Saint Elizabeths Is a Hospital Reborn

By Douglas Gordon, Hon. AIA

Sited on a bluff overlooking the confluence of the Potomac and Anacostia rivers, the 336-acre Saint Elizabeths compound accommodated the first large-scale federal psychiatric hospital in the U.S. from 1855 until the federal government transferred the hospital to the District of Columbia in 1987.

Healthcare innovator Dorothea Dix originated the idea of the hospital, which, she wrote in 1852, was to provide the “most humane care and enlightened curative treatment of the insane of the Army, Navy, and District of Columbia.” The originally named Government Hospital for the Insane became better known during the Civil War by the moniker ascribed to the colonial tract—Saint Elizabeth’s (although the apostrophe was inadvertently dropped when Congress officially changed the name in 1916). Wounded and sick soldiers and sailors at the time were averse to mentioning in letters home that they were housed in an insane asylum. There are still two cemeteries on the grounds from those days in which military and civilian dead, both white and black, are interred—very unusual for the time.

The new hospital, foreground, with the historic campus and Anacostia River beyond.

The General Services Administration is currently rehabilitating the western campus, which still belongs to the federal government (as reported in the 2010 Inform, issue 6). It will become the new home of the Department of Homeland Security.

The District, in turn, owns the 118-acre east campus, which, since 2010, has been the site of a new Department of Mental Health-run, state-of-the-art psychiatric facility for about 300 in-patients, designed by EYP Architecture and Engineering. It is this facility—which houses both civil and forensic patients, separately—that is the focus of this article.

The new facility houses and treats the civil patients—individuals with serious and persistent mental illness—in the transitional section of the complex. In the adjacent and more secure (although aesthetically identical) part of the hospital are the individuals who have been committed by the courts as unable to stand trial by reason of insanity. That section of the hospital, generally undifferentiated other than by extremely unobtrusive security monitors and fencing, is the intensive section.

Each living unit has access to an outside area. All photos courtesy of EYP Architecture & Engineering.

Treatment for these patients (about half of whom are transitional and the other half intensive) includes recreation and education within a daily schedule that mirrors what patients might experience in the outside world. The goal is to educate and assimilate people to return to the outside world as productive members of society. The means involve a range of incentives, training routines, and an environment filled with light, access to the out-of-doors, and an over-riding sense of what one might call normality (although staff prefer to avoid that comparison lest it denote that being inside the facility is anything but normal).

In fact, says Saint Elizabeths CEO, Dr. Patrick Canavan, the facility and many of its amenities—including a 250-person theater and congregation/ballfield area—are open to the public. Bringing the hospital as an activating element into this east-of-the-Anacostia community is very much a part of the hospital’s over-arching purpose, he says. Moreover, it is interesting to walk about the hospital with Dr. Canavan and see how the patients know and respond to him as a familiar (not always with respect and grace, incidentally). He and his staff, for their part, are not only understanding of their patient’s behavior, there is an award voted on by the patients—the Respect Award—which recognizes staff whose demeanor the patients regard most highly. On showing a visitor the display of the Respect Award recipients, Canavan is quick to note: “In every instance, not surprisingly, these people are, in my opinion, very deserving of this recognition.”

Treatment within Saint Elizabeths

A therapeutic learning center computer lab.

Patients’ access to privileges within the hospital is based on both their status and behavior. With the biggest two challenges of adjusting to life in the outside world being housing and employment, Canavan says, the hospital focuses on creating an environment that mirrors the world into which, hopefully, patients will aspire. This includes a schedule that brings individuals outside of their rooms into the general population and recreational and educational opportunities. The hospital also treats out-patients who freely move between the facility and outside community.

A hub of the hospital’s activities is the therapeutic learning center. Patients spend much of the day in these centers, located in both the transitional and intensive-care areas. In addition to these areas, supplemented with computer-training rooms, there are the very popular plant-germination rooms where patients with permission are able to plant and care for seedlings destined for the outdoor areas.

The caregivers’ desk has a direct sight line to all patient lounge and living areas.

These kinds of amenities, as well as levels of supervision and outdoor access, strengthen social skills that allow patients to connect to the outside world. Another major factor is their connection with what many of us consider a normal day: Get up and have breakfast at home, go to work and take a lunch break midday, go home at the end of the workday and have dinner, and go to bed at a reasonable hour.

This is in contrast to what often happened at the older Saint Elizabeths facility, where many people stayed in their sleeping area a large part of the day. Moreover, they weren’t able to go outside unless their entire group was able and willing to go out. With the older five-story facility, this often meant hours of gathering residents together, taking them via elevator down to the ground floor, and making sure they were safe and secure outside. And, if any one individual had a physical or emotional problem, the whole group would have to go back up the elevator in either a drastically postponed or, more likely, cancelled attempt to connect to the out-of-doors. The amount of staff hours devoted to this laborious routine took them away from the more important tasks of patient care and healing.

For that reason, says Saint Elizabeths Director of Facilities Planning Richard Warsh, the design team for the new hospital kept three design goals in mind from the outset: maximum natural light, ready access to green outdoor settings, and a minimal need to use elevators.

The daylighted basketball courts are always available.

Other amenities EYP Principal Eric Kern, AIA, points out include privacy in showers and bathrooms (as opposed to the previous facility’s communal arrangements), large and comfortable bedroom areas, quiet rooms for people who need to get away temporarily from any feelings of disturbance, and a basketball court (very reminiscent of a high school court and identical—one each—in the transitional and intensive areas).

Sustainability as an added amenity

Although the D.C. government did not require LEED® certification of its major construction projects when EYP took on the design of the new hospital, sustainable design was a goal from the outset, says Marc Shaw, AIA, who worked on the project as an EYP principal earlier and now oversees his own firm in Washington.

“D.C. didn’t have a LEED requirement at the time,” Shaw explains. “We decided on our own that these elements of resource management should be there. For one thing, there were practical aspects of having, for instance, the large green-roof areas to absorb water and provide additional insulation. If we had installed storm drains to handle the large amount of runoff from the impervious paved surfaces, we would have had to install a huge underground holding tank fed by large-diameter pipes. That alone would have cost nearly a million dollars. Although, obviously, the green roof had costs involved, the net effect was to save a lot of money.”

The facility also has a bio-swale system and landscaped rainwater retention areas as part of its overall water-management strategy, Kern says. Rhodeside & Harwell was the landscape architect.

The gym is one of the “greenest” areas of the building, Shaw asserts. “You have several thousand square feet where patients, staff, and community can come in, play basketball, and burn off energy. Clinically and socially it makes sense. It’s not sexy, but it communicates that the residents are part of the community, and, with the clerestory windows, you can operate that gym for 8 to 10 hours a day without turning on the lights.”

Exterior building materials are respectful of the brick historic campus.

The designers were also mindful of other LEED-oriented considerations. The brick—which is reminiscent of the original west campus—and the copper and manufactured-stone highlights were locally sourced. (Two brick subcontractors competed to put two of the wings in place with the understanding that whichever performed the best would be awarded the middle wing, Shaw says. The resulting competition meant both higher quality and an accelerated pace of construction.)

With the patients in mind

Patients and staff are under unobtrusive yet constant video monitoring.

From the facilities to operations, and even with the move from the old hospital to the new, the well-being of the patients was foremost on the minds of staff and the design/construction team.
For instance, the security system—necessary for the well-being of the patients as well as the security of the community, given the nature of patients in the intensive wards—is as unobtrusive as possible. Although privacy for bathing and bathrooms is paramount, every other aspect of patient and staff movement is carefully monitored from a central closed-circuit-television control room. Camera direction and focus are operable and precise. Climb-resistant fences, with a mesh of about an eighth of an inch, have motion-sensitive detectors. Staff have direct visual oversight of all living and activity areas all day, every day. And public traffic into and out of the facility is monitored scrupulously at all times. Certainly the public has access to the hospital, but the staff monitor that access, both closely and in a friendly way.

Recognizing the distress that moving to a new facility would have on the patients, the hospital staff endeavored to make it as smooth a transition as possible, Canavan says. “We tried to give patients a sense of owning their new space by having an open house and letting them move their clothes and personal effects themselves,” he says. Still, there was an uptick in disturbances in the first months of the move. According to the Environmental Survey Report that the hospital regularly posts, resident disturbances increased temporarily in May 2010, but soon tapered back to a level lower than in the original facility.

CEO Canavan responds that although the cause-and-effect relationship is too complicated to address directly, the access to the outside, normalized schedule, educational opportunities, and light and fresh air are all positive influences on patient recovery. He points out that reducing the stress on the staff was also a programmatic concern.

There was a conscious effort to separate on-duty and off-duty physical space. Staff have “away” areas if the stress gets unbearable. They also have separate lunch areas so that they are not eating or enjoying a coffee break in the presence of patients (who would not have access to the food or beverage, which would be inexplicable to them). “When you’re on duty, you are working for the patients; when you are off duty, you are away from the stress of the job,” the doctor says.

In addition to patients bringing over objects and a sense of place that is meaningful to themselves, the design team saw it meaningful to reflect the aesthetic of the historic hospital in the new facility, which includes a small museum in the entryway lobby, the brick with stone and copper highlights, and bringing a number of stone plaques and other artifacts from the west campus.

With EYP and its client and construction team as partners, Saint Elizabeths is reborn as the state-of-the-current-art of psychiatric care, as Dorothea Dix envisioned.

RESOURCES:
ARCHITECT: EYP Architecture & Engineering; GENERAL CONTRACTOR: Turner Construction Company; CIVIL ENGINEER: Alpha Corporation; LANDSCAPE ARCHITECT: Rhodeside & Harwell