important to discuss when the skills will be used and how likely it is the skills will be used. Another useful technique for addressing behaviors is role playing and visualizing which helps to practice the skills and address any blocks or anxieties around the behavior.


Flashcards can be used to remember the key points of the session or a mantra that may help with certain thoughts or feelings. If I am working with a patient who is struggling with depression, I will title the flashcard something like “Survival Kit” and it will include strategies to cope with the depression such as reaching out to a friend, getting out of the house, reaching out to me, or taking care of a small chore.


At the beginning of treatment, goals for therapy are discussed. Sometimes, the therapy session may head in a direction that is unrelated to any of the goals of treatment. This is appropriate at certain times, but if this is happening every session and for the entire duration, then there can be a limit to the progress of therapy. Structure is important in CBT, but flexibility is also important. This would be a time to collaborate to discuss whether to continue on the current diversion or issue that is being discussed or go back to what was discussed in the agenda.


Towards the end of each session, a collaborative discussion takes place about homework or “action tasks” to perform between sessions. An action task might be to buy a calendar if one of the issues is time management or recording thoughts and images that occur during stressful periods in a notebook to discuss and address at the following session. Always make sure to follow-up on the homework or action task at the next session or it creates the impression that working on problems or goals in between sessions is not a crucial part of getting better.


Towards the end of the session, ask what went well during the session, what could have gone better, and what the main take-away messages are. This helps to build the alliance, improve future sessions, and maximize progress.

Cognitive behavioral therapy is an extremely effective form of therapy, either with or without medications and is an excellent way to practice psychiatry.

If I can be of help or you have any questions about cognitive behavioral therapy, adult ADHD or medications, please feel free to email me at [email protected] or call 212-631-8010.

Warmest Regards,


Scott Shapiro, MD, FAPA

Assistant Professor
Behavioral Health
New York Medical College

Specializing in Adult ADHD,
Depression and Anxiety

286 Fifth Avenue, 10H
New York, NY 10010

email: [email protected]

About Scott Shapiro, MD

Scott Shapiro, MD is a psychiatrist in private practice who sees patients struggling with depression, anxiety, bipolar disorder and attention deficit and hyperactivity disorder (ADHD). He enjoys working closely with other high quality and personable specialists in providing comprehensive care. He uses evidenced based treatments including psychopharmacology, cognitive behavioral therapy (CBT), and schema therapy.

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Behavioral Sciences Schools – Gaining an Education

Gaining a degree in behavioral sciences gives students the knowledge to understand relationships and the factors that affect them. Students are able to obtain a strong foundation by gaining and education through behavioral sciences schools. Accredited programs can be worked through while enrolled in one of several colleges that offer training.

Human behavior and actions are explored, which allows students to step into various fields related to behavioral sciences. Students should research the possible options to choose the program that focuses on the skills needed for their desired careers. Fields such as social psychology, ethology, and organizational behavior are some areas that are integrated into many of today’s degree programs as well as careers. Educational training is available at every level including graduate certificate programs. Programs can be pursued through concentrations, which can include:

  • Counseling
  • Sociology
  • Human Development

Students that don’t have a specific direction they want to follow may find associate degree programs highly beneficial. The field is explored through basic concepts and theories that prepare students for further education and some entry-level careers. Courses may include developmental psychology and introduction to sociology, which starts to build the skills needed for the industry. Business or government careers are obtainable upon completion of an accredited degree program.

Bachelor’s degree programs in behavioral science focus primarily on giving students a solid foundational understanding of the field. Through courses and class lectures students learn the techniques used to evaluate human behavior and interactions. Social environment is studied to help students understand why people make certain decisions. The different disciplines of the field give students the knowledge required for careers and continued education. Course subjects cover sociology, abnormal psychology, social research, and problems of society. Careers that center on human relationships and behavior are widely obtainable for students that complete programs. Students can step into positions as community health workers, assistant social services caseworkers, and more.

When students decide to pursue further education at the master’s degree level they work through concentrations. Areas of study can have students working through programs in public health, marketing, applied behavioral science, and more. Before working through coursework that is related to a concentration students will complete a core curriculum that establishes an advanced behavioral sciences understanding. Coursework stresses empirical and conceptual components of the field. Behavior development, direct observation, elderly care, scientific research and communication courses are some topics covered regardless of the specialization. Advanced careers as gerontologists, neuromarketers, and behavioral scientists are open to students that complete this level of education.

Behavioral analysis is examined inside a PhD degree program as students work through advanced research practices. Education focuses on developing research projects that explore new ways to work with individuals in regards to behavioral science. Students often become professors and behavioral health specialists.

The field prepares students to take their knowledge about relationships and human behavior and apply it to numerous career possibilities. Students can begin training by finding programs that provide the skills needed for their professional goals. The Accrediting Council for Continuing Education and Training ( ) provides full accreditation to qualifying behavioral sciences schools that offer quality career preparation.

DISCLAIMER: Above is a GENERIC OUTLINE and may or may not depict precise methods, courses and/or focuses related to ANY ONE specific school(s) that may or may not be advertised at

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