Mental Health Services Integration: Making Help for College Students More Accessible

Many of us look back fondly on our college days, and for good reason. College life is full of opportunities for new experiences, rapid learning, and personal growth, especially for those living away from home for the first time.

Yet, for some students, day-to-day college life can cause insurmountable stress – as unavoidable as tuition, fees, and final exams.

Students in this generation are working and growing up in a fast-paced society. There’s additional academic, social, and financial stressors that fall on their shoulders. According to the young adult mental health advocacy organization Active Minds, “a majority of mental illnesses manifest between ages 14 and 24, when teens and young adults are enrolled in high school and college.” In the last decade, anxiety has overtaken depression as the most common reason college students seek mental health services.

The pressure to balance it all, and do well, can be overwhelming. That’s why colleges are looking closer and closer at what it means to seamlessly integrate wellbeing and mental health spaces into the design of campus communities.

As we think about supporting the whole wellbeing of a student, we need to carefully create spaces that fit within college life – making it both easy and comfortable for students to seek and receive the help they need. The following design principles can guide planning of mental health spaces on campus to successfully serve students:

Blend with campus community

Integrating mental health spaces into areas that receive lots of foot traffic such as athletic or recreation facilities, student centers, or dormitories increases the chance for students to receive services because of higher visibility and convenience. Additionally, integrating such services into everyday life on campus reduces the stigma surrounding mental health. Universities send the message that academic success and making sure people are healthy go hand-in-hand.

It can be difficult to reach out for help. Collocating services with other popular destinations and everyday routes on campus will make the space a more recognized resource, removing the physical challenge of finding the services as well as the mental barriers of accessing care in out-of-the-way spaces. Raising the profile of services in easy-to-find centers increases the likelihood that a student will get the services needed and recommend these services in the future to students in need.

Create an inviting space that welcomes wellbeing

Wellbeing design should incorporate natural elements to create a welcoming front door and comfortable spaces to share personal information. Incorporating lots of natural light, visually appealing artwork, access to nature, and other healing elements improves mood, provides calming effects, and serves as a positive distraction.

Provide anonymity through shared spaces

Visiting for a broken bone, cold, or therapy session? Shared waiting room spaces for both health and counseling services helps provide anonymity for students seeking mental health services. With added social pressures in an unfamiliar environment, students can seek help without fearing that a friend or a student in class will see them going in for a counseling session.

Make a safe space

A safe space is a welcoming environment where students can connect with one another and talk without fear of being negatively judged for it. Safe spaces can be physical areas set aside to recharge between juggling responsibilities. Often times these spaces have more of a residential feel with area rugs, casual furniture, table lamps, and art work to counter the institutional feel of the school. These spaces are meant to remove students from stressful days and to relax.

Students building trust with their peers and having a dialogue about their entire experience in college – both the fun and the struggles – can create a sense of belonging on a new campus in a new town with new friends. The Suicide Prevention Resource Center lists peer support and an inclusive environment as two of the three protective factors that decrease the likelihood of suicide. A safe space can encourage students to share what resources are available for help and even access those resources together.

These protective factors contribute to resilience, developing the capacity to cope positively with challenges. Increased resilience will increase utilization of professional services, decrease the amount of students dropping out, and help to prevent student suicide. A safe space on campus can make all those college challenges a little easier to bear.

Designing communities that make wellbeing a central part of college life needs to include a mental health component that can foster all-around student development. Students are at a time in their lives where the behavior they practice in college can become permanent practice once they graduate; according to the American Psychological Association, 65% of counseling center clients indicated counseling had helped them remain in school and improve their academic performance. By continuing conversations with school administrators and faculty to explore the issues surrounding student anxiety and how better to integrate these spaces on campus, colleges can positively impact students personally and academically.

The Joint Commission Issues New Guidance on Suicide Prevention in Healthcare Settings

In February 2017, the Center for Medicare and Medicaid Services (CMS) issued a directive to The Joint Commission requiring that hospital surveyors cite all potential ligature risks regardless of the size of the risk or patient acuity levels. The new directive lead to unrealistic expectations from surveyors.

As a result, many hospitals surveyed this year were cited for issues even though previous inspections may not have considered the same items a risk.

After months of discussions with the American Hospital Association (AHA), National Association of Psychiatric Health Systems (NAPHS), and other healthcare associations, CMS decided to reevaluate the approach to surveys for ligature risk. The Joint Commission assembled a panel including representatives from provider organizations, experts in behavioral design and suicide prevention, Joint Commission surveyors, and representatives from CMS.

On October 25, The Joint Commission issued a special report intended to provide guidance for providers and surveyors on potential hazards in healthcare settings. The following is a summary of those recommendations. To read the full report (Special Report: Suicide Prevention in Health Care Settings, 25 Oct. 2017).


Healthcare organizations should do a risk assessment and prepare a mitigation plan. The expert panelists emphasized the critical importance of well-trained, vigilant, compassionate staff who, in their words, “rigorously” follow procedures for protecting patients.

The report suggests that facilities should focus as much on staff training and monitoring compliance with their policies and protocols as they do on identifying and correcting specific environmental hazards.

Minnesota Security HospitalLigature-Resistant

The panel recommended the term “ligature-resistant” rather than the term “ligature-free” because they did not think it possible to remove all the potential ligature risks. The panel also defined the term ligature resistant: “Without points where a cord, rope, bedsheet, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or loss of life.”


The following areas must be ligature-resistant:

  • Patient rooms
  • Patient bathrooms
  • Corridors (see below)
  • Common patient care areas

Corridors and Common Patient Care Areas

Areas that have an unobstructed view from the nurse station (so that a patient attempt at self-harm can be easily seen and interrupted) and areas behind self-closing/self-locking doors do not need to be ligature-resistant and will not be cited for ligature risks.

Karner Blue Education CenterPatient Toilet Room Doors

The transition zone between patient rooms and patient bathrooms must be ligature-free or ligature-resistant. Feedback from several facilities is that this has been a frequently cited issue. The report suggests several examples of acceptable solutions that include removing the bathroom door, use of soft suicide prevention (foam) door, top-of-door alarm system, and using a specially engineered door with a sloped top. Another potential solution might be to lock the toilet room door denying access unless staff is present; this solution still requires the door and hardware be ligature-resistant in the closed arrangement.

Patient Room Doors to the Corridor

Doors between patient rooms and corridors must contain ligature-resistant hardware which includes, but may not be limited to, hinges, handles, and locking mechanisms. The expert panel recognized that there is some potential ligature risk at the top of doors but facilities are not required to have risk-mitigation devices installed at top of corridor doors to decrease the chance that doors will be used as a ligature attachment point. However, facilities should note this on their environmental risk assessments and describe their mitigation strategies (e.g., appropriate rounding/monitoring by staff, requiring that doors be left open during certain hours). 


All patient rooms and bathrooms must have a solid ceiling. Drop (or lay-in) ceilings can be used in hallways and common patient care areas as long as all aspects of the corridor are fully visible to staff and there are no objects that patients could easily use to climb up to the drop ceiling, remove a panel, and gain access to ligature risk points in the space above the drop ceiling.

Drop ceilings in areas that are not fully visible to staff (for example, a right-angle curve of a corridor)  or for which it is possible that patients could easily move objects to access the area above the drop ceiling should be noted on the risk assessment and have an appropriate mitigation plan. Mitigation strategies for existing drop ceilings in these areas might include using tile retention clips, installing motion sensors above the ceiling to sense tampering, or using another comparable harm-resistive arrangement.


Patient-Bed Type

The medical needs and a patients’ risk for suicide should be carefully assessed and balanced to determine the optimal type of patient bed required to meet both medical and psychiatric needs. Healthcare organizations must have appropriate mitigation plans and safety precautions for patients who require medical beds with ligature points.

Patient Toilets

The expert panelists concluded that standard toilet seats with a hinged seat and lid do not pose a significant risk for suicide attempts or self-harm. While some facilities have been cited for toilet seats over the past several months, this report suggests that this should not be cited during future surveys and facilities do not need to list this on their risk assessment.

The special report suggests that additional clarification will be provided at a later date for outpatient psychiatric and other acute care areas.

Healthcare Veteran Dan Morgan Joins BWBR

Dan Morgan, AIA, EDAC, a healthcare architect who has spent his 32-year career helping organizations transform and improve the way they deliver care, recently joined BWBR, one of the largest and most experienced design firms in the Upper Midwest serving the healthcare market.

Trained in evidence-based design, Morgan has served both large and small healthcare organizations to examine their practices and find solutions that create more efficient and patient-centered facilities. Among the organizations with which he’s worked include Aurora Health Care, UW Health, and SSM Dean Medical Group in Wisconsin and Centegra Health System in Illinois.

“Dan brings experience and talent that bolsters what we are able to offer healthcare organizations,” said Peter G. Smith, FAIA, president and CEO of BWBR. “Hospitals and clinics are facing generational, technological, and regulatory challenges that are changing the way they deliver care. Dan’s insights and knowledge of best practices is helping create the facilities to meet those challenges.”

“BWBR’s work is known for being client-centered and focused on the needs of the communities that the organizations serve. That approach to healthcare design creates environments that are intuitive, efficient, and sustainable for generations to come, and it’s what has attracted me to join them,” Morgan said.

Morgan has spent his career working in the southern Wisconsin and northern Illinois market. A graduate of the University of Wisconsin-Milwaukee College of Architecture and Urban Planning, he most recently worked at Kahler Slater where he provided project leadership on architectural and planning services totaling about $3.6 billion in total project costs.

Building on Success, Second BWBR-designed School for Children with Severe Autism Opens

In 2014, Northeast Metro Intermediate School District 916 in the northern suburbs of Minneapolis-Saint Paul opened the first known primary school of its kind. Created specifically for children who live with severe autism and emotional-behavioral disorders, Karner Blue Education Center took a dramatically different approach to school design that married the functions of education with elements more akin to behavioral health.

The results have been nothing short of remarkable: a more-than 50-percent increase in the number of students served compared to previous school years, a nearly 30-percent drop in use of restrictive procedures for students who deregulate, and a noticeable increase in time actually focused on teaching rather than behavioral control.

Based on what is working and what has been learned from the non-traditional school design, the school district opened the doors to its second school, Pankalo Education Center, in September for the 2017-18 school year. The school brings an arts-based focus to its compassionate education model with the capacity to serve up to 130 students with complex special needs.

Pankalo – a name created from the Greek words meaning “complete” and “beauty” – is designed around four neighborhood communities, each with five classrooms and a common area. The neighborhoods also include other small rooms like a sensory room that allows a student to refocus their minds and bodies and return to classrooms ready to learn.

It is more than the neighborhoods, though, that make the design of the school different. The key to the success of the educational/behavioral combination design are the layers of interventional spaces for students learning coping skills for self-regulation:

  • The common areas provide room for students to pace and move without disruption to the other learning environments inside the classrooms or in other neighborhoods.
  • Sensory rooms feature student-chosen LED lighting, music, and sounds designed to calm students and help them self-regulate.
  • Shorter hallways control sight lines to obscure exits and discourage students looking for an “escape” from running through the corridors.
  • Intervention rooms allow staff to work with students one-on-one in a controlled setting with limited distractions.

Northeast Metro Intermediate School District 916 Pankalo Education Center

In addition to the layers of interventions, lighting and mechanical elements are specifically designed for the needs of students who are highly sensitive to environmental triggers such as noises and air movements caused by artificial lighting and air ducts, respectively. Large, elevated windows and skylights reduce the need for artificial lighting in classrooms and common areas, and a strategically placed mechanical penthouse over non-student spaces mitigates any possible triggers caused by noise and vibrations of mechanical units.

“As a healing learning environment, the strategy is to bring these students into a school that is both therapeutic and academic,” said Hanna Kuehl, CID, LEED AP, project manager at BWBR. “By removing the environmental stressors that can lead to behavioral escalation, students can focus on learning as well as developing coping skills to navigate the world outside of the school.”

Working with state fire inspectors, even fire alarms are specific for this special student population, replacing loud alarms and strobe lights with calm voice alarms and LED reader signs more often found in mental health facilities. Not specific to Pankalo, the fire alarms were one of many successful strategies that carried over from Karner Blue, including soft, movable, child-friendly furniture; rubber flooring and strategically used carpeting; and nesting windows, this time made deeper for students to sit inside.

“We took all the things that were working at Karner Blue and enhanced those elements,” said Steve Berg, AIA, designer on both Karner Blue and Pankalo. “The radical-looking floor plan allows Pankalo to leverage all the innovations established by Karner Blue and improve on the strategy.”

Northeast Metro Intermediate School District 916 Pankalo Education Center

The most notable enhancement may be the amount of windows and daylight entering the facility. Where skylights brought in daylight to interior common areas in each neighborhood at Karner Blue, Pankalo features large windows with child-friendly and playful furniture in each learning community, giving students equal chances to relax and focus on their own or expend energy with other children. Window seats in the hallway also provide a place for students to sit and compose themselves when needed.

“If this was a college or university, there would be outlets for laptops at those sitting areas,” Berg said.

Classrooms are also designed for flexibility in furniture layouts to facilitate a variety of teaching preferences. Teachers can adjust the learning environment based on the needs of the students on any given day and throughout the day to enhance learning activities. As an intermediate school district that only receives students referred by member school districts, the student mix changes regularly. It is also temporary for most of the students, making the flexibility of the classrooms more beneficial.

Taken as a whole, the design elements create layers of intervention and passive seclusion opportunities that help students learn how to manage their bodies and minds through self-awareness and control while avoiding physical interventions with staff. Coupled with a softer, warm atmosphere and elegantly integrated safety features, the healing learning environment allows students with severe autism and emotional-behavioral disorders to discover their potential both as students and as individuals with special needs.

“These schools are giving students room to learn who they are and what they are capable of achieving,” Kuehl said. “With the self-coping skills to manage a stimulating world, these unique students can return to their home schools and community ready to flourish both academically and socially.”