In the spring of 1969 a new psychiatric facility was opened on the campus of the University of British Columbia, the first component of a full service teaching hospital. This clearly heralded the future of psychiatry and the treatment of the mentally ill, or so I thought: a large outpatient department, space for a day hospital, and small wards for inpatients, wards for only 20 patients each, wide corridors, accessible nursing station, private rooms for some, no more than two to a bedroom and bathroom, earth-coloured patterned carpeting, earth-toned walls, residential style beds, comfortable furniture, warm lighting, pleasant dining room, a sitting area with lounge chairs and fireplace, meeting rooms, no locks on the doors. Even sliding doors to small balconies for many rooms occupying the ground and second floor.
Perhaps there was not quite enough security to manage the most disturbed, potentially violent patients, but it is really a small percentage of the mentally ill who do not respond well to treatment offered in a non-threatening compassionate fashion within a very comfortable environment. The impulse to flee is actually reduced when the door is open. The impulse to say NO is reduced when the treatment is offered gently and patiently. The impulse to rant and break things is reduced when the lighting is soft, the chairs comfortable, the colours soothing, the sounds not echoing off concrete walls. The impulse to hit someone is greatly reduced when that someone is not threatening you.
We were experimenting with forms of something we then called “The Therapeutic Community”, which really meant open meetings of staff and patients sitting in a big circle each morning, discussing everything from housekeeping issues to medications to ward rules and protocols, to the question of whether or not one patient should go off his medications or take more, and if another is ready for a weekend pass. It wasn’t thought of as “the treatment” but rather as a humane and democratic context for treatment, and an environment that would bring out the best in people.
It is true we were reading Thomas Szasz, R. D. Laing, Jay Haley, Erving Goffman, Michel Foucault, Gregory Bateson and all the others postulating that the roots of madness could be found in distorted parenting or unbridled capitalism or imposed social conformity, but you really don’t have to spend much time with someone in a manic state, a stuporous depression or an active schizophrenic psychosis before you know, as a colleague once succinctly put it, “It’s a brain thing.”
My next stop was England, to see first hand a large mental hospital that had eliminated locked doors altogether. Serving Cambridge and the surrounding shire it sat brooding on the fens just as you and Thomas Hardy would imagine, a large winged Victorian mansion with a few marginally more contemporary buildings around it. It was, by North American standards, poorly resourced, under-heated, and I was quickly appointed physician to six wards of forty patients each. But the doors were all unlocked; each ward had its daily community meeting, its occupational therapy programs, good nursing and medical care, grounds to walk on, work to do, social and entertainment programs. It was an asylum, a humane asylum, and proof of a sort that decent psychiatric care did not require modern buildings with state of the art security.
Still, it can be assumed, (and my personal survey supports this) that everybody, every patient, would prefer to live and be cared for in his own home rather than in any kind of institution.
It was 1971. We now had effective treatment for most psychiatric illnesses (not all but most). It was time to build an array of outpatient, community, and home treatment services that might gradually reduce reliance on mental hospitals.