Unobtrusive Suicide Prevention Design in Mental Health Facilities

Unobtrusive Suicide Prevention Design
in Mental Health Facilities

Name : Yeong Kam Loong
Matric Num. : SB/696/12
Supervisor : Ar. Haris Fadzilah Abdul Rahman
i

ACKNOWLEDGEMENT

First of all, I would like to express my gratitude to my supervisor, Ar. Haris Fadzilah
Abdul Rahman for his generous suggestions and advices given in preparation and
completion of this dissertation.
Furthermore, I would like to give my appreciation to Avera Behavioral Health
Center and Array Architects for uploading information of their owned/ designed
mental health facilities online. Such information is allows me to study in greater
detail terms of unobtrusive suicide prevention design and to produce more
comprehensive case studies.
Last but not least I would like to offer my gratitude to friends and family who had
helped me in completion of this report directly and indirectly in the form of moral
support and suggestions and encouragement.

Unobtrusive Suicide Prevention Design in Mental Health Facilities
ii

ABSTRACT

Suicide and suicide attempt risks in mental health facilities are high due to the
deterioration of mental state of patients as well as the affected emotion due to
involuntary hospitalisation for treatment. This is often responded with highly
institutionalised and inhumane suicide prevention designs applied in inpatient wards
which are not conducive in facilitating patients healing.
Several Western countries has noticed the importance of the balance between suicide
prevention and therapeutic environment in mental healthcare facilities and provided
design guides for architects references in design of future mental health facilities.
This dissertation will study and analyse on the pattern of suicide of mental health
patients and the existing available design guides local and abroad which will
eventually lead to a proposal of localised version of design guide to suit with the
current local context.

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LIST OF FIGURES

Figure 1.1: Research Methodology diagram.4
Figure 2.1: Location and percent of inpatient suicides and suicide attempts in Veteran
Affairs hospital..6
Figure 2.2: Reported methods and and percent for inpatient suicide and suicide attempts in
Veteran Affairs hospital8
Figure 2.3: Hanging points for inpatient suicide and suicide attempts in Veteran Affairs
hospital..9
Figure 2.4: Materials used as a noose for inpatient suicide and attempted suicide by hanging
in Veteran Affairs hospital..10
Figure 2.5: Suicide hazards in patients room .......................................................................11
Figure 2.6: Jumping locations for inpatient suicide and attempted suicide by jumping in
Veteran Affairs hospital..11
Figure 2.7 Typical patient room..20
Figure 2.8: Types of suggested lighting fixtures21
Figure 2.9: Types of suggested diffuser and sprinkler head...22
Figure 2.10: Anti-ligature door hardware...22
Figure 2.11: Door pressure sensitive alarm solution for bathroom door23
Figure 2.12: Chamfered door top solution for bathroom door24
Figure 2.13: Recommended accesories for bathroom25
Figure 2.14: Examples of handrails and wall guards for corridor..26
Figure 2.15: Examples of furniture for communal areas27
Figure 2.16: Examples of recommended hardware for doors at inpatient unit...31
Figure 2.17: Example of recommended window for inpatient unit32
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Figure 2.18: Example of recommended ceiling for inpatient unit......32
Figure 2.19: Example of recommended handrail for inpatient unit.......32
Figure 2.20: Example of recommended toilet accesories for inpatient unit.......33
Figure 2.21: Example of recommended plumbing installations for inpatient unit.........33
Figure 2.22: Example of recommended ceiling mounted diffusers for inpatient unit34
Figure 2.23: Example of recommended lighting fixtures for inpatient unit...34
Figure 2.24: Example of recommended fire fighting components for inpatient unit.35
Figure 3.1: Photos of the behavioural health facility.38
Figure 3.2: Floor plan showing threecorridor circulation system......38
Figure 3.3: Floor plan showing relationship between public, patient and staff circulation39
Figure 3.4: Geriatric unit design.....40
Figure 3.5: Anti-barricade door that have two opening direction...........................41
Figure 3.6: Anti-ligature hardware used to conceal door lock............................41
Figure 3.7: Unit toilet design..42
Figure 3.8: Unit toilet design..43
Figure 3.9: Dining room and day area43
Figure 3.10: Central public courtyard corridor...............44
Figure 3.11: Central light court corridor.45
Figure 3.12: Threshold and skylight at patient room entries......46
Figure 3.13: 2-corridor system flanking patient support areas...46
Figure 3.14: Adult patient room interior.47
Figure 3.15: Details inside the adult patient room......47
Figure 3.16: Patient bathroom interior............................48
Figure 3.17: Patient common area..............................48
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Figure 3.18: Outpatient clinic interior....49
Figure 3.19: Admission entrance interior...49
Figure 3.20: Admission outdoor area..49
Figure 3.21: Open nursing station design.......50
Figure 4.1: Diagram of fire staircase provision in 2 different layouts....68
Figure 4.2: Aesthetically chamfered doors and windows designs..............68
Figure 4.3: Diagram of 2 windows with 100mm opening..69
Figure 4.4: Suicide prevention screen design at NYU library69
Figure 4.5: Unaesthetic grilles installed at Kinta Heights low cost flat,
Ipoh.70
Figure 4.6: Diagram showing buffet zone concept.70

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LIST OF TABLES

Table 2.1: Methods of suicide in reported cases in Malaysia...7
Table 2.2: Distribution of place of suicide act in reported cases in Malaysia..7
Table 2.3: Ligature points in menta health facilities...30
Table 4.1: Maximum suicide prevention application in mental health faciliry..60
Table 4.2: Intermediate suicide prevention application in mental health faciliry...63

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CONTENTS
Acknowledgement.i
Abstractii
List of Figures.iii
List of Tables..vi

CHAPTER 1 INTRODUCTION
1.0 Introduction..1
1.1 Research Issues.3
1.2 Research Objective...3
1.3 Limitations4
1.4 Research Methodology.4

CHAPTER 2 LITERATURE REVIEW
2.0 Introduction..5
2.1 Pattern of Suicides6
2.2 Design Guides Review...12
2.2.1 Mental Health Act 2001 (Act 615) and Regulations .12
2.2.1.1 Introduction12
2.2.1.2 Suicide Prevention Strategies (Summary)..12
2.2.1.3 Appraisals...12
2.2.2 Psychiatric and Mental Health Services Operational Policy..13
viii

2.2.3 Health Building Note 03-01: Adult Acute Mental Health
Units...14
2.2.4 Mental Health Facilities Design Guide..18
2.2.4.1 Introduction....18
2.2.4.2 Suicide Prevention Strategies (Summary).19
2.2.5 Patient Safety Guidelines, Materials and Systems Guidelines...29
2.3 Analysis and Reviews....35

CHAPTER 3 CASE STUDY
3.0 Introduction37
3.1 Zucker Hillside Behavioural Health Facility, Glen Oaks, New York37
3.1.1 Project Introduction37
3.1.2 Suicide Prevention Features...39
3.1.3 Appraisals...44
3.2 Avera Behavioural Health Center, Sioux Falls, South Dakota..45
3.2.1 Project Introduction45
3.2.2 Suicide Prevention Features...46
3.2.3 Appraisals...50
3.3 Overall Review...51
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CHAPTER 4 Proposals: Unobtrusive Suicide Prevention Design Guide For
Malaysia Mental Health Facilities
4.0 Introduction53
4.1 Proposal..53
4.1.1 Maximum Application53
4.1.2 Intermediate Application60
4.1.3 Minimal Application..64
4.2 Complimentary Requirements65
4.3 Authors Suggestions..67

CHAPTER 5 CONCLUSION
5.0 Conclusion..71
5.1 Recommendation for further study73

REFERENCES.74

1

CHAPTER 1
INTRODUCTION

1.0 Introduction
According to National Health and Morbidity Survey 2011 (Fact Sheet), 0.3
million (1.7%) of national population have General Anxiety Disorder, 0.3 million
(1.7%) have Depression while 0.2 million (1.1%) reported to have attempted suicide
in the past. Mental health illness, especially depression, affecting 350 million of
global population, is the third leading cause of global burden of disease in 2004 and
will move to the first in 2030 (WHO).
According to the National Suicide Registry Malaysia (NSRM), the overall
suicide rate at 2009 was 1.18 per 100,000 with majority were Malaysian citizens
(89% or 293/328). The age ranges from 1494 years, with a median of 37, consisting
of more men than women, with gender ratio being 2.9:1 (male:female). Mental
illness was reported in 22% (72/328) of the cases and physical illnesses in 20.4%
(67/328). Previous suicide attempts were reported in 15.5% (51/328) of cases.
History of substance abuse was present in 28.7% (83/328). Life events were positive
in 41.2% (135/328) of cases. (Ali, NH, 2012) The statistic revealed that mental
illness is among the major causes of suicide.
The rate of suicide has since increased on an alarming rate, with 425 people
committed suicide between January and august 2010, averaging 60 per month
(including undetermined deaths). Suicide rate has increased to 10 to 13 per 100,000
people which nearly equal to the US. (The Star, February 10, 2011) In response to
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this situation, the government had decided to launch a five-year National Suicide
Prevention Strategic Action Plan starting in 2012 where part of the plan is to shift
mental health treatment from purely institutionalized in hospitals to more
community-centric and to me made available in community mental health centers.
(The Star, June 5, 2012)
This would mean the facilities will be catering for a high concentration of
potential suicidal population and the facilities must implement suicide prevention
design to avoid attempted suicide from patients during phases of treatment in the
said facilities. Occurrence of suicide in such facilities will cause distress to the
unstable emotions of patients or even provoke their urge to follow suit and commit
attempts of suicide.
Suicide prevention design strategies in mental health institutions in the past
emphasized much on the security consideration which neglected its effects on users.
The installation of screens, anti-climb barriers that are both visually imposing and
sometimes inhumane to the eye of both the patients and staff affects the overall
architectural aesthetics and mood of the premise into a prison-like setting.
Architectural critics often comment these solutions as afterthoughts where
suicide prevention design should be considered at the early stage on the drawing
board as part of architectural design. With increasing awareness of the need of
humane yet secured environment for healing, recent mental health facilities design
trend in overseas has shifted the emphasis to unobtrusive suicide prevention design
strategies and therapeutic architecture.

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This purpose of this paper is to study the general suicide pattern of
psychiatric inpatients in mental health facilities in order to identify the high risk
areas for suicide prevention design intervention. Appraisals on current unobtrusive
suicide prevention design practices will be conducted with attempts to enhance or
modify the designs appropriate to the Malaysia context.
1.1 Research Issues
With the provision of Mental Health Act 2001 and Regulations, Psychiatric
and Mental Health Services and Operational Policy and Private Healthcare Services
and Facilities Act 1998 by the Malaysia Ministry of Health, it is anticipated more
mental health facilities will be established in the country in response to the
increasing number of mental health patients. This would mean deinstitutionalisation
of mental health services to the public from government healthcare institutions to
community setting.
However, there are inadequate design standards or guidelines for local mental
health facilities at present where the design requirements are general and not specific
enough. This situation might lead to non-uniform suicide prevention design qualities
and standards in upcoming new mental health facilities.
1.2 Research Objective
To study suicide patterns by psychiatric inpatients in mental health facilities
and identify areas for suicide prevention design.
To analyse and enhance/modify existing suicide prevention designs in mental
health facilities building practice to achieve higher level of unobtrusiveness
and appropriateness to the local context.
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1.3 Limitations
As local design standards for mental health facilities in the country is still
insufficient for analysis currently, the dissertation will study and appraise the design
standards of guidelines established in developed countries and attempt to enhance or
modify the designs to suit the local context.
In order to compensate for the lack of detailed information from the National
Suicide Registry Malaysia in terms of the suicide patterns of psychiatric inpatients in
local mental health facilities, reference to foreign statistics where established
institutions has been conducting research in related topics is necessary.
1.4 Research Methodology

Figure 1.1: Research Methodology diagram

Selection of Research Topic
Unobtrusive Suicide Prevention
Design in Mental Health Facilities
Literature Review
Suicide patterns local and abroad
and existing design guides
Case Study
Recently completed projects
with critical analysis and
appraisals.
Proposal
Unobtrusive Suicide Prevention
Design Guide for Malaysia
5

CHAPTER 2
LITERATURE REVIEW

2.0 Introduction
Suicide (suicidium in Latin), to kill oneself is the action of intentionally
causing ones own death. It is frequently regarded as the result of a mental disorder
such as depression, bipolar disorder, schizophrenia and borderline personality
disorder (Paris, J, 2002) besides alcoholism and drug abuse (Hawton, K; van
Heeringen, K, 2009).
Mental health facilities in definition are the healthcare facilities where
mentally ill patients undergo psychiatric treatment both voluntarily and involuntarily
in order to curb or get the symptoms under control. The mental healthcare services
are often offered in both inpatient and outpatient basis, depending on the mental
stability of the patient.
The Joint Commission Journal on Quality and Patient Safety titled Inpatient
Suicide and Suicide Attempts in Veteran Affairs Hospitals prepared by the Joint
Commission on Accreditation of Healthcare Organizations in 2008 revealed that 185
inpatient suicides and suicide attempts (42 completed suicides, 143 suicide attempts)
were reported in veteran affairs hospitals in US. 52% of the events occurred in
inpatient psychiatric units.
6

Figure 2.1: Location and percent of inpatient suicides and suicide attempts in Veteran
Affairs hospital (Source: The Joint Commission Journal on Quality and Patient Safety,
August 2008)

This chapter will analyse on the suicide patters (methods and locations) and
review on the existing suicide prevention design guides available in Malaysia and
abroad and identify areas where unobtrusive suicide prevention design can be
applied on.
2.1 Pattern of Suicides
The National Suicide Registry Malaysia 2009 report states that the three
commonly used choices of suicide methods are hanging, strangulation and
suffocation (176 cases), pesticides (43 cases) and jumping from high place (34 cases)
in 2009. It is observed that mental illness factor is has grown from 17.2% (50/290) in
2008 to 22% (72/328) in 2009 of the reported cases, showing an increase of 4.8%
over the course of one year, which the most common mental illness of suicide
victims was depression (47.2%) and schizophrenia (26.4%). Though the statistics
revealed that 32 or 9.8% of the cases happened in residential institutions, it is unclear
on the exact percentage of it happened in mental health institutions.
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It is unable to generate the suicide pattern of mental health patients in local
mental health facilities as the NRSM report does not provide further study into that
aspect which necessitates the need to study the pattern through available statistics
abroad.

Table 2.1: Methods of suicide in reported cases in Malaysia (Source: National Suicide
Registry Malaysia 2009 Annual Report)

Table 2.2: Distribution of place of suicide act in reported cases in Malaysia (Source:
National Suicide Registry Malaysia 2009 Annual Report)

According to the Joint Commission Journal on Quality and Patient Safety
report, in 2008, hanging (31.4%), cutting with sharp objects (20.1%) and drug
overdose (18.9%) accounted for 70.4% of the total inpatient suicide and attempted
8

suicide events in VA hospitals at US. Other methods of suicide and suicide attempts
include strangulation, jumping, stabling self, asphyxiation, fire, ingestion of
chemicals and etc.

Figure 2.2: Reported methods and and percent for inpatient suicide and suicide attempts in
Veteran Affairs hospital (Source: The Joint Commission Journal on Quality and Patient
Safety, August 2008)

It has to be noted that the inpatient suicide pattern has changed over time
after a number of strategies recommended by the Joint Commission to reduce
inpatient suicides in 1998. Prior to the recommendation in 1998, 75% of the cases
involved hanging, 20% involved jumping from roof or window. From the study, 18
of the 42 completed suicides were hangings, 15 were drug overdoses, and 4 were
jumping from high place.

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The recommendations in 1998 include removing or replacing non-breakaway
hardware, weight testing all breakaway hardware, and blocking patient access to
sharp objects and potentially harmful items such as cleaning solvents. Consequently,
the suicide pattern was significantly changed as new kinds of methods are always
being found in response to reduction of environmental hazards which intended to
discourage suicidal behaviour.
For building infrastructure-related environmental hazards, anchor points are
identified as one of the primary environmental hazards that lead to hanging within
mental health facilities. Though door or door hardware is the most common choice
of anchor point for hanging, wardrobe cabinet as anchor point has a higher success
rate in suicide attempt.

Figure 2.3: Hanging points for inpatient suicide and suicide attempts in Veteran Affairs
hospital (Source: The Joint Commission Journal on Quality and Patient Safety, August 2008)
10

Figure 2.4: Materials used as a noose for inpatient suicide and attempted suicide by hanging
in Veteran Affairs hospital (Source: The Joint Commission Journal on Quality and Patient

Patient rooms and toilets are the areas of highest risk where patients are alone
for periods of time. They are able to hang themselves from objects as close to the
floor as 18 and one study shows that 50% of non jucidal hangings were from
heights below the waist of the victim. (Hunt; Sine, 2009) This reveals the importance
of furniture and fittings to have minimal anchor points for patients to attempt
suicide.
11

Figure 2.5: Suicide hazards in patients room (Source: Pennsylvania Patient Safety
Reportying System, 2007)

Inpatient suicides involving jumping are mostly occurred from balcony and
walkway, which is another building infrastructure-related environmental hazard. It is
assumed that the balcony or walkway are inadequately secured to prevent inpatients
from jumping. Though jumping is less chosen as method of suicide, injury inflicted
to inpatients from unsuccessful suicide attempt is more serious compared to hanging
which might result in head injury, broken bones or even paralyzation.

Figure 2.6: Jumping locations for inpatient suicide and attempted suicide by jumping in
Veteran Affairs hospital (Source: The Joint Commission Journal on Quality and Patient
12

2.2 Design Guides Review
2.2.1 Mental Health Act 2001 (Act 615) and Regulations (Ministry of Health,
Malaysia)
2.2.1.1 Introduction
The regulation provides certain requirements and standards for private psychiatric
hospital, private psychiatric nursing home and private community health center, etc.
encompassing general requirements in terms of general spaces (reception and lobby),
specific spaces (seclusion room, electroconvulsive therapy room, treatment room and
etc.) openings, security and management of equipment. However, this report will
emphasize only on the aspects related to suicide prevention design:
2.2.1.2 Suicide Prevention Strategies (Summary)
Doors (Section 32):
All doors in patient care areas shall be made of safe and non-hazardous material and
be able to be locked and accessible by the staff in an emergency. Single outward
opening door made of study material with observation panel made of safety glass
shall be provided for seclusion room.
Windows (Section 33):
All windows in patient care areas shall have panels made of safe and non-hazardous
material with restricted degree of opening using aesthetic and non-prison like grills,
where applicable.
Lighting in patient care area (Section 36):
Recessed lights shall be provided in all patient care areas.
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2.2.1.3 Appraisals
The guideline provided some fundamental required standards in patient care area. On
the downside, it lacks information to the detailed level such as the dimensions of
degree of restricted opening for windows, suggested type of safe and non-hazardous
materials for doors and windows, anti-ligature requirement for doors in wards and
etc.
The limitation of 100mm window opening might not comply with UBBLs Section
39(2) regarding natural ventilation in providing uninterrupted passage of air even
though the window area is not less than 10% of floor area.

2.2.2 Psychiatric and Mental Health Services Operational Policy (Ministry of
Health, Malaysia)
The document focused on standards of operational procedure in mental healthcare
services along with partial suggestions on infrastructure and facilities requirements.
High dependency ward
The ward should preferably be fully air conditioned with toileting, dining facilities
separate from patients in other wards.
Acute ward
Same as high dependency ward with exception of lockers provided for patients at a
secured place away from their beds.
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Convalescent ward
The ward should have a sense of domesticity in terms of structure and aesthetics.
Each patient should have a locker that can be accessed at all times.
2.2.2.3 Appraisals
The reason of suggestion for fully air conditioned ward was not explained. It was
assumed to compensate with the limited window opening dimension to keep indoor
air quality at comfortable level. However, further elaboration on the application of
suicide prevention strategies for air conditioned ward is needed such as the supply
and return air grill design and location and etc.
The availability of lockers to various levels of patients differs due to their tendency
to hide and store materials of suicide and self-harm in lockers or even abuse the
locker itself for suicide attempt. No specific description on the types and design of
the lockers that should be used in terms of suicide prevention.

2.2.3 Health Building Note 03-01: Adult Acute Mental Health Units
(Department of Health, UK)
The guide covers several aspects including: scope of guidance, policy and service
context, principles of planning and design, stakeholder needs, planning
considerations, design considerations, room spaces, furniture, fixture and fittings,
building construction and components and engineering considerations.
The key consideration of suicide prevention design in the design guide is focused on
anti-ligature design and robustness through specific hardware, concealment of
15

ligature points while being as domestic in style as possible. Attention is given on
sanitary fittings, windows and doors to minimise ligature risks. Any fixture or fitting
that could provide an anchor point should safely break free under weight of patients
in a suicide attempt.
Bedroom
The layouts of rooms, fixed furniture and equipment should ensure that patients are
not able to hide themselves inside the room. Anti-ligature wardrobe, drawers or
shelves and chair should be provided and be built-in where possible.
Kitchen/ servery
All food preparation and waste disposal equipment within the kitchen/servery should
be able to be locked and isolated by staff when needed. Cupboards and drawers
should be provided in the kitchen and lockable by staffs.
If a server hatch is provided between the kitchen/servery and dining room, it should
be fire resistant and designed to be able to lock securely.
Sanitary facilities
All sanitary fittings should be of robust construction, ligature free and constituted of
materials that will withstand sustained attack. Conventionally exposed fittings such
as WC cisterns, pipework and electrical conduit are required to be concealed behind
secure panels, through boxed or set into the wall.
All shower components are required to be anti-ligature with fixed shower heads,
either wall or ceiling-mounted. Fittings such as wash basin, WC and shower
activation by pressure switch or sensor as mechanical or electrically activated water
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supply are recommended as anti-ligature strategy besides concealed traps and anti-
ligature taps. Timed supply for shower may be needed to avoid flooding.
Windows
All windows should be ligature-free, robustly constrained to provide maximum
100mm opening to avoid patients from climbing out and secure mesh to prevent the
passage of contrabands or weapons. Windows can be opened to greater dimensions
shall the opening area protected by a secure ventilation grill.
Window frames should be constructed of steel and hardwood timber to ensure
robustness. The use of polycarbonate, toughened or laminated glass in patient care
areas is recommended. Aluminium window frames are unsuitable for opening lights
as they can be flexed or twisted out of shape.
Doors
Design of doors should minimise the opportunity for ligature risk and contraband
concealment, the means to barricade or prevent the door from being opened and
avoid parts that could be removed by patients to use as weapons. No protrusions
except security lock handle on the outside face.
Bedroom doors should have a vision panel to allow staff observation into the room
with provided means of control by staff to access the panel for viewing only when
needed in order to preserve the privacy of patients.
Doors should be equipped with override facility for staff to be able to open them
outwards if a patient barricades themselves in. The door handle for patients room
should be ligature-free. Clear opening width of 850-900mm is required.

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Ceiling
Ceiling heights are minimum 2700mm in mental health design and 3000mm in a
secure unit so that light fittings, detectors etc. are out of reach. Grid type suspended
ceilings with removable ceiling panels should not be provided in patient-accessible
area. It should be able to withstand damage by implementing plywood backing and
the like.
Security locks
Electronic systems can be used in coordination with fire escape strategy of facility to
ensure the means of escape is controlled but no compromised.
2.2.3.3 Appraisals
It is noticed that besides surveillance and supervision, suicide prevention design in
the design guide gives a significant amount of emphasis on the use of anti-ligature
hardware, minimisation of ligature point through concealment and the use of high
tech equipment such as sensors and other electronic activation equipment to replace
conventional hardware with visible ligature points.
Though well intended and effective, the high tech solution is disputable in terms of
cost effectiveness and limitation of patients control on sanitary fittings (especially
shower with timed water supply). 100mm maximum opening for windows seemed to
be inadequate to harness natural ventilation for access to fresh air as discussed in
previous design guide. However, the installation of ventilation grille for windows
with large opening would solve the problem of inadequate ventilation but it creates a
secondary problem of higher construction cost.
18

The suggested use of override facility for doors is commendable in balancing both
patients and staffs control of access to space in response to changing situations.
The use of electronic lock for fire escape strategy could prevent escape of patients to
higher grounds of building fir jumping but the strategy has to be given exception of
UBBL requirement Section 166(2) regarding exits to be accessible at all times.

2.2.4 Mental Health Facilities Design Guide (Office of Construction and
Facilities Management, Department of Veteran Affairs, US)
This design guide is provides general operational narrative, planning and design
criteria, technical narrative and sample layouts for spaces ranging from bedrooms to
nurse station. The design guide provides comprehensive graphical reference to
communicate the strategies.
Similar to Health Building Note from UK, the design guide emphasizes on
minimizing hanging and cutting risk from patients through minimizing anchor points
and vandal-proof fixture and fittings that can be used as weapons and tools for self-
harm. More emphasis is given to inpatients bedroom and en-suite bathroom in terms
of suicide prevention strategy.
The design guide referred to The Design Guide for the Built Environment of
Behavioural Health Facilities to identify various level of risks based on the function
and level of accessibility, patients privacy of spaces with in order to determine the
zones where suicide prevention design applications is used.

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Level 1: Staff and services area which is inaccessible by patients
Level 2: Counselling rooms, examination rooms, group therapy rooms, multi-
purpose rooms and interview rooms where patients are highly supervised and
not left unattended for periods of time
Level 3: Corridors, dayrooms and dining areas where patients are given
minimal supervision.
Level 4: Patient rooms (semi-private and private) and patient toilets where
patients are given minimal or no supervision for a longer periods of time.
Level 5: Admission rooms and seclusion rooms where staff interacts with
newly admitted patients with unknown potential risks/ in highly agitated
condition.
Level 4 & 5 spaces should have nothing in space that can be used as anchor point,
weapon, or projectile.
Bedroom
Aesthetic and safety standpoint is emphasized in the design of inpatient bedroom
with features explained through illustrations below:
20

Figure 2.7 Typical patient room (Source: Mental Health Facilities Design Guide, December
2010)

1. Use of integral blinds for exterior window (reduces hanging risk from using
conventional blinds that provide anchor points on railing) and laminated
glass on interior face ( does ont create shards that can be useds as weapon in
the event of breaking).
2. Pressure sensitive alarm at door head of bathroom door (to alert staff in event
of attempted suicide using bathroom door as anchor points for hanging),
continuous hinge and anti-ligature lever with magnetic latch. (minimize
anchor points)
3. Provide secured, non-breakable artwork, marker board and area rug as
optional elements for domestic feeling to the room without compromising
patient safety.
4. Secure trim, headboard and soothing colours to create domestic feel to the
room.
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5. Built in desk and shelving unit for patients cloth and belonging storage.
(Avoid creating ligature points from tall wardrobe and standalone furniture,
preventing usage of furniture for barricade and vandalism purposes by
inpatients )
6. Wood grain pattern sheet vinyl flooring for aesthetic purposes.
Lighting
Recessed fluorescent lights may be used combined with high strength acrylic lens
and flush trim anchored with tamper resistant screws to prevent vandalism by
patients. Over bed lighting should be installed above the bed and be designed to
avoid creating anchor points.

Figure 2.8: Types of suggested lighting fixtures (Source: Mental Health Facilities Design
Guide , December 2010)

Air cond diffusers and sprinklers
Louvered diffusers should not be used (louvers can be used as anchor points);
perforated holes diffusers is recommended to be used in the ceiling with tamper
22

proof fasteners. Vandal-proof sprinkler head should be used with designs that do not
provide anchor points.

Figure 2.9: Types of suggested diffuser and sprinkler head
(Source: Mental Health Facilities Design Guide, December 2010)

Windows:
Heavy gauge commercial units with insulated double glazing are recommended for
exterior windows and are required to be operable for emergency ventilation. Window
openings should not exceed 4 (101.6mm)
Doors:
Patient bedroom doors should be out-swinging to prevent inpatients barricading
themselves inside the room unless corridor width is inadequate. Anti-ligature
hardware is recommended to be used for patient room doors.

Figure 2.10: Anti-ligature door hardware (Source: Mental Health Facilities Design Guide,
December 2010)

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Bathroom door has the highest probability of being used as anchor points for
hanging as patients are left unattended. The design guide offers 3 strategies to deal
with this challenge:
Option 1: Door-top pressure sensitive alarm which will signal the nurse station if
weight is exerted on the door during suicide attempt.

Figure 2.11: Door pressure sensitive alarm solution for bathroom door (Source: Mental
Health Facilities Design Guide, December 2010)

Option 2: Out-swing door with chamfered top to prevent the door being used as
anchor point with a 30 degree cut at the top of the door. However, it provides less
privacy and reduces the domestic feel of inpatients room.
24

Figure 2.12: Chamfered door top solution for bathroom door (Source: Mental Health
Facilities Design Guide, December 2010)

Option 3: Sliding door deign will render hanging using door top as anchor point
impossible as the door top is fixed in the sliding track. Though the advantage of
maintaining privacy and visual appeal, the design guide concerns over the issue of
infection control with the use of track on the floor and unsuitable for patients with
weaker upper body strength.
Its not recommended to use the door without a track on the floor as it provides
opportunity for inpatients to kick the door.

25

Bathroom flooring
2x2 ceramic tile is recommended only for floor and not wall as it can be easily
dismantled and misused.
Sanitary facilities
Piping in toilets should be concealed and controls be used to prevent excessive
flushing and flooding. Push button flush actuator is recommended. All piping below
the sink should be concealed behind a panel fastened with tamper-proof screws
accessible only to maintenance staff.
Shower controls should be recessed stainless steel panels with no part able to be used
as anchor points. In case where grab bars are needed in accessible rooms, a welded
horizontal plate is needed on the bottom part to prevent it being used as anchor
points. Shower or floor traps should be screwed with security screw to prevent
removal by patients

Figure 2.13: Recommended accesories for bathroom (Source: Mental Health Facilities
Design Guide, December 2010)
26

Patient activity areas
Lighting or other ceiling mounted fixtures should be recessed. Vandal resistant
properties are needed for fixtures surface mounted to the ceiling. The space should
have no sharp wall, furniture or fixture edges that patients can be used for self-harm.
All wall mounted fixtures should be flush mounted and fastened with security screws.
Equipment used by patients under supervision such as computer and other facility
equipment should be located in lockable rooms when not in use.
Corridor spaces
Handrails should be provided along corridor for patient use and wall protection, its
design should not have anchor points. Hard edges on wall corners can be soften by
corner guards to prevent self-harm from patients. The design of both handrail and
corner guard should enhance the aesthetic image to the corridors.

Figure 2.14: Examples of handrails and wall guards for corridor (Source: Mental Health
Facilities Design Guide, December 2010)

27

Inpatient communal areas
Furniture plays a major role in suicide prevention in communal areas it can be used
as weapons. Furniture should have round edges and robust to prevent parts being
dismantled and used for self-harm. Furniture should be stain-resistant, easy to clean,
not easily thrown and able to withstand abuse including punctures while domestic in
aesthetics to avoid creating an institutional like atmosphere.
Fittings such as TV should be located within a niche with cords not exceeding 12
(304.8mm) while not accessible by patients. Furniture such as book shelf should be
built-in and have fixed shelves to prevent patients from overturning or climbing the
furniture.

Figure 2.15: Examples of furniture for communal areas (Source: Mental Health Facilities
Design Guide, December 2010)

Outdoor spaces
Outdoor spaces should be designed with landscape and hardscape features that do
not support self-harm or violence behaviour. It should be located within line of sight
from nurse stations for surveillance purposes.
28

An enclosure height of 14 feet (4.27m) is recommended and it should prevent
climbing and used as anchor point. Trees should not facilitate climbing over a wall
or fence. Landscape materials such as toxic plants, rocks, gravel, dirt planting bed or
pathway material that can be used as weapon or tools of self-harm should not be
used.
Outdoor furniture must be immovable by using heavy furniture or anchored to
concrete pads. It should not be located close to fence or wall to avoid patient escape.
Balconies or elevated outdoor porches must have all openings covered with security
railings or screenings to remove the potential of jumping.
2.2.4.3 Appraisals
It is noted that surveillance, anti-ligature furniture and fittings are among the major
strategy concerns to achieve suicide prevention in this design guide. Though
comprehensive, some of the proposals are obtrusive such as the height of enclosure
height of 4.27m in outdoor spaces is could be reduced to a more humane scale with
anti-climb designs on the top of fencing.
Architecture solutions are mainly focused on security control and surveillance while
suicide prevention solutions are focused mainly on interior hardware, furniture and
fixtures, which in a way still inevitably exert some obtrusiveness to the inpatients
such as the use of pressure sensor on door top that gives a sense of distrust,
chamfered bathroom door that compromises privacy, 101.6mm window opening that
limits the flow of air and etc.
29

The use of electronic substitutes such as control panel for shower and pressure
sensor on door top would mean higher construction cost and repair cost if subjected
to vandalism which is not uncommon in mental health facilities.
However, it is commendable that the design guide provide some options for the bath
room door case ranging from sensors to chamfered doors and to sliding doors. The
design guide can be enhanced if similar kinds of alternative suggestion are given on
other design aspects such as windows, doors and balconies.

2.2.5 Patient Safety Guidelines, Materials and Systems Guidelines (New York
State Office of Mental Health, US)
The guideline was created to provide a selection of materials, fixtures and hardware
that the office has reviewed and supports for use in mental health units. It stated the
utilisation of the listed products is not mandatory.
The guideline has identified specific anchor points within the facility for suicide
prevention application stated as below:

30

Above the waist ligature points Additional ligature points
Windows and vision panels
Door hinges
Sprinklers
HVAC terminal devices and
covers
Thermostats
Door closers
Light fixtures
Window treatments
Shower curtains
Access doors
Fire alarm components
Shower heads
Clothes hooks
Cabinetry and hardware
Hanger rods
Ceilings
Electrical receptacles
Medical gas enclosures
Bulletin boards/ picture hanging
systems
Toilet partitions
Mirrors
Fasteners

Door knobs/levers
Door bumpers
Cabinet hardware
Lavatories
Faucets
Lavatory valves
Shower actuators
Toilet seats
Toilet operator valves
Plumbing traps and piping
Grab bars
Furniture
Toilet accessories
Trip strips between assemblies
Sealants/ caulk
Fire extinguisher and hose
cabinets

Table 2.3: Ligature points in menta health facilities (Source: Source: Patient Safety
Guidelines, Materials and Systems guidelines, March 2013)

The guideline categorizes the products based on evaluation on their suicide
prevention effectiveness with suggestions on areas where it is safe to install (low,
medium and high risk areas). The following are excerpts of the guideline:

31

Doors

Figure 2.16: Examples of recommended hardware for doors at inpatient unit(Source: Patient
Safety Guidelines, Materials and Systems guidelines, March 2013)

32

Windows

Figure 2.17: Example of recommended window for inpatient unit(Source: Patient Safety

Ceiling

Figure 2.18: Example of recommended ceiling for inpatient unit(Source: Patient Safety

Handrail
All handrails and grab bars are subjected to wedge ligature with a shoe or other
object and should be used only at places required by building code.

Figure 2.19: Example of recommended handrail for inpatient unit(Source: Patient Safety
33

Toilet accessories

Figure 2.20: Example of recommended toilet accesories for inpatient unit(Source: Patient

Plumbing
Detention grade stainless steel fixtures are prohibited to be used in mental health
facilities.

Figure 2.21: Example of recommended plumbing installations for inpatient unit(Source:
Patient Safety Guidelines, Materials and Systems guidelines, March 2013)

Air cond diffusers
Avoid patient escape thru duct by providing smaller diffusers. Should be anti-
ligature.
34

Figure 2.22: Example of recommended ceiling mounted diffusers for inpatient unit(Source:

Lighting fixtures

Figure 2.23: Example of recommended lighting fixtures for inpatient unit(Source: Patient

35

Fire fighting components

Figure 2.24: Example of recommended fire fighting components for inpatient unit(Source:

2.3 Analysis and Reviews
Based on analysis on the suicide patterns from both local and abroad, it is observed
that hanging is the common building-related suicide method. Drug overdose in US
and pesticide exposure in Malaysia will not be discussed as they are non-building
related suicide methods.

Jumping from high place is a more common choice in Malaysia compared to the
statistics from the US. But it has to be noted that the difference of subjects between
the two report, Malaysia on general public suicide while US on inpatient suicide
which could mean the option of jumping from high place in healthcare facilities is
less compared to non-healthcare facilities with assumption of lack of access to
jumping places in an institutionalised facility.
36

Hanging on the other hand, could happen in any unsupervised places with anchor
points compared to jumping where it can happen only at high places accessible by
inpatients. This explains the emphasis of design guides abroad to focus on ligature
point reduction as the major suicide prevention strategy in mental health facilities.

However, the proposals of using anti-ligature hardware and fixtures are deemed to be
expensive as more materials are used to conceal the ligature points and increase the
robustness. Some of the solutions are inevitable such as the anti-ligature shower head
design while some could be replaced by innovation in architecture and redesigning
of the fixtures such as windows (to be further discussed in Chapter 4). It has to be
revaluated whether 100mm opening for windows could be extended to 150mm or
more in order to harness adequate natural ventilation especially in the local context
of tropical climate where relative humidity is higher.

Construction costs can be reduced by cutting down building services that can be
nullified such as sprinkler system is not needed if building height is less than 18m
(not exceeding 250sqm per floor) and 5 storeys (exceeding 250sqm) according to
10th schedule in UBBL.
In cases where fire staircase access has to be equipped with locks limited to staff
digital access only, the number of fire staircase can be reduced by providing lopped
corridor layout instead of straight corridor which means dead end limit would be
inapplicable and subsequently requires fewer staircases as long as running distance
radius is covered. Fewer fire staircases would mean fewer digital locks and reduced
construction cost.

37

CHAPTER 3
CASE STUDY

3.0 Introduction
The case study will analyse recently completed mental health facilities and other
projects related to suicide prevention design. Due to privacy, security and sensitivity
nature of mental health facilities, the author decided it would be appropriate to study
projects from available secondary data.

3.1 Zucker Hillside Behavioural Health Facility, Glen Oaks, New York
3.1.1 Project Introduction
Year of completion : January 2013
Total area : 140,000 sq ft
Architecture firm : Array Architects, Ennead Architects
The project consists of 115 beds divided into five-19 bed units (2 adult, 2 geriatric, 1
women and 1 twenty-bed adolescent unit). Patients unit are located on the ground
and first floor of the building. The rooms are designed to be able to flex from private
to semi-private. The typical 19-bed unit comprises of eight semi-private and three
private rooms. The public access to the building is located at rotunda main entrance
into a double volume lobby. The lobby serves as gathering space, reception and
security with glass stair case providing access to the second floor. Seating is
provided outside patients room as area of respite as they travel along the corridor.
38

Figure 3.1: Photos of the behavioural health facility(Source: array- architects.com)

The innovation of this project lies in its three corridor system dividing patient, visitor
and staff into three separate circulation system. Visitors and family circulation
surrounds the central courtyard with occasional seating areas provided for visitors
waiting. Patient circulation within the ward allows freedom of movement within the
ward around the activities and dining areas. Staff circulation is located at the central
core where consultation rooms, charting, medication room, soiled and clean utility
are connected by a corridor linking the nurse station with clinical and support areas.

Figure 3.2: Floor plan showing threecorridor circulation system(Source: Youtube.com)
39

Figure 3.3: Floor plan showing relationship between public, patient and staff circulation
(Source: Youtube.com)

3.1.2 Suicide Prevention Features
Photo shown below is the geriatric unit of the facility are provided with anti-ligature
handrail to assist patients to go into the bath room and cubicle curtain to allow exams
be performed within the room. Recessed shelves and artwork shown in the photo are
one of the suicide prevention features of the room. The door knob is ligature proof
and can be overrided and opened outwards by staffs when needed as anti-barricade
measures. Recessed circular light seen next to the window in this photo. Lock cover
with tamper resistant screw is used to conceal door locks to prevent them to be used
as anchor points for hanging.
However, the bathroom door top does not have any suicide prevention strategy
aapplied as suggested in the VA mental health facility guide where door top pressure
sensor is used to detect potential hanging activity using door top as anchor point.
CCTV which is installed next to circular recessed light is used to monitor patients
40

activity on next to the bathroom door to compensate for the absence of door top
pressure sensor.
The application of CCTV to momitor patients acticity on bathroom door is a
compromise of patients privacy where their partial room acticity is being monitored.
Psychiatric security window used in the room is fixed window with integrated
controllable blind for sunshading purposes. Though safe and comply with standards,
fixed window would mean no user controlled natural ventilation is allowed.
Summary of suicide prevention features in rooms:
recessed ceiling light, anti ligature handrail, anti-ligature door knob, recessed shelves
and artwork.

Figure 3.4: Photo showing geriatric unit design (Source: Youtube.com)
41

Figure 3.5: Photo showing anti-barricade door that have two opening direction (Source:
Youtube.com)

Figure 3.6: Photo showing anti-ligature hardware used to conceal door lock (Source:
Youtube.com)
The toilet design of the units complies with universal design with anti ligature grab
bars provided that have extra plate behind to prevent looping around the bar which
which could be a ligature hazard. Recessed toilet paper holder and built-in wall shelf
are provided to store toiletries. Floor mounted WC is used rather than wall mounted
toilet as wall mounted toilets can be stepped on which will disengage and break the
WC. Anti ligature shower head is used for the shower cubicle.
42

Figure 3.7: Photo showing unit toilet design (Source: Youtube.com)

Push button nurse call system is provided with no cords to comply with maximum 6
cord length for behavioural health facilities requirement. Coat hooks have pressure
sensitive bar which the mechanism will turn down if patients try to loop on it. Every
fixtures in the toilet are fixed with tamper-resistant fasteners.
Basins are built into a niche to prevent it being used as anchor point. Shatter proof
mirror is used to prevent shards being used as weapon or tool of self harm. Sanitary
piping for basin is concealed by lockable apron panel underneath which can be
accessed for maintenance. Anti ligature soap dispenser is used to comply with
suicide prevention standards.
Summary of suicide prevention features in toilets:
Anti ligature grab bar, recessed toilet paper holde, opressure sensitive coat hook,
built in wall shelf, anti ligature shower head and soap dispenser, basin apron panel,
shatter proof mirror
43

Figure 3.8: Photo showing unit toilet design (Source: Array Architects Youtube video)

Common areas such as dining area and day room emphasises on the use of robust
and heavy furniture to prevent abuse and used as weapon or tools of self-harm. As
such common area is under supervision most of the time; the choice of ceiling type
die dining area is not the anti-ligature while the lighting fixtures at day area are not
recessed into ceiling but protected by cover. This approach of selective application
of suicide prevention measures helps in creating domestic and therapeutic
environment to facilitate patients healing. The open nurse station is design in such a
way that prevents patients from taking things from the workstation while not
obstructing line of sight of staffs supervising the surrounding space.

Figure 3.9: Photo showing dining room and day area (Source: array- architects.com)

44

As the public corridor surrounding the central courtyard is used by visitors and
family member to access the patients unit and not intended to be accessed by
patients unless escorted by staff, therefore the area is not required to be tamper proof
and anti-ligature.

Figure 3.10: Photo showing central public courtyard corridor (Source: array- architects.com)

3.1.3 Appraisals
The application of public, patient and staff zoning system allows for flexible
application of full (patients unit and bathroom), partial (patients communal area)
and zero (area accessible to public only) suicide prevention design within the facility
in a more defined approach. This allows for effective control on project cost without
having to apply suicide prevention design in most of the area within the facility.
However, the use of CCTV inside patients room to prevent suicide attempts on
bathroom door or to monitor patients bath duration is deemed to be excessive and a
violation of patients dignity. Available alternatives such as door top pressure sensor
or chamfered bathroom door should be used instead though each of the proposed
alternatives has its own setbacks.
45

3.2 Avera Behavioural Health Center, Sioux Falls, South Dakota
3.2.1 Project Introduction
Year of completion : 2006
Total area : 130,000 sq ft
Architecture firm : BWBR Architects
The project consists of 110 beds (74 private rooms, 18 semi-private rooms) for
paediatric, adolescent, adult and geriatric patients with attached outpatient
psychiatric clinics. The building design features a central two-storey light court
complimented with water feature to welcome visitors, patients and staffs. Thresholds
with integrated seating are provided at each patient room entries serving as front
doors to provide buffer space for patients to leave their rooms on their own pace.
The project is one of the pioneers in having open nursing station to enhance staff-
patient interaction, something which is not the norm in 2006. Day areas on second
floor are illuminated by natural daylight through skylight to provide therapeutic
environment.

Figure 3.11: Photo showing central light court corridor (Source: BWBR.com)
46

Figure 3.12: Photo showing threshold and skylight at patient room entries (Source:
BWBR.com)

Double corridor system is used to replace traditional locked door entrance to
inpatient spaces where patient support spaces (family visitation and physician
consultation room) are located in between the corridors. This established a new type
of protocol which promotes dignity and confidentiality of patients while removing
the negative experience of passing through locked doors.

Figure 3.13: Photo showing 2-corridor system flanking patient support areas (Source:
BWBR.com)

3.2.2 Suicide Prevention Features
Photo shown below is the adult unit bedroom with en suite toilet. To minimize
ligature point, chamfered wardrobe and psychiatric window with integrated blind is
used. However, not much suicide prevention strategy is applied on bathroom door
which is neither chamfered nor equipped with door top pressure sensor besides the
47

use of anti-ligature door hardware. The underside of outboard sink is covered with
apron to conceal the piping with mirror securely fixed to the wall. However, the
water tap seems to be loop able and can be used as anchor point. Radiused stainless
steel framed security mirror is used

Figure 3.14: Photo showing adult patient room interior (Source: BWBR.com)

Recessed lighting fixture with tamper resistant cover and air diffuser with small
holes are used for anti-ligature purposes. Prebuilt shower cubicle, concealed push
button toilet flush, anti-ligature grab bar and floor mounted toilet are used for
patients bathroom.

Figure 3.15 Photo showing details inside the adult patient room (Source: Avera.org)
48

Figure 3.16: Photo showing patient bathroom interior (Source: Aver.org)

Conventional type of air diffuser is used on patient common area where suicide risk
is lower. Furniture is mostly heavy and robust to prevent abuse. Curved Plexiglas
which is tamper resistant is used as partition to enclose the TV area. Recessed
lighting fixture with tamper resistant cover is used in the area which is assumed for
vandal proof purposes rather than anti ligature purposes as the area is under clear
supervision from nursing station.

Figure 3.17: Photo showing patient common area (Source: BWBR.com)

Similar approach applies to outpatient clinic and admission entrance where
conventional sprinkler head and uncovered recessed circular light is used at
admission entrance
49

Figure 3.18: Photo showing outpatient clinic interior (Source: Avera.org)

Figure 3.19: Photo showing admission entrance interior (Source: Avera.org)

The outdoor courtyard uses garden furniture which is hard to move and used as
weapon. Fencing height is less than 14 feet (4.27m) as recommended by Mental
Health Facilities Design Guide by VA office (Chapter 2.2.4.2: outdoor spaces). The
use of rocks as landscape decoration poses a risk of abuse where it can be used as
weapon or tools of self-harm.

Figure 3.20: Photo showing admission outdoor area (Source: Avera.org)
50

3.2.3 Appraisals
The application of suicide prevention measure is much loose than Zucker Hillside
Behavioural Health Facilities where anti ligature strategy is not applied to bathroom
door. A 5-year post occupancy evaluation study on the facility by the architect firm
found out that geriatric patients take advantage of the open nursing station to take
things, tip over computers and cross barrier. This is a potential hazard if sharp office
stationaries are left on the workstation.

Figure 3.21 Photo showing open nursing station design (Source: BWBR.com)

However, the evaluation does not have any reviews about patients room and
bathroom in terms of suicide prevention design deficiencies other than spatial
discomfort of having room door facing the room desk which creates insecurity to the
patients. It is safe to assumed that the patient room design has been able to prevent
suicide attempts so far.
There were several drawbacks due to the need to create anti-ligature environment in
patient rooms such as the lack of place to hang clothes while showering in bathroom
and inadequate shelving or storage for books or glasses when reading in bed.

51

3.3 Overall Review
Both of the projects have applied selective suicide prevention measures spaces based
on levels of risk and supervision which in compliance of the design guides discussed
in Chapter Two. However, having CCTV inside patient room is inappropriate for
Zucker Hillside Behavioural Health Facilities and out board basin in patient room at
Avera Behavioural Health Center is an inconvenience for patients in the local
context.
From authors observation, the application of suicide prevention measures in various
areas has various concerns other than just suicide prevention.
Full suicide prevention
measures
Partial suicide prevention
measures
Minimal suicide
prevention measures
Patient room and
bathroom
Patient common area Public area
Suicide prevention
(mostly hanging)
Prevention of violence
resulting in vandalism and
turning anything available
within the space into
weapon or tools of self-
harm.
To create welcoming
environment for both
visitors and incoming
patients
.

52

Though this report focus mainly on tangible aspects of unobtrusive suicide
prevention design within mental health facility, it has to be noted that the will for
suicide attempts among inpatients has direct relationship with the environment where
they are recovering. A therapeutic environment and caring staffs are the intangible
aspects of suicide prevention design besides active suicide prevention measures
applied within the facility.
Provision of therapeutic environment should be listed as pre requisite of any mental
health facilities design in design guides without making defined requirements on
elements that create therapeutic environment as it depends on the creativity and
common sense of architects.
Hence, it is suggested a separate research has to be done on the effects of therapeutic
environment towards the will of suicide among patients in mental health facility
which will not be discussed in this study.

53

CHAPTER 4
PROPOSAL: UNOBTRUSIVE SUICIDE PREVENTION
DESIGN GUIDE FOR MALAYSIA
MENTAL HEALTH FACILITIES

4.0 Introduction
As therapeutic environment is one of the intangible aspects in suicide prevention as
discussed in previous chapter, the proposed design guide will focus on the tangible
aspects of suicide prevention within mental health facilities. The outcome of the
proposal will be similar to the US and UK version, but appropriate to the local
context in compliance of Mental Health Regulation, UBBL and BOMBA
requirements.
4.1 Proposal
The unobtrusive suicide prevention design guide is divided into 3 categories of
suicide prevention measures application: maximum, intermediate based on the
inherited risk and level of supervision.
4.1.1 Maximum Application
Applied Spaces: Patient bedroom and bathroom, admission interview and waiting
room

54

Description Illustration examples
Patient rooms
Walls: Brick wall/concrete wall/ impact and abrasion
resistant gypsum board on metal studs in paint finishes/
impact and abrasion resistant IBS composite wall.
Painted finish is preferred.
Ceiling: No grid type suspended ceilings with
removable ceiling panels should be used. Minimum
ceiling height is 2700mm to ensure ceiling mounted
fixtures are out of reach. Provide key-lockable access
panels at location which requires services access.
Solid ceiling preferred for admission interview, waiting
room

Doors: Anti-barricade double swing door system with
staff override facility. If space is available, a separate
narrow 500mm wide door that swings to the corridor
can be used for emergency access.
Clear width of corridor leading to exit must not be
reduced to less than 1000mm by door in out swing
mode. Continuous/ concealed hinges should be used for
anti-ligature purposes.
Optional: sliding door/ pocket door/ chamfered door/
conventional door with door top pressure sensors to

55

prevent doors used as anchor points
Anti-ligature door lockset should be used for all patient
room doors. Types of recommended door locksets:
a. Lever handle
b. Crescent handle
c. Push/pull handle
*Note: for fire doors which requires wired glass to
comply with BOMBA standard, request permission
from BOMBA to install a layer of polycarbonate on
both sides of wired glass (broken wired glass yields
shards that can be used as weapons)

Windows: Limited opening of 100mm, glazing should
be made of shatter proof material (impact resistant
glass/ polycarbonate/ film)
Use of curtain track is not advisable inside patient
room. If used, it must be of anti-ligature type and
special care must be taken in installation according to
manufacturers specification to prevent creating anchor
points.
Optional: psychiatric security window with integrated
blinds

56

*Note: clerestory window should be provided to
compensate for reduced air flow in room by limited
100mm window opening in order to fulfil UBBLs
Section 39(2) requirement. Louvers should not be used
as it poses ligature risk.
Lighting fixtures: Recessed and tamper resistant, with
polycarbonate cover securely fixed in the frame with
tamper resistant screws.
No glass components should be used. Use of table
lamps is not advisable. But if used, must be firmly
anchored in place and shatter proof bulb must be used.

Fire sprinkler: Anti-ligature sprinkler
*Note: Refer to Tenth Schedule UBBL for necessity of
sprinkler system for the facility

Air cond grille: Fully recessed vandal resistant diffuser
with S-shaped air passageways recommended for wall
and ceiling mounted grilles.
Locate AC equipment outside patient room to allow for
servicing without entering patient room.

57

Furniture: Robust wood/ thermoplastic/ composite
furniture should be bolted to floor or walls whenever
possible.
Desk chair are preferred to be light weight and tamper
proof which resists breaking into sharp pieces or
heavier chair that is difficult to throw and used as
weapon.
Storage option: 1: Open shelves are recommended to
eliminate the need of wardrobe door which is a hazard.
Drawers and doors should not be provided as they can
be removed and broken to use as weapons.
Storage option 2: if drawers and wardrobe with doors
are provided, they should be lockable with keys
controlled by staff. Anti-ligature considerations must be
taken such as the pulls and wardrobe top (can be sloped
top or built into ceiling)
Wardrobe with cloth poles for hanging is discouraged
as hangers present suicide hazards.
Beds: Non-adjustable platform beds without spring or
storage drawers. It is recommended to be anchored in
place to prevent patients from barricading the door.
Openings below bed are allowed to accommodate
portable bed lifts.

58

*Note: If medical beds are necessary, special care must
be taken on anti-ligature and barricade concerns.
Others: Pull cords for nurse call button (if applicable)
should be less than 30cm and as lightweight as possible
All electrical switches and outlets should be made of
robust material such as polycarbonate and secured by
tamper resistant fasteners to avoid being broken to
access wiring or broken sharp pieces.
Cloth hooks and curtain cubicle tracks are not
recommended
TV sets should not be provided in patient rooms
Plastic trash can liners should not be used due to
suffocation risk, breathable paper liner is allowed.

Patient toilets
Floors: Ceramic tiles are acceptable as long as it is well
maintained
seamless epoxy flooring with integral cove base
sheet vinyl flooring with integral cove base (without
metal/plastic trim piece on top)
one piece floor units, Pre-built bathroom (anti-ligature)

59

Walls: Ceramic tile (small tiles are not advisable as
they can be dismantled and misused)
Gypsum board/IBS composite wall with impact
resistant with moisture and mould resistant facing
finished with epoxy paint or ceramic tile

Ceiling: Plaster ceiling with moisture resistant finishes
Mirrors: Shatter proof mirror/ radiused stainless steel
framed security mirrors

Doors: must be double swing with staff override
facility for anti-barricade purposes.
Door top should be anti-ligature and can be done in
various options: chamfered door top (only on private
bedroom)/ sliding door with tracks on top and bottom/
conventional design with door top pressure sensor (not
recommended)
Locksets should be anti-ligature (refer bedroom section
for example)

Lighting fixtures: Refer to bedroom section except for
water resistant requirement
Fire sprinklers & air cond grilles: refer to bedroom
section

60

Sanitary fixtures: Anti-ligature basin. Recommended
to be built into a niche with concealed piping below for
anti-ligature purposes. Anti-ligature water tap must be
used.
Toilet should be floor mounted with push flush button
Soap dishes should be recessed
Anti-ligature shower head and handle
Anti-ligature paper towel and liquid soap dispensers
Built-in/ recessed open shelf for item storage
Anti-ligature grab bar
Recessed/ anti-ligature toilet paper holder

Table 4.1: Maximum suicide prevention application in mental health faciliry (Source:
Author)
4.1.2 Intermediate Application
Applied Spaces: Patient common area, corridors, counselling, interview and activity
rooms
Description Illustration examples
Wall: Refer to 4.1.1
Ceiling: Preferably plasterboard ceiling.
Suspended ceiling with removable acoustic tile is
allowed, if clipped-in-place ceiling tiles are used,

61

regular safety rounds should check to see that the clips
are in place.
Doors: Subject to heavy use and possibly extensive
abuse. Durable door with wood grain pattern synthetic
faces with removable end caps which can be replaced
when damaged are preferable
Painted steel door are durable and easy to maintain but
institutional looking.
Lockset recommendation refer to 4.1.1
*Note: All exit doors (including fire staircase) to be
able to lock at all times with fail safe or fail secure
configuration (only applicable when approval is given
by BOMBA on exemption of UBBL requirement
Section 166(2)

Lighting fixtures: Normal fixtures can be used as long
as it is located at height inaccessible by patients and
staff observation from nursing station is present.
For areas where fixtures are within patients reach and
staff observation is not available, refer to 4.1.1

Fire sprinklers: Refer to 4.1.1
62

Air cond grille: Standard grilles/ grilles with small
perforations secured with tamper resistant fasteners are
acceptable in these zones as long as ceiling height is
enough to be inaccessible by patients.

Windows: All operable windows should have limited
opening of 100mm
Exception: Full swing revolving windows with 100mm
opening when opened.

Others: Lockable cabinets must be provided to store
items that can be used by patients to harm themselves.
Cabinet pulls should be recessed or closed with no
protruding openings that can be used as anchor points.
Digital locks with card access can be used.
Telephones located in this zone must be securely wall
mounted with stainless steel case with and non-
removable shielded cord of 35cm maximum.
Room signs should be of material that cannot be used as
weapon if removed.
- All electrical switches refer to 4.1.1 : Others.
TV should be installed in built-in furniture and should
not be mounted on walls using brackets as it creates
ligature risks. All cords and cables length should be as

63

minimal as possible.
All fire alarm button and fire extinguisher cabinets
should be locked. All staff on duty must carry these
keys at all times
Emergency exit lights should be vandal proof and
installed tight to the ceiling with full length mounting
bracket to avoid use as anchor point. Wall mounted
installation perpendicular to wall is not recommended.
Furniture: Heavy and robust, furniture are
recommended to be anchored in place to prevent
throwing, stacking or barricading of doors
If movable seating is required for spaces like dining and
activity rooms, light weight or heavier chairs as
discussed in 4.1.1 is recommended.

Pictures and artwork: Should be protected with
polycarbonate and heavy frames screwed to walls with
minimum one tamper resistant screw per side, or fixed
recessed into wall.

Table 4.2: Intermediate suicide prevention application in mental health faciliry (Source:
Author)

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4.1.3 Minimal Application
Applied Spaces: staff working spaces, services areas and public accessible areas
(lobby, cafe)
Staff working spaces, services areas
Comply with UBBL and BOMBA requirements Unattended services areas should be
locked at all times to prevent patient entering those areas.
Anti-ligature and tamper proof consideration in these areas are optional or not
applicable depending on managements choice.
Lobby, Cafe
Furniture is recommended to be robust and heavy (optional) in lobby area in cases
when it is accessed by both patients and public upon arrival before patients are
diverted to more patient-specific areas.
Ceiling height should be high enough for ceiling mounted fixtures to be inaccessible
by visiting patients.
Special consideration should be taken on caf if it is run by patients or serving mix
of visitors and patients. A lockable cabinet/ larder must be provided to store potential
hazardous equipment (knife, boiler and etc)
Comply with UBBL and BOMBA requirements.

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4.2 Complimentary Requirements
The requirements stated below (adopted from Design Guide for the Built
Environment of Behavioural Health Facilities by National Association of Psychiatric
Health System) is not directly related to suicide prevention design but recommended
to be applied in complimentary to enhance its efficiency.
1. The design of mental health facilities should avoid the institutional outlook
and should be designed to appear domestic, comfortable and attractive in
character as possible. This helps in creating a more healing environment to
facilitate patients recovery.
2. Nurse station should be designed with least barrier between staff and patients
although it is in conflict of staff safety requirement of mental health facilities.
Care should be taken on the design of nursing station counter to prevent
patients from jumping over while remaining an open counter design.
Patients record, electronic, staff monitor or otherwise, should be protected
from patients view.
3. Gathering areas are encouraged to be provided near the nurse station as
patients often congregate there to socialise. This places should be provided
with comfortable seating and encourage conversation, board game or other
quiet activities that will not distract staffs working at nurse stations.
4. Chart rooms and other staff areas should be designed in location that allows
for staffs private conversations regarding patients and other clinical matter
without being overheard by patients and visitors.
66

5. Medication room should be designed with adequate area to accommodate the
number of staff needed for peak times and for future computer systems. It
should be equipped with hand washing sinks and storage for medication cart.
6. Service areas such as refuse, soiled and clean utility rooms are recommended
to be located in areas accessible from the unit and service corridor to avoid
disturbance to treatment areas by maintenance staffs during servicing.
7. Traditional nurse call systems for patients to get assistance from nursing
staffs are not needed. It can be replaced by sensors in patient areas and duress
alarm can be used by staff to alarm other staffs for assistance when in
threatening situations.
8. Electrical outlets in each patient room should be tamper resistant. Ground
Fault Interrupted Circuits (GFCI) are recommended with breakers located at
staff areas readily available to staffs without entering patient rooms.
9. Water shut-off valves are recommended to be located in corridor walls and
accessible by locked access panel.
10. Serviceable parts of patient room air conditioning systems are advised to be
located outside patient rooms where it can be serviced without disrupting
patients inside their room.
11. Housekeeping rooms should be large enough to store carts. Cleaning agents
must be locked at all times.
12. Smoking areas should be located at outdoors, verandas or balconies and
covered with heavy stainless steel fabric. It should be available for staff
67

observation without exposed to second hand smoke. No waste baskets
allowed and furniture should be securely anchored in place.
13. 100 net usable square feet minimum for private patient room and 80 net
usable square feet per patient in semi-private room are the minimum
requirement for patient room sizes.
4.3 Authors Suggestions
Noticing the extra costs needed for suicide prevention measures in mental healthcare
facilities compared to conventional healthcare facilities, the suggestion is formulated
to provide alternative low cost solutions when budget, components or construction
skills for such measures are unavailable in the local context.
1. To remove potential hanging hazard of sprinklers if anti-ligature sprinkler are
not available, it is suggested the building height is limited to below 7 storey
or 18m (exceeding 250 sqm per floor) or below 5 storeys for floor area
exceeding 250 sqm as stated in Tenth Schedule in UBBL.
2. To reduce the number of fire staircase which access is limited to staff control
only which might make patients feel they are being locked in a facilities with
many locked exit points, it is suggested the building be designed in
courtyard/loop arrangement rather than linear arrangement where dead end
limit is needed to comply with UBBL requirement. A courtyard/ loop floor
plan has no dead end hence dead end limit is not applicable which means less
fire staircase is needed.
68

Figure 4.1: Diagram showing fire staircase provision in 2 different layouts (Source author)

3. More innovation can be invested on the design of chamfered doors and
windows to provide more therapeutic effect besides serving as suicide
prevention measures. A well designed chamfer door could convince patients
that the door is meant for aesthetic purposes rather than constantly reminding
them that the door and window is chamfered because they are prone to
suicide

Figure 4.2: Photo showing aesthetically chamfered doors and windows designs (Source
Places of the Soul, 2004)

69

4. Windows with limited 100mm opening deemed to be inadequate for natural
ventilation in tropical climate and gives a sense of restriction to the patients,
it is suggested rotating windows to be provided at areas of intermediate
suicide prevention measures application. Opening remains at 100mm but the
different method of opeining could give more sense of freedom as it can be
rotated 360 degree unrestricted.

Figure 4.3: Diagram showing 2 windows with 100mm opening (Source author)

5. To avoid jummping incidents, aesthetically pleasing screens are
recommended to replace conventional grill installations at balconieswhich
gives prison-like feeling to inpatients. Care has to be taken to the design of
the screen where it has to be anti-ligature or in locations of easy supervision
(intermidiate suicide prevention application areas) shall the screen creates
ligature points.

Figure 4.4: Photo showing suicide prevention screen design at NYU library (Source
joelsandersarchitect.com)
70

Figure 4.5: Photo showing unaesthetic grilles installed at Kinta Heights low cost flat, Ipoh
(Source Wikimapia.com)

6. To remove the use of screens and grills on balconies while ensuring patient
safety, a safety buffer zone should be provided where patients will land on
the zone but not on ground shall they attempt suicide by jumping.. The
suggested buffer zone can include secondary function of a planter box in oder
to be unobtrusive. Floor to floor height must be high enough to accommodate
such design and the buffer zone span shall be adequate to avoid successful
jumping.

Figure 4.6: Diagram showing buffet zone concept (Source author)
71

CHAPTER 5
CONCLUSION

5.0 Conclusion
The current suicide prevention measures in other countries in general are unobtrusive
in nature except for use of pressure sensors, restricted window opening and poorly
designed chamfered doors solutions which compromises patients privacy. Use of
CCTV inside patients room is generally unacceptable as it undermines patients
dignity and self-esteem.
From authors observation, the emphasis of suicide prevention mental health
facilities in the studied design guides are mostly on the hardware within the building
(door knobs, sanitary fittings, lightings and etc). Open balcony seems to be non-
existent in such facilities to avoid jumping risk which adds further the sense of being
confined to the inpatients.
As the suicide pattern in Malaysia and the US is similar in general, it is safe to apply
the major suicide prevention strategies practiced there with some changes to suit
with the local context in terms of UBBL, BOMBA and Mental Health Regulation
requirements. Alternative solutions were proposed for cases when the required
budget, skills and components are unavailable in local context. Exemptions on
certain UBBL and BOMBA requirement should be given consideration such as

72

With more areas where application of unobtrusive suicide prevention strategies
application within the ward is possible, less area would need constants supervision
from nursing staffs which could contribute to more time focused on the therapy and
treatment of inpatients instead of surveillance.
Some of the anti-ligature and jumping prevention designs can be considered to be
used in public spaces such as schools, hospitals and high rises where suicide
incidents on such places is increasing. Perhaps partial suicide prevention strategies
should be applied on low cost residential high rises where incidents of suicides are
higher due to daily life struggles of its residents living in poverty.
It is of authors personal opinion that the increasing number of suicides and people
with mental illness in Malaysia which leads to the deinstitutionalisation of mental
healthcare service provision can be seen as a symptom of unhealthy progressing
society which cannot be reflected in GDP of a nation. Thoughts have to be given on
whether the environment of the society or individual mental health fitness is the root
cause of the problem.
Having more mental healthcare facilities is not the solution as it only supress the
symptoms but not curing the disease. Developed nations have higher rates of
mental illness among its population and it is inevitable Malaysia will face the same
problem as it develops. Societal environment has to be drastically changed if it is
found to be the root cause of the problem, not the people. Whether Globalisation and
Capitalism is the root cause of the problem remains an open question.

73

5.1 Recommendation for further study
As the current research on suicide prevention design are more focused on the
tangible aspects of minimizing ligature points and jumping risks, further research on
the intangible aspects of suicide prevention such as the effects of therapeutic
environment on suicide will of mental health patients is needed.
Theres a growing discussion where therapeutic environment has the potential to
serve as passive suicide prevention method in complimentary of active suicide
prevention method (as discussed in this dissertation) besides providing conducive
environment of healing.
Topics such as the intensity of natural day light, the acceptable noise level, and the
effects of colours and space volume that could affect patients suicide will be the
major substance of discussion of the proposed study supported with relevant
scientific research and case studies.
In addition, further research can be done on unobtrusive suicide prevention design on
public buildings and infrastructures where jumping and hanging risks are higher. The
proposed solutions should have much lower level of unobtrusiveness and should be
camouflaged in the form of street furniture or aesthetic installations. Hence, the
aspects of aesthetics and ability camouflage itself should be given higher priority in
the study.

74

REFERENCES

1. National Health and Morbidity Survey 2011 (Fact Sheet), Ministry of Health
Malaysia.
2. National Suicide Registry Malaysia Annual Report 2009, Ministry of Health
Malaysia.
3. Mental Health Act 2001 (Act 615) and Regulations, Ministry of Health Malaysia.
4. WHO Depression Fact Sheet
http://www.who.int/mediacentre/factsheets/fs369/en/
5. Inpatient Suicide and Suicide Attempts in Veteran Affairs Hospitals, Joint
Commission on Accreditation of Healthcare Organizations, 2008.
6. Psychiatric and Mental Health Services Operational Policy, Ministry of Health
Malaysia.
7. Health Building Note 03-01: Adult Acute Mental Health Units, Department of
Health UK.
8. Mental Health Facilities Design Guide, Office of Construction and Facilities
Management, Department of Veteran Affairs, US.
9. Patient Safety Guidelines, Materials and Systems Guidelines, New York State
Office of Mental Health, US.
75

10. Hunt, J; Sine, D.M (2013). Design Guide for the Built Environment of
Beahavioural Health Facilities; National Association of Psychiatric Health
Systems.
11. Pennsylvania Patient Safety Reporting System: 2007, Pennsylvania Patient
Safety Authority.
12. Hunt, J; Sine, D.M (2009), Common Mistakes In Designining Psychiatric
Facilities: AIA Academy Journal.
13. Uniform Building By Laws, Malaysia
14. BWBR Architects Avera Behavioural Health Center 5 year POE.
15. Sell. J (2013) A Salutogenic Approach to Designing Behavioural Health
Facilities, http://www.array-architects.com/a-salutogenic-approach-to-
designing-behavioral-health-facilities-2/
16. Part 1: Building Organization and Planning Drivers, Zucker Hillside
Behavioural Health Facility, https://www.youtube.com/watch?v=tr9viL6JXLc
17. Part 2: Universal Room Model and Patient Safety, Zucker Hillside Behavioural
Health Facility, https://www.youtube.com/watch?v=l2ac2nGZP_s
18. Part 3: Staff Support Areas and Safety, Zucker Hillside Behavioural Health
Facility, https://www.youtube.com/watch?v=rTLvO08vszg
19. Part 4: Patient Bathroom Features, Zucker Hillside Behavioural Health Facility,
https://www.youtube.com/watch?v=6pfEx2h6dpo
20. Avera Behavioural Health Center Virtual Tour,
http://www.avera.org/behavioral-health-center/virtual-tour/index/

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