EP 101: Designing the Immune System of Mental Health | Susan Swick
Learn about how Dr. Susan Swick is challenging the paradigm of mental health, redesigning the future of behavioral health facilities and why every community needs a gym for building our mental health resilience.
Susan Swick, MD, MPH is the Executive Director of Ohana, designing and leading the development of this Center for Child and Adolescent Behavioral Health at the Community Hospital of the Monterey Peninsula in Monterey, California. In addition to evaluation and treatment programs that are evidence-based and family-focused. Ohana programs will also emphasize the cultivation of mental health at the individual, family and community level. This Center is being created with the support of a landmark $100 million gift from a single donor in the hospital’s community, reflecting a recognition on both the hospital’s and the community’s part that the resources available to families seeking care for their children’s mental health challenges were sorely lacking. Dr. Swick has a long-standing interest in how adversity affects children and families, and in how well-timed interventions can make a critical difference. Prior to relocating to California in 2018, Dr. Swick served as the Chief of Child and Adolescent Psychiatry at Newton Wellesley Hospital for five years. While at Newton-Wellesley Hospital, she created a new community health initiative called “The Resilience Project,” partnering with local High Schools to promote the mental health and well-being of youth and their families. She also directed the Parenting At a Challenging Time (PACT) program at Newton-Wellesley, a parent guidance program available to cancer patients who were still raising young children. She was an Instructor in Psychiatry at Harvard Medical School and at Massachusetts General Hospital, where she created and ran a course on Parent Guidance for the Child Psychiatry fellows. She attended Medical School at Columbia University, where she also received a Masters in Public Health. She, her husband and their four children are all east-coasters originally, but are happy to call California home.
Episode Mentions and Links
AIA 2022 Healthcare Design Awards: Montage Health Ohana Center
NBBJ Architects: Ohana Center for Health
NBBJ Architects: Hope, Healing, and Healthcare
A New Tool in Treating Mental Illness: Building Design via NYT
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Bon Ku: Welcome. Welcome to another episode of design lab. I'm your host Bon Ku.
On today's episode, you are going to learn about how a child psychologist is challenging the paradigm of mental health, redesigning the future of behavioral health facilities.
And we're going to talk about why every community needs a gym for building mental health resilience.
Today's guest is Dr. Susan Swick, the executive director of Ohana. She is designing and leading the development of a center for child and adolescent behavioral health. At the community hospital of Monterey peninsula and Monterey, California. We talk about the montage health Ohana center, that was one of the winners of the AIA 2022 healthcare design award. Dr. Swick is interested in how adversity affects children and families. And how well time interventions can make a critical difference prior to going to California in 2018. Susan serve as the chief of child and adolescent psychiatry at Newton Wellesley hospital in Massachusetts.
She was an instructor in psychiatry at Harvard medical school and at Massachusetts general hospital. She attended medical school at Columbia university and also received a master's in public health there.
Some exciting news, we celebrated the hundredth episode of the Design Lab Podcast.
Our producer, Rob Pugliese was so excited about this, he was pumped, he created a website. You could find the website at designlabpod.com.
There, you can find a link to our newsletter and thank you for all our listeners for supporting us for the past two years.
Going to Apple podcast, leaving us a review, giving us five stars if you haven't done, so please do that. Go to apple podcasts, give us five stars. That's how you support the show. Now here's my conversation with Dr. Susan Swick. Dr. Susan Swick, welcome to Design Lab.
Susan Swick: Oh, it's so great, Dr. Bon Ku. It's wonderful to be here with you.
Bon Ku: Cool, and can I call you Susan? Is that all right?
Susan Swick: Please do. Only my mother calls me Dr. Susan Wick
Bon Ku: Only my kids call me Dr. Ku, but
Susan Swick: It's good to know they'd be in good company.
Bon Ku: Well, I've been looking forward to this conversation because I first heard about you when I read this New York Times article and featured in that article, it's says, A rendering of a mental health facility in Monterey, California. And, It looked stunning, I was floored when I saw this building. It overlooks this valley.
There's swoops and curves to this building that's made out of timber.
Susan Swick: Mm-hmm.
Bon Ku: And then I couldn't believe that this was a mental health facility. what, is this space like? How did it come into being? And can you walk us through this?
Susan Swick: All right, you tell me if it gets boring, but I'll tell you. Just a tiny bit about the idea for this, this whole center, and how the physical space for the center became really central to what we wanted to design. So, community Hospital of the Monterey Peninsulas, a small 200 bed community hospital here in Monterey.
A pretty beloved institution. In a fairly physically isolated region. A very beautiful one, I had never been out here. I was born and raised in the east coast, lived in New York City for a long time, and then in the Boston area for almost 20 years before, getting tapped to come out here and help build this about four years ago. And this hospital got a gift from a single donor, of over a hundred million dollars.
incredible.
Bon Ku: this is pretty unusual.
Susan Swick: It's very unusual. It was actually, at the time it was the largest gift ever given to a healthcare institution by a single donor. yeah, I know, for this lovely little community hospital, and the donor's name is Birdie Elliot. She's a, 50 year resident of, the neighborhood. And she happens to be Warren Buffett's sister, but had a long-term relationship with the hospital.
One of her husbands was a surgeon. And, her third husband, I think, , was, an Oncologist. There was just a long time where she was, and she's been a, a supporter and advocate for the hospital for all of her time here.
So she had come to the hospital and said she wanted to leave a legacy gift and the hospital had made four proposals. One of which, and you work in healthcare of course, so you know, how unusual it is for a hospital to make proposals that maybe aren't capital intensive projects. So rather than it being a new robotic surgery suite or sort of, gamma knife center.
Bon Ku: Usually it's something that has in mind, not only helping patients, but will make the institution money, and so that ends up being like a surgery center or something like that.
Susan Swick: Exactly. It's something where that degree, like it's a very capital intensive, money intensive development that could make money, but it would take a lot of money to get it set up. and instead they made, three proposals that were had to do with, sort of aging gracefully, women's healthcare. And one of them was, youth mental health.
And she and her three daughters all chose the youth mental health program unanimously.
Bon Ku: Wow.
Susan Swick: Her only stipulation is that the program be called Ohana, which, she lives half the year in Hawaii on the big island, and Ohana is Hawaiian for family. As anyone who watched Lilo and Stitch apparently knows. But it also, it's a, broader concept than the English word of family. So the word comes from Oja, which describes the tarot plant, which is a plant that grows commonly in Hawaii and has a single root and a leafing plant at the center and then grows in concentric circles around that central leaf to shoot off many more leafing, flowering plants.
And it can grow to be enormously big out of this one central root. And the idea of Ohana is that a family is, maybe it starts with a child and then you have a nuclear family around the child. And then the extended family, a family of friends, of coworkers, these sort of concentric circles that emanate out from the center, of connection and support.
So it's a very broad idea of family and she said she really wanted the center to be a place where families, and not just the child, the whole family was at the center of care.
and where the care they received enhanced their connections to the community, rather than isolation, which was such a common experience for families facing a mental illness in their child. so they found me cuz uh, I don't think there were too many chiefs of child psychiatry at community hospitals anymore. And I was at, part of the partner system outside of Boston. I was the chief at Newton Wellesley Hospital, a place that I really loved and had been, for almost 10 years. And, I came out just to see what they were doing.
I actually wasn't looking to move, but when I came out here, I was so, I was so impressed to discover both, the real shortage of resources I had kind of imagined that, California had a sort of similar array of resources as Massachusetts had or New York City had, that's where I had kind of grown up professionally and done my training and was working. And I thought there were all the same general problems we had accessing appropriate services or coordinated services. But really there was a, even more profound shortage of services out here.
Bon Ku: That's surprising to me too cause I thought there would be the same amount of service cuz that, I mean California especially Central Northern, has so much money. It seems like you always hear about Silicon Valley and.
Susan Swick: Yeah. Yeah. Well that's interesting. The stats from the American Academy of Child and Adolescent Psychiatry are that, Massachusetts is actually number one in terms of the concentration of child. This is just child psychiatrists. and the ratio of child psychiatrists to children, is the best in the state of Massachusetts.
California, as estates go, is just in the middle of the pack. We're about 25th. For ratios, but the devil's in the details. And actually, it turns out there's really robust ratios in the Bay Area, in LA and in San Diego and outside of those three urban centers, the rest of the state is more like, Nebraska and sort of the, the bottom tier of, access, for children.
So there's many counties with zero child psychiatrists, this county, Monterey County in California. A handful of child psychiatrists servicing a total of about 125,000 children in the county.
Bon Ku: What?
Susan Swick: Yep. And zero inpatient beds. And in fact, most counties in the state have zero inpatient psychiatric beds for children.
Bon Ku: So if, uh, if a teenager is going an having an acute mental health crisis and needs an inpatient treatment, where do they go?
Susan Swick: They go two hours north or six hours south, which does two things. One, it means, that they have a harrowing, an expensive ambulance ride, and two, it means their family probably cannot be involved in their treatment. , unless their family has the means, uh, to stay in a hotel for the duration of their stay In a hospital, the family's gonna be two to six hours away from where their child is hospitalized.
Bon Ku: That's such a, dislocating experience,
Susan Swick: Dislocating at a moment of, deep need for stabilization. So the need was profound, and I was so impressed though with the, the curiosity on the part of hospital administrators and the clinical community here to think creatively about how to make the best use of this gift because a hundred million dollars it's a lot of money by any standard , any standard. My kids were like, are we getting a car? And I was like, no, that's not how this works, but it's a finite amount of . Money and, You know, psychiatric illnesses are probably the most common illnesses of childhood after routine infectious diseases. So, children will develop a psychiatric illness at a rate that has climbed in the last decade. It used to be about 20% of kids will experience a psychiatric illness by the time they turn 18 by adult, by the time they become adults.
Now it's closer to 30% , and that was happening before Covid. Covid accelerated that trend.
Bon Ku: And just doing some research that's, uh, it's so common that psychiatric illnesses in the children, adolescent populations, you said, I think it's twice as common as asthma. Right?
Susan Swick: it's twice as common as asthma. Now it's almost three times. Asthma affects about 11% of children. And psychiatric illnesses are gonna affect two to three times that number of kids. And we
Bon Ku: I think, I think that's like shocking because I think most of the public don't realize how prevalent it is. We think so many kids have asthma, but three times that many kids have psychiatric illness.
Susan Swick: That's right, that's right. And you know, my husband's a pediatrician and even when I'm talking about this with him, he still is like, really? It's that many. And I'm like, come on you, you're married to me. You should know this by now. But I always want to remind or to follow that up by saying, here's the good news though, cuz people feel shocked and feel like something's deeply wrong.
but I'll say, listen. Psychiatric illnesses are not only common in youth, they are illnesses of youth, right? Meaning 50% of all lifetime psychiatric illnesses have presented by the age of 15 and 75% of all lifetime psychiatric illnesses present by the age of 25 and 25 matters because, From a brain development perspective, 25 is when children become adults.
like adolescence is puberty to about 24 or 25. From a brain perspective, there's enormous amount of renovation, pruning, and myelination that's happening during adolescence and it's, complete somewhere in the mid twenties.
It makes sense since there's rapid brain growth and then brain renovation that happens in childhood and adolescence and that, those are the years when problems show themselves.
Right? Three quarters of lifetime psychiatric illness will have shown itself, by that age. And the good news is psychiatric illnesses are always treatable in, and the illnesses of childhood are usually curable, usually curable. 75% of them with the right diagnosis and access prompt to timely access to evidence-based treatment cure, we will put that illness into remission and not need ongoing treatment.
It'll be done.
Bon Ku: So this mismatch of you see a one, child psychiatrist for over a hundred thousand,
Susan Swick: it's a real problem. It's
a grave
Bon Ku: because these are treatable
Susan Swick: Yeah.
Bon Ku: conditions Curable.
Susan Swick: Yep. And here's the last piece of good news. It's like many of the illnesses of youth are preventable. They're preventable. So, anxiety disorders are the most common psychiatric illnesses of youth. We know something about risk for anxiety disorders.
And we also have we have robust evidence about how to prevent anxiety disorders and depression, in certain at risk populations from. Emerging. we know how to teach kids and sometimes how to teach their parents, how to teach kids to essentially brush and floss, to improve their mental health so that they won't develop the mental health equivalent of a cavity.
Right? They won't develop an anxiety disorder or depression.
Bon Ku: Okay. So you're an expert in your field. Having, you know, taking care of many patients in Massachusetts. Then what led you to jump ship and go across the country?
Susan Swick: Oh my God,
Bon Ku: To Monterey?
Susan Swick: my mother is still asking me that question, . So I'm bringing my mother up a lot in this podcast. Clearly I need to talk about it. Um, You know, as I was saying before, I loved, the hospital I was working at. I loved my team. I had built a wonderful, amazing team. I still, I care about them so much.
They're an exceptional team. I love the work I did, and I really loved New England. I had grown up there. It it was a happy place. Our family and friends are all there, but after coming out here to visit, and I really, my initial visit, I was like, I'm not looking for a job. I'm just really curious what they're gonna do.
How are they gonna do this? How are they gonna take a hundred million dollars and try to actually make a real difference in the community? I came back home and I couldn't stop thinking about it. I couldn't stop thinking about essentially, I mean the design challenge, like the challenge. And I was a public health person before I even did my psychiatry training.
I got my MPH in med school and I was thinking, so we have this really prevalent problem that if you get the diagnosis right and you get involved early, and in fact if you know something about risk, you can educate and empower non-doctor level clinicians to do prevention work. we might be able to actually improve the mental health of a community, not just build a great psychiatric hospital. And the hospital that had you know, was talking to me about this, was like, we're interested, we're interested in thinking about not just building a bigger clinic or building an inpatient unit, but how do we take this gift and this idea, and maybe it's seed money for a bigger project and how do we actually improve the health of the community and it's.
Bon Ku: mm.
Susan Swick: It's a hospital that's really dedicated to the community's health across different settings. They think that way, you know, with their, it's an older population generally here, and , the hospitals, , built its own Medicare Advantage plan to try and help provide coaching and additional support for patients here in improving their quality of life and improving their health.
And not just, not just be a place where people can come when they're sick and functioning within the, the business model that hospitals usually live and die by. So I couldn't stop thinking about it. And then my, you know, basically I went through that process that you go through where I was like, well, maybe this is what I'm supposed to be doing.
And so, my husband came out and looked at it with me too, and he said, I don't see how you can say no. He's like, this is a chance. This is a sort of once in a lifetime chance to try and build a better system, maybe build something that doesn't exist yet, in youth mental health where it could be easy to access high quality evaluations and treatment.
But where we also could create what would feel to the community, like its own center, like a community center, where, everyone had a sense of ownership and would be comfortable and even excited to come and participate in, educational programming around building mental health for their children, for themselves as adults.
so that's how I sort of stepped into it. And interestingly when we got out here, which was in the late fall of 2018. Literally, my first full meeting at the hospital was with the architecture firm.
Bon Ku: Yeah, I love that how you frame this as a design challenge. And I, in my research you had put this prompt to them. You said, uh, you wanted a design that would possess some of the wonder of a children's museum or a public library.
Susan Swick: Hmm.
Bon Ku: A place you step in that gives you a sense of soaring possibility.
I love that. What prompted you to give that design constraint to the architects?
Susan Swick: Hmm. Well, the firm that the hospital had already selected before I came, is NBBJ. It's a firm that designed, the Amazon headquarters in Seattle, but they've done a lot of healthcare design, and I think the big one that had gotten the hospital's attention was, nationwide Children's, in Ohio .And, in my experience, mental health spaces were designed where the constraints were the only guiding principles where they would say, okay, we have to design a space that prevents people from hurting themselves. And so every single thing about that space was determined by that directive, but in the end, it came to feel like a fairly grim clinical spaces. Austere.
Antiseptic. Like prisons. Like places where all agency is obliterated because there's danger, right? And the truth is that childhood, what we wanna do in building health is, provide buffers around kids. so that they, they actually are, we support their curiosity, their, willingness to explore the world around them and themselves, you know, learning about their thoughts and their feelings.
and we help them when they fall. We prevent irremediable consequences of falling, right? So it's like, as parents, we think about a kid getting on a. and you want them to get on the bike. You don't wanna have to just force 'em because that's not gonna go well. You wanna make it fun, but you also wanna put a helmet on 'em.
You don't want them to have a pet injury if they're learning how to ride, but you expect them to scratch their knee. You expect them, to fall a few times. And if we were going to do, there's, there's so few times where children in mental health treatment, need to be protected from themselves and there's nothing else you're trying to accomplish that can happen, but it's rare and it's usually very temporary.
So thinking about those spaces as being super sub-specialized spaces that you, will need to preserve, but the remainder of space where you actually want to engage with families and with children should be space that is both reassuring, particularly to parents, and alluring. It should draw you in with a sense of what's possible , with curiosity.
like the best libraries, you know, there's some libraries that can feel static and just like storage boxes and there's others that feel like you wanna explore, like what could be around that corner, what could be up that flight of stairs. So creating a sense of possibility and curiosity.
Soaring, for me, was a word that I came to really naturally because that, you know, for children there should be moments, where the future feels limitless.
That is just a healthy part of development of earliest childhood, and it's still there in adolescence and we want to hook kids in, when, we wanna hook that part of their natural hunger for things they, so that they might feel like this is the place for me, you know, we want kids to actually get to a place where they are, figuring out how to be the hero of their story. And when a child has gotten stuck developmentally because of anxiety or depression or some other problem, they're often not feeling like the hero of their story.
And we, could tell them that they're still heroic or they're great and their parents are trying to do that. And that's actually not the way forward. Like the way forward for them is to rediscover it themselves. for it to be authentic. , so most broadly that's what I was thinking of and I was like, we wanna make this space safe.
It has to be secure, it has to be reassuring, for parents and kids alike. And yet it also has to have parts of it where there's sort of like limitless skies. There's really some wide open spaces in the sort of metaphorical sense.
Bon Ku: So it Ohana is both an inpatient and an outpatient facility, has inpatient beds, and can you speak on some of the design features that accomplish this? Like for example, there's a, it's sent around a gymnasium and there's a outdoor fruit and vegetable garden that's
gonna be there as well.
Susan Swick: yeah, yeah, yeah. one of the wonderful architects in the group said that the feeling he had after one of our conversations was that he wanted the building to actually feel like an embrace, and, an embrace of the whole family. And so it contributed to this physical design. maybe we can post pictures if there's a, a link for people
Bon Ku: we'll put in the show notes, some articles that show the space. So, definitely
because it's so beautiful. Yeah, cuz you look at it does not look like care facility.
I mean, it is, it is a place where I wanna just visit and hang out in like,
Susan Swick: Yeah.
Bon Ku: a beautiful museum and Yeah.
Susan Swick: it's also a really unusual space. Like you know, the architects came to a, essentially a circular design
Bon Ku: It's so
curvy. Yeah. I
Susan Swick: It's
Bon Ku: like what?
Susan Swick: So curvy. Yeah. It's like two figure eights sort of laid, you know, across each other. And with the inside is, opened up so that it's a series of like four connecting courtyards.
and, but the outside of the building wraps all around. And so at its end, it's a, it's an enclosed space with, nooks and crannies, and yet it's secure so that kids and actually staff members have lots of options of different parts of the space, where they might find what they.
Bon Ku: Yeah.
Susan Swick: At a given moment, and yet it still is open connected.
So there's visual security, that you can't sort of run away from the courtyards and, and in some ways we're also trying to think a little differently that the building shouldn't be doing all of the work from a security perspective, meaning the building creates possibility, and that what we put programmatically into the building and staff wise that we really are thoughtful about how much staff will we have? How will they be trained? that, that's really our priority in terms of ensuring the safety of, kids and staff. Rather than just saying we need, tall walls and ligature resistant, fixtures and, lots of cameras and alarms.
there'll be some cameras. But, you know, we want, people to drive by the building and feel like, I wanna go there. I wanna go check it out. We're gonna have public spaces in the building
so that when we have educate, we'll have educational programming, we'll have workshops that are for children of all ages who wanna learn about how do you build mental health.
How do you, what does
Bon Ku: yeah. And this, and this normalizes mental health
Susan Swick: Yeah,
Bon Ku: like,
Susan Swick: that's right. That's right.
Bon Ku: I've been, I've driven by so many facilities that
like prisons, they look secure. And you think the message you're sending is like, oh, that's where crazy people go, you know?
Susan Swick: That is the message. Think of scary movies. They're usually, you know, they use, I know there's some scary movies that have been filmed in old state hospitals, like, in Massachusetts, I think one of the state hospitals in Tewkesbury had been used to, to film a horror film. They are effectively, frightening places and they do then I think, anchor an idea about mental illness that we've been working hard to dissolve.
Right? Which is that it is the rare and devastating lot of an unlucky feud.
And that's just not true. That psychiatric illnesses are common. And they are curable. And the corollary and the piece that I always will talk about is that mental health is not the absence of illness. It's not the lucky many who have mental health and the unlucky few who have illness that mental health has to be built.
The same as we brush and floss to build dental health, we have to build our mental health
Bon Ku: And so this space is almost like a, a gym
Susan Swick: Yeah, I love that. I hadn't even thought of that. That's so great. Cuz I always call it like, yeah. I call it mental fitness. So
Bon Ku: yeah, but it's a gym for, the pediatric population, but it's also a gym for the community cuz you're inviting them in as, as well. And there aren't those spaces.
That where the community can see is like, here's a place where we could build our resilience.
Susan Swick: That's right. That's just right. And, you know, childhood and adolescences are where we are naturally building our mental fitness, the same as we build our, immune systems primarily during childhood. That's why you get asthma usually as a child, cuz when you're in preschool and you get all those illnesses, all those viruses and a few bacteria you start building up.
That's how your immune system naturally, you know this and, but like that's how we expect kids to be sick all the time when they first go to school. And we know it's better to get chicken pox when you're four than when you're 40.
We are building our psychological immune system, our mental fitness in childhood adolescents and young adulthood.
But the truth is we are always building it. It's, that's primetime for building it
Bon Ku: I don't remember learning this at Medical School, this concept, but building the immune system of our mental health.
Susan Swick: No, it's not really commonly the way we think about it within psychiatry either. First of all, why would it be any different? we have a biological protoplasm and we get exposed to a stress, right? A viral infection, and our immune system learns to recognize it and respond.
So in the same way as a six-year-old, when you're kindergarten, you get exposed to a new psychological stress, right? of someone took your toy at school, and you have to figure out. How to manage that conflict, right? Maybe you grab the toy back and someone yells at you and you get in trouble and then you feel ashamed, and then the teacher says, but that's okay.
You, why don't you try to find a way to use your words and not your fist in solving the problem? And that that is actually how we grow. And it's not that that kid is a bad kid because he took his toy back. That child was trying to figure out how to manage the challenge of two people, you know? And limited resources.
And those are skills that children only build, just like learning to ride a bike by doing it. and it goes faster and better when you have caring adults in a child's orbit, especially if they are able to sometimes step back. And let kids lean in and learn themselves and then know when to intervene and offer support.
But we don't, we haven't really thought about, I mean, psychiatry has not, since Freud said mental health was like the ability to love and work, we really kind of let it go. After that, we were kind of like, yeah, that's a pretty good definition. We haven't thought about. I mean, and medicine generally I would say has not prioritized defining health, you know, until maybe there have been, a lot of popular interest in how to protect, promote, and define health, whether it's around nutrition, exercise, sleep, and we can say things about cardiac health. You know that like you don't think you have good cardiac health just cuz you haven't had a heart attack. You think you have cardiac health.
If you know that you can, run five. Or that you, your ability to do that has gotten better and better. Or if we're gonna test it, we're gonna give you a stress test, right? And see how your heart performs when you stress it physiologically, and how quickly does it recover. That's mental health too.
right? Mental health is your capacity essentially to manage and master adversity. And there's different kinds of adversity. There's internal adversity, there's distress, pain, confusion, uncertainty. There's really mild adversity like boredom and really intense adversity like grief. And there's environmental adversity, interpersonally like conflict.
Other kinds of environmental adversities, like broader frustrations or maybe structural racism or trauma, or being stuck in traffic , which in some ways is an environmental stressor and an internal stressor, right? Whether or not you can manage distress. So to the degree, I mean, one of my real goals is to try to offer , a simple and digestible framework. This is where I think psychiatry is not done. We could do a better job where, when we try to think about what is mental health? We fall prey to trying to be as thorough and complete as possible. And we've written here, I'll show you this book.
We've written books. You're in Philly, so like Marty Seligman's. Marty Seligman is a psychologist of Penn. He's incredible and like the father of positive psychology and of health, but this is like his book on like character, strengths and virtues. But it's, as close as we come to a book on mental health.
No one's gonna read this,
right? No one's,
Bon Ku: and you're showing me, a huge book that's like probably a thousand pages, like
Susan Swick: like, it looks like a dictionary, right? It looks like a dictionary. and it is, I mean, to be fair, it's a reference, but, we need to make it as simple as brushing and flossing. We need to make it as simple as saying, here are the three or four building blocks of mental fitness.
and you are creating your own narrative, your own story, your own personal self. But these are the basic building blocks of fitness that are gonna help you to fully realize then what is particular about you. You know, exploring interests, building relationships, leaving a trace in a way that you find meaningful.
Bon Ku: I think it's just fascinating that the Ohana Center is a physical representation of how you are challenging these conventional norms about mental health, right? I mean, you are challenging the conventional norms of what a mental health facility looks like, even like there. I mean, it is. Extraordinary.
There was nothing that I've seen like it. That's why when I saw images of this, I was thinking, what is this? Who is creating this and designing this? And, and even the spaces for the, for the staff, which I love because, there's a stat that I read that a third of, behavioral health caregivers, quit right?
Susan Swick: Yeah.
Bon Ku: turnover.
Susan Swick: Very high turnover
Bon Ku: and the architects intentionally design spaces for staff, right? There's like some like private outdoor patios or something like that, or, and I think that's so important because I look at our emergency department staff, like we don't have spaces where we could decompress. we don't have spaces to take care of our own mental health, and that's common among many units across many hospitals because there's such a pressure that every square footage is for clinical care, Is used to put a patient in, in a room.
Susan Swick: No, that's huge. And we, we thought a lot about that. I mean, I, well, I'll start with staff, but you made me think about something with the building too, which was about how people process images so much faster than they process words. and that we in psychiatry are, we're really word focused
We're, we're talking profession. My kids are like, you're the talking doctor. And sometimes, sometimes we want you to put your license away. But where there are images that capture some of the things that we're trying to communicate with words, it's so much more potent. and people have a reason to stop.
It's critical where part of what we're trying to accomplish, I guess, is a paradigm shift. and prevention only works if people, if there's uptake. Right? Brushing and flossing only work if people do them. , like you can educate people and say, Cavities are terrible and you, these are the only teeth you get after the first set falls out.
So you wanna keep 'em because cuz false ones are really a pain and they're a little uncomfortable and it's nice to have your own teeth. So here's what you have to do and people might, you know, we, if we know something about behavior, we know that people can actually believe you. They can take in cognitively the fact of what you're saying and it will not change behavior.
You have to give it a hook. You have to either make the behavior implicitly rewarding, it has to feel good or smell good, or include time with people you really like, or the payoff has to be immediate. Part of the payoff has to be immediate. So you're like, well, you brush your teeth and it tastes good, or it gives you good breath and people like talking to you.
Bon Ku: hmm.
Susan Swick: So you have to find ways to hook people. To the degree that our hook could be, the space that we're in is immediately gratifying its implicitly engaging. It's so much easier than telling people what's good for them. It's potent, it's potent. And for staff, you're, I mean, you're right.
Uh, the rates in behavioral health of burnout and turnover are as high as they are in emergency departments, which is pretty high.
Bon Ku: Yep. only exacerbated by the pandemic.
Susan Swick: ugh. Well, and I think the pandemic has done two things, right? It's made the demand much higher and our connections to our colleagues more tenuous. Particularly when all of our work for those that started doing all, virtual work, it, worked pretty well in psychiatry compared to emergency medicine, for example. And our colleagues in surgical specialties couldn't do anything. but that's meant that it has staying power in behavioral health, but it leaves the clinicians stranded on islands of isolation.
And we know that the work, even when we're doing it beautifully, when we're doing it really well, it includes holding a lot of uncomfortable emotions and a lot of uncertainty and clinic. Of all levels of training, whether they are master's level therapists, doctoral therapists, physicians, nurses, need an opportunity for both connection to peers, not just to patients, cuz that's a different kind of connection, connections to colleagues and peers and decompression, there have to be spaces where you can meaningfully decompress.
Bon Ku: you mean the bathroom isn't enough? Cuz that's where I decompress during
Susan Swick: where, that's, I used to joke that. I was like, this is my office. What are you doing in my office? So, And you're right. And look at what the way hospitals used to be built. Really most decompression happened.
I mean, back in the day when people would smoke, people would step outside and have a cigarette in that smoking zone. And that's where decompression happened. we're a step up from that, but we haven't replaced that with, we know that smoking is dangerous for you. Some people still do it, cuz it's very addictive., but we haven't replaced it with. Spaces that can promote brief or slightly more substantial decompression.
So when we were designing this building and creating all these spaces for the patients and for families, we thought of the staff a little bit differently.
and we decided to create, cuz we want the experience to be truly family centered so that in looking at and walking through the building as a family. We want them to feel that they are seamlessly at the center of this experience with staff circling around them in a way that they don't have to conduct.
They don't have to go find the therapist or the social worker or the nutritionist, you know, or all the different referrals that we offer them, that they're gonna get sort of varied through a system. It's not passive, but it should feel intuitive and natural. It should go, it should feel like an. You know, we're like, you're engaged, but you don't have to be an engineer to do it.
It's intuitive. for the staff, we really tried to think about creating staff spaces that would promote connection, collaboration, and the opportunity for recharging, decompression and recharging. And of course people, recharge in different ways. Some people need to have fresh air. Some people need exercise.
Some people need a quiet break. Some people need the bathroom . We have, we have different options, but we created a few central organizing spaces for the staff that feel like home spaces. So we have essentially a, the main staff spaces are living room and we have a living room in the middle of the clinic, and then there's a smaller one.
The building is divided into three levels. The top level where you enter and it's on a hillside and then overlooks a valley in a mountain range. And so it's a naturally sloping site. You enter on the third floor, but that's the top floor and that's the level where there's administration, a big public and educational space.
And then our clinic, and in the center of the clinical offices is the shared staff space, the living room. It's a big living room with big windows and very high ceilings, and it has space easily for 40 or 50 staff members
Bon Ku: Oh, that's a lot of square footage that,
Susan Swick: living room. We gave up. That's right. We gave it up there's a lot that we didn't create space for in our building. We said this is the nice part of being part of a community hospital so that our IT department isn't in the building. Our billing department is not in the building. Right? They still, they exist where they exist at, offsite office parks, where they wanna come to our building to, to hang out.
Um, and they can if they want to, but they get to hang out in the living room. So the living room has like
Bon Ku: I mean, think about how crazy that is. Like that. Oh, other people want to go to a mental health facility
Susan Swick: They wanna hang out in our building and because we have really comfortable collaborative indoor spaces, we have essentially a living room, a kitchen and a dining room and then lots of smaller spaces where staff can retreat to have smaller meetings. But where, our therapy rooms, treatment rooms where individual doctors or therapists will be meeting with children or families.
There's a limited number of them. We only have 16 of them, and we expect to be able to service, probably 6,000 or more unique patients a year. And the way you do that with only 16 individual therapy rooms is clinicians are only in those rooms when they're with a patient.
Bon Ku: Mm.
Susan Swick: at the ed, right? You don't have an office in like room 12 in the ed. That's where patients get put and then the, the doctor or the clinician that's gonna go work with that patient goes to them. It's gonna be the same in our clinical offices. And that when you're done with your three hours of seeing patients that morning, you will go back into a collaborative space, but that.
Creates the possibility of recharging. Mostly it's about work and we have outdoor spaces. We have a sort of a deck that's next to our dining room, um, where staff can sit outside, they can be at a table with others and eating, or they can have a meeting out there or they can sit out by themselves, and just be looking out over the mountain range and getting some air and some sunshine.
Bon Ku: and I wanna play devil's advocate here. And some listeners would go, well, you had a hundred million dollars to do
that, but, but you still had to make tradeoffs, right? So like it did not come the decision to take care of the people taking care of the patients came with trade-offs, right? Because,
Susan Swick: exactly right.
Bon Ku: that square footage could have been used for a clinical space for example, but you valued, the providers and, and you knew that space can help decrease turnover and can help the mental health of the people taking care of patients who are having mental health issue.
Susan Swick: Well, you know, one of the things I say to my team is we're talking about treating symptoms and building fitness, building wellbeing. We can only take care of others if we also are taking good care of ourselves and one another of our communities. We have to walk the walk as well as talk the talk. And we totally had to make trade offs. And it was, it was, you know, we have a theory. We have a theory that doing it this way. We're investing a lot of, you know, time, energy, and, and money in training our staff. So there's a shortage of therapists, uh, nationwide and regionally here. There's a shortage and recruiting and hiring people to move to the Monterey Peninsula to be therapist has been challenging cuz it's expensive here, I mean, it's California plus it's kind of about the same price point as the Bay Area.
so what we are doing is finding those that are already here who've just finished a master's program in social work or marriage and family therapy, and we have pivoted to become essentially a training program. To say If you're interested in working with youth and families and you join us, we're gonna give you your supervised clinical hours, and we are gonna give you training in the evidence-based treatments that we wanna be delivering.
We're not gonna just hope to recruit and hire people that have been trained in those treatments, so we protect some of their time for all of that work and really invest in developing our people. And so it really is important. that it feels like a humane place to come to work. and not just for the expensive therapist, but for every single person.
We really, we have all staff meetings that include, every single member of our team for those answering phones, those ordering supplies, all the way up to the, you know, medical directors and the other child psychiatrists. e Flat In many ways, we are very collaborative, and connected to one another.
And that is, also sort of a, a parallel to what will happen in the building.
Bon Ku: Well, I want to continue this conversation when I visit. I, I would love to visit the space, and I have so many more questions, but I wanna be sensitive to your time. I, I know you are very busy and
Susan Swick: Well, can I tell you one more thing? I wanna tell you
one more thing about it, because the last thing that you made me think about is that this gift gives us a chance to experiment, and maybe learn lessons, hopefully learn lessons that we can share with other communities who don't get a hundred million dollar gift.
So we want the building to support our experimentation, to support our ability to learn. but the truth is, we also thought about this building. So that it could create spaces, where when families left, when they graduated from care, they could find those spaces themselves, whether it is going to the beach as family or making sure they protect time to cook a meal together.
you know, that we, we've created collected eating and food prep spaces for the staff, the patients, and for families when
Bon Ku: Yeah.
Susan Swick: care. you're giving them kind of like mental health exercises that they
Yeah, of course. That we want this to be an extraordinary place, but not the only place where you can feel healthy. we want you to be able to, to start building habits and skills that you internalize and you take them back to your home, or you take them to school or you take them to work, and you disseminate them.
into your community. So in that way, it should be a special and unusual place, but a place that, in its details feels like many other places where, where people could generalize. And our hope is that if we start to maybe happen upon the parts of this that are really critical, both for, staff wellbeing and effectiveness, both in treatment and prevention, we wanna share that, you know, we wanna be able to say, You don't need, a 60,000 square foot circular building to do this work. come here and learn about it. but, maybe making good use of, uh, the cool old Victorian house that the hospital that your hospital bought, and figuring out how to turn it into your, treatment program space.
or, you know, what do you have and how do you create a sense of possibility there? so that's our other hope then we will have truly achieved our mission, I think is not just improving the health of this community, but figuring out, how to do it without a hundred million dollars
Bon Ku: I love that you're open sourcing the design principles for mental
health that can be shared
Susan Swick: Yeah.
Bon Ku: by everyone.
Susan Swick: Yep. No copyrighting
Bon Ku: Yeah, when, when is the official kickoff? So I could plan my visit.
Susan Swick: Okay. Well, you get to come visit. I'll send it to you. So we're, already starting to experiment with our clinical programming, but we're in temporary digs. We're like borrowing a primary, like two, uh, pods of a primary care office building. and we can't wait to be in our building because it, it feels a little like we're wearing an ill-fitting suit because we put so much time and effort into thinking about our space.
Bon Ku: You're testing out the software of the programs
Susan Swick: it. You got it
Bon Ku: the new hardware,
Susan Swick: got it. You got it. You got it. So the building is supposed to be finished on May 11th.
Bon Ku: Wow.
Susan Swick: yeah, then we get to do art. We didn't even get to talk about art, but we really have put a lot of thought into art and into youth art. There's gonna be a whole music center. cuz the idea is that helping people to do procedural things that are creative, challenging to do well that you can practice and you practice with others or by yourself. We're, really putting that into the space, but, all those installations will start happening, and we expect the building to open in July, sometime in July.
Bon Ku: Amazing. Well, I thought we were just gonna talk about this space, but I learned so much about mental health and resilience and, this is fascinating. thank you Susan, so much for your time.
Susan Swick: what a pleasure to spend time with you. Bon. I can't wait to come out and look at your ER and have us imagine how do we bring, you know, our architecture firm has a neuroscientist that works there. And so they had
a lot That's so cool. And they had all this about, just even about aromatics, about what are the plants that you plant, that are the most potent, in, activating certain parts of your immune system that seem to predict wellbeing and health. And, know, it includes rosemary and lavender and all the, all the things that just grow wild out here. It's a little, it's a little crazy out here.
Like that's the part that's unfair. Like it does smell really good out here. ,
Bon Ku: Yeah. And, And, and, then I forgot to talk for the listening audience and, just look at the images of this because it is one of the largest healthcare buildings to use, timber.
Susan Swick: Yeah.
Bon Ku: it, it doesn't feel very, when you think of hospitals, it's like stainless steel,
like
Susan Swick: feel like cement and, yep, not concrete and cement.
There's a lot of glass. ,but it's very soft. all of the walls where there isn't glass, there is wood. And in fact, even on the sort of curving glass walls, there's slats of wood. So that we're letting in light without letting in as much direct sunlight so it doesn't feel like a greenhouse.
House. and it looks inviting from the outside because there's so much timber and there's a beautiful history on this peninsula of, timber frame and, and stonework, buildings,
Bon Ku: I'm drooling right now.
Susan Swick: But it's, it, it sits comfortably in this, community, there's a lot of timber, and it's a little, you know, we also had to be really careful with the design because we're aware of the risks of wildfires here and of course of earthquakes. So in its heart, it is protected, it's protected against those risks.
but it also, it looks so comfortable. It looks really soft, warm, approach.
Bon Ku: Hmm. Well, well, thank you Susan. This was so much fun.
Susan Swick: Oh, Bon. It was a delight.
Bon Ku: I was so inspired by what Dr. Susan Swick is designing and creating how she's really challenging the paradigm of mental health. if you want to donate to Dr. Swick’s work, There is a link to do that in the podcast Show notes. Reach out to me on Twitter at B O N K U on Instagram at D R B O N K U.
Design Lab is produced by Rob Pugliese, editing by Fernando Queiroz, theme music was created by Emmanuel Houston and the cover design by Eden Lu. See you next week.
