An Argument for Environment as an Evidence-Based Practice
Michael D. Rosberg, Ph.D.
ASC Treatment Group
Mental illness is often a topic in the news, the media, and within our communities. When people talk about treating serious mental illness, we often get questions such as “can you really help those people?” Those conversations usually turn quickly to the medications people take, the therapy or long-term care they need, the hospital stays, the legal consequences and arrests, and the emergency units that are clogged and inaccessible. These services matter. They protect and help real people. But anyone who has worked in this area long enough knows that medication and therapy alone do not explain why some people stabilize and improve enough to rebuild their lives while others cycle in and out of hospitals for years.
Within our group, the ASC Treatment Group, we think a large part of what accounts for the difference is the environment itself, and the people providing the services. The place where a person lives, the rhythm of their days, the people around them, what they see, hear, and do from morning until night.
A field with better tools than ever
A well-known psychotherapist, Milton Erickson, once said, “my voice will go with you,” a reference to the power of the metaphors his methods provided. The participants in our programs, people struggling with significant and competing problems, often take very little with them at the end of the day. The medicines they take and the environment they live in are what endure, and what most shape their treatment, their adherence, and their potential recovery.
It is widely acknowledged that we have the best resources we have ever had to provide treatment services for these problems. Medications are the most studied and validated treatments. Psychotherapies are also better defined and better studied than they once were. Antipsychotic medications in particular are more tolerable, though they remain far from perfect standalone solutions. Coordinated specialty care, community based wraparound services, supported employment, family psychoeducation, and cognitive remediation all have strong evidence behind them. And yet the people moving through the system are not recovering any faster than they did in the 1970s, 80s, and 90s. The gap between what the profession knows and what people experience remains painfully inconsistent.
Discontinuity of care explains some of this. People lose access to providers, programs change, insurance shifts, housing falls through, and the thread of treatment breaks. But there is another reason, less often named. Research on medications and psychotherapies is, by comparison, robust and well funded. Research on the circumstances and environments in which people with difficult and chaotic problems actually live is comparatively thin, and even where it exists, it is rarely treated as central to evidence-based practice. Our premise is that evidence-based best practice should include all available practice options that affect outcome, and that the design of the treatment environment and the style of service implementation are critical partners in either success or inconsistency.
What we mean by “environment”
At the risk of oversimplifying, imagine two rooms. One is loud, crowded, brightly lit, and unpredictable. People come and go. Voices overlap. There is little to do but wait. In contrast, another option is quiet, but not empty. There is a garden outside. A few people are cooking together. Someone is painting at a table by the window. A pet wanders through. There is structure to the day, and also choices.
Most of us would feel different in those two rooms. For a person living with a serious mental illness, that difference is not a matter of choice or comfort. These rooms and facilities are chosen for them. The fit between the person and the setting is often the difference between being able to participate in their own recovery and not being able to. It is not hard to understand why so many reject treatments that, however well intended, ignore or invalidate the person at the very center.
What other fields already know
Almost every other field that designs spaces for human beings has spent the last several decades taking this seriously. Architects, retailers, schools, workplaces, general medical hospitals, hotels, and airports have all absorbed the research on human centered design. Light matters. Acoustics matter. The presence of nature matters. So does control over one’s immediate surroundings, the ability to choose where to sit, when to be alone, when to engage. Businesses invest in this because they know it affects how people feel, how they perform, and whether they come back.
Mental health treatment for people with serious and persistent illness has been slow to catch up, though that is beginning to change. A growing body of work in inpatient psychiatry, trauma-informed care, evidence-based design, and therapeutic landscapes points toward design principles that support recovery rather than simply contain crisis. Liddicoat et al. (2020) have proposed a set of principles for the built environment of mental health services, drawn from research across psychiatry and adjacent fields, that emphasize safety without institutionalization, access to nature, opportunities for both privacy and contact, and design choices that communicate dignity rather than custody. A recent systematic review by Rodríguez-Labajos et al. (2024) likewise concluded that the built environment can function as a therapeutic intervention in mental health facilities, though the authors are appropriately careful to note that the direct outcome literature, while suggestive, is still developing.
The research is generalizable. It applies as readily to a residential treatment program as to an office or a clinic waiting room. The people who arguably need the most thoughtfully designed environments have, in many cases, been given the least. The tools for closing this gap already exist. We do not need to invent the science so much as commit to applying it.
A related and useful concept comes from nidotherapy, from the Latin nidus, meaning nest. Nidotherapy aims to identify the need for, and make changes to, a person’s environment and surroundings. It works alongside other treatments to improve a person’s well-being, housing, relationships, work, and other factors. The aim is not to change the person but to create a better fit between the environment and the individual. As a consequence the individual may improve, but this is understood not as a direct result of clinical change so much as the natural outcome of a more harmonious relationship with the surrounding world. A Cochrane review of nidotherapy for people with schizophrenia (Chamberlain & Sampson, 2013) found that randomized evidence is limited and that further trials are needed before strong conclusions can be drawn, but the concept itself remains clinically intuitive and consistent with what staff observe day to day. Naming it gives the work language.
Patterns worth noticing in our own work
It is easy to picture the chaotic ward and recognize it as a setting that works against recovery. Some of the environments that fall short of their goals, though, are ones built with real care and intention. Pointing this out is not meant to disparage the effort behind them. It is meant to widen the definition of what counts as evidence-based practice.
A day packed with back to back groups, activities, and skill building sessions can be just as overwhelming as an empty one. For a person whose attention and emotional regulation are already taxed, a well meaning schedule with no breathing room can produce the same shutdown, withdrawal, or agitation as a setting with nothing to do at all. Stimulation is not the same as engagement. Behavioral therapies, too, can be experienced as punitive, undesirable, or overly rigid, even when the underlying intent is supportive.
A subtler pattern involves behavioral systems that begin as reasonable structure and gradually become something else. A program sets clear expectations. A client struggles to meet them. The response is to tighten the structure. More rules, more consequences, more restrictions on what the person can access. The client, already dysregulated, responds poorly to the tightening. The tightening tightens further. Access to the things the person actually wants, a walk outside, a phone call, a familiar staff member, a preferred activity, becomes contingent on behavior they are not currently able to produce.
What started as a behavioral plan can drift toward something closer to withholding. It is almost never one person’s decision. It happens through small, defensible choices made by people who care. A shift change. A team meeting. A new restriction added because the last one didn’t work. Most are acting in good faith. The result, over weeks or months, can be a person increasingly cut off from the very things that might help them organize themselves, and a staff increasingly convinced that the person is the problem.
All of us who have worked in this field have participated in patterns like this. Recognizing them is not an accusation. It is a precondition for treating the environment as a variable we can adjust rather than a circumstance we cannot.
Behavior responds to surroundings
Psychologists sometimes talk about operants or operant conditioning, terms that sound technical but mean something simple. An operant is anything in the environment that shapes behavior by responding to it. If you water a plant and it grows, the growing is feedback that shapes whether you keep watering. If you say hello to a neighbor and they smile, the smile shapes whether you say hello tomorrow.
People are constantly shaped by the small responses of the world around them. This matters even more for people whose attention, motivation, and emotional regulation are already strained by illness. A setting that offers steady, meaningful, manageable feedback, a garden that needs tending, a meal that needs preparing, a peer who notices when you show up, gives a person something to organize themselves around. A setting that offers nothing, or chaos, or a system of rules that keeps moving, gives them less to work with.
Why this matters for treatment
Much of what we already know about helping people with serious mental illness loses traction in environments that work against the very behaviors we are trying to encourage. We ask, and sometimes demand, that people engage, then place them in environments that are themselves disengaged or disempowering. We ask people to calm down, or to regulate, but surround them with noise and unpredictability. We ask them to participate in their self-care, but leave them in environments that do not reinforce desirable options. We treat them as patients to be managed, rather than as people with something to decide and contribute.
The settings ASC has built serve as alternative examples, sometimes approaching desirability in ways residents and staff both recognize. They include gardens, kitchens, art rooms, animals, quiet spaces, and communal areas that invite contact without forcing it. These are part of the treatment. They give residents real things to do, real responsibilities, real reasons to show up the next day. Over time, showing up becomes a habit. Habits become identity. Identity supports recovery.
A culture, not just a program
When several people in a setting are engaged in their own recovery, that engagement becomes contagious. New residents see others tending plants, cooking, helping out, and they begin to do the same. Adherence to treatment stops being something staff have to enforce and starts being something that simply happens, because that is what people around here do.
This is what we mean when we say environment is part of treatment. It is not just the building. It is the culture inside the building, and the culture is built deliberately, day by day, by the people who work there.
What this means for the people in this field
If you are a clinician, a mental health worker, a case manager, a family member, or someone just starting in this work, pay attention to the room. Pay attention to the day. Pay attention to whether the people in your care have anything real to do, anyone real to talk to, and any reason to believe tomorrow will be different from today. Medication and therapy will do their part. The rest of the job is building the conditions in which those things can actually take hold.
An invitation to the evidence base
There is growing recognition that physical and social environments influence engagement, agitation, autonomy, dignity, and recovery in mental health care. Much of the supporting literature, however, has been extrapolated from adjacent fields, including inpatient psychiatry, trauma-informed care, evidence-based design, dementia care, hospital design, residential addiction treatment, therapeutic landscapes, nature exposure research, and person-environment fit. Existing work, including the principles articulated by Liddicoat et al. (2020) and the systematic review by Rodríguez-Labajos et al. (2024), supports the clinical and ethical importance of therapeutic environmental design. What remains underdeveloped is the direct outcome literature for severe and persistent mental illness, the rigorous studies linking human-centered residential design to hospitalization rates, medication adherence, behavioral incidents, sustained participation, and community functioning. This is an opportunity rather than a discouragement. Programs like ours, working at the intersection of clinical care and deliberate environmental design, are positioned to contribute practice-based evidence to a field that is clinically intuitive, increasingly discussed, but not yet adequately researched.
References
Chamberlain, I. J., & Sampson, S. (2013). Nidotherapy for people with schizophrenia. Cochrane Database of Systematic Reviews, 2013(3), CD009929. https://doi.org/10.1002/14651858.CD009929.pub2
Liddicoat, S., Badcock, P., & Killackey, E. (2020). Principles for designing the built environment of mental health services. The Lancet Psychiatry, 7(10), 915–920. https://doi.org/10.1016/S2215-0366(20)30038-9
Rodríguez-Labajos, L., Kinloch, J., Grant, S., & O’Brien, G. (2024). The role of the built environment as a therapeutic intervention in mental health facilities: A systematic literature review. HERD: Health Environments Research & Design Journal, 17(2), 281–308. https://doi.org/10.1177/19375867231219031