Psychiatric Hospital Design and Security Part Three

By Dr David Laing Dawson

I was going to write about my continuing search between (1970 and the present) for the answer to Marvin’s question but I decided to cut to the chase. I worked in Fulbourn Hospital for about 8 months in 1970 and 71. Yes, the Therapeutic Community idea is not effective treatment, but it is a way of returning to psychiatric inpatients at least some sense of power and control over their own lives.

While Pat F. recounts a couple of escapes from the unlocked wards of Fulbourn, they are chaotic and frightening events but not tragic. I have been there.

What research there is on the subject actually shows that suicides and escapes leading to tragedy are actually less frequent in unlocked wards. The act of locking the ward does enhance the urgency of fight or flight.

Anecdotally I have been very convinced of this. The very modern hospital of which Marvin writes, with all its high tech security, has a vastly poorer record of suicides and violence than its old mental hospital predecessor, the Hamilton Psychiatric Hospital, with mostly unlocked doors, at least between 1985 and 1995.

Even when psychotic we respond to the messages of our physical and social environment. In the development of the programs at the UBC hospital in 1969 we argued at length about the wisdom of carpets during those years everybody smoked everywhere, having seen the marks on old linoleum floors. And we found nobody ground out a cigarette on carpet. They used the ash trays provided.

But there are complex forces at work, especially today. Societal expectations pushing in conflicting directions: On one hand expecting absolutely no risk and complete safety for the public, on the other hand idealistic about individual human rights to the point of denying the existence of mental illness and incapacity.

With most mental hospitals, including HPH and Riverview, there were expansive grounds to walk upon, to sit in quietude, to blow off steam, after prematurely leaving a ward. In fact sitting parallel on a bench under an oak tree is a fine and safe place to conduct a therapeutic and de-escalation intervention.

On the other hand a patient running from the locked or unlocked psychiatric unit on the fifth floor of a general hospital can create much havoc and fear going through a surgical or pediatric ward before getting to the front door.

And lawyers. And risk management committees. And unions. And more lawyers.

But Ill fated de-institutionalization may have made the issue partly moot. In 1954 the largest mental hospital in the U.S. housed 13,875 patients. Today the largest mental health facility in the US is actually a wing of a county Jail in Los Angeles. You can be sure its doors are locked.

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