By Dr David Laing Dawson
In the late 1960’s through the 1970’s I was one of many who worked to unlock the doors of psychiatric wards. We were, after all, highly influenced by the idealism of those years. And to a large degree we succeeded. At least here and there. At least until this century when they began to be locked again.
Suicide was never the main concern. An actively suicidal inpatient had already come to the hospital (which meant he or she wanted help) or had been brought to the hospital (which meant he or she had let their “intentions” be known to someone, and thus, at least partially, welcomed intervention). Besides, we still had seclusion rooms and one on one staffing to watch over such a person while we waited for the treatment to take effect. And usually it did. In fact, the highest suicide rate of any demographic is during that first year post discharge from a psychiatric ward. And usually (with some autopsy evidence to back up this observation) after they stop taking their medication.
An elopement followed by an act of violence was the real concern with unlocked doors. In theory and practice, we need but recognize that potential for violence in timely fashion and quickly institute treatment for the underlying illness, usually a psychotic illness, usually very treatable.
Still, that was the fear. And that fear encompassed our fear of failing, or making a mistake, of the consequences to a victim and the patient, of the community reaction, and of any legal repercussions. Not to mention the frustration of the police who had just apprehended and brought this man to hospital last week and now were looking for him again.
And there is another day-to-day reality. On a ward of 20 or 30 patients there might be only three or four of concern. One might be demented, confused, and likely to wander, perhaps over to the pediatric ward. Another might be actively psychotic and still talking of revenge. And another might be planning a break to acquire drugs. Another, a teen or youth, might simply want to go partying with his friends and be bridling at any restrictions.
So each day the ward staff would have to decide to keep the door locked or not, or place a nurse or security person on the door through the day and lock it at night. Or put each of these three or four at-risk patients on one-to-one staffing. And each of these solutions, save the permanently locked door, is expensive. And sometimes that number of worrisome patients might exceed 50% of the total with insufficient staff to assign one-on-one.
Statistically an elopement from a psychiatric facility, locked or not, followed by an act of violence is very rare, but always news worthy. Far more often the act of violence is committed by someone who should be in a psychiatric facility receiving treatment but is not. (Vince Li)
Elopements from psychiatric facilities, whether locked or not, are usually followed by inconvenience, folly, worry, drama and comedy. The whole human condition. Here are just a few of my experiences:
One evening the ward calls me at home to say William has eloped, and then he has phoned the hospital from a pub to say he is suicidal. I drive 30 miles in a rainstorm, find him in the pub, buy him and his newfound friends a drink, and drive him back to the hospital.
She has been divorced 20 years, but is now a little manic. She elopes. I am called by an irate ex-husband who tells me he arrived home to find her naked in his bed with a bottle of champagne. I cannot help but chuckle at the image; he tells me it is not a laughing matter.
The young man has been gone a few days. We worry about him. He has some unhealthy attitudes about the police. He is also manic. The police bring him back to the hospital. They found him making a loud and rambling speech from the roof of the police station.
She elopes. She is gone a few days, and not returned to her home. We receive a call from a psychiatric facility 400 miles away. Traveling on a Grey Hound Bus she had threatened suicide and been dropped off at their hospital. At our expense they would send her back.
He eloped from the open door facility, having refused treatment for his bipolar illness. He went straight to the Vancouver Aquarium, jumped in and swam with the Orcas, which attracted much attention, and then gave a press conference for some Vancouver reporters.
On the other hand, another woman suffered from depression but appeared much better now. Her husband said he wanted to take her home for the weekend. This seemed to be a reasonable step in her recovery. But on that weekend-leave from the hospital he took her to visit Niagara Falls. She jumped to her death.
Doors locked or unlocked or partially locked or locked at the discretion of the staff. It has, I suppose, very strong symbolic meaning.
But a psychiatric facility is a world of illness, despair, insanity, confusion, risk, drama, worry, folly, comedy and tragedy. A world of decisions being made about people’s complex lives with limited tools to do so, sometimes with limited information, often with limited staffing. A world in which we now have effective treatments but a myriad set of rules restricting their use. A world in which the staff are asked to keep everybody safe, but with the least possible restrictive methods. A world in which questions of civil liberties, freedom from illness, the right to refuse treatment, the right to be insane if not harmful, the right to unrestricted movement, the right to die – it is a world where all those profound issues are debated every day, and not merely as theory.
I am no longer as concerned about a locked or unlocked door as I once was. As long as everybody is doing their best to care, to protect, to keep safe, to reduce harm, to comfort, and to treat mental illness. And as long as we have hospitals and staff to do this.