Medicine: Open Door in Psychiatry

The women patients in ward 37 at New York’s St. Lawrence State Hospital, overlooking the seaway then abuilding, were all agitated and ill at ease, and one was frantic. A housemaid from Alabama by way of Chicago, she rushed up to the nurse supervisor, shouting: “Mrs. Holmes has gone crazy—crazier than we are—she won’t lock the door!” As a matter of fact, Attendant Irene Holmes was doing just what the doctor ordered. First, the doors of individual wards, then of whole buildings, were being unlocked and left unlocked for lengthening periods up to twelve hours a day.

For a day or two, the unwonted freedom seemed also unwanted. Patients like Housemaid Anna, who had been in the hospital for ten years, did not know what to make of it. One man had devoted most of his waking hours during 20 locked-up years to testing every door on his ward, trying to get out: when he found them all unlocked, he refused to leave, for fear that he would not be able to get in again. It took him two weeks to get used to the return of freedom.

Out of Sight . . . What had happened at St. Lawrence was a dramatic and belated revival of what is essentially an ancient idea: the mentally ill are sick, but still people, and they must be treated as people, if they are ever to return to society. For several centuries B.C., some Greek temples were maintained as retreats, where the emotionally disturbed could recover in a calm and restful atmosphere (“milieu therapy” in the jargon of today’s psychiatry).

Advantages of the system, with reduction of physical restraints, were widely recognized and discussed in the 1870s by the American Psychiatric Association. But in North America, as in much of Europe, this was the twilight of a new Dark Age for the mentally ill. More and more of the mentally ill were herded into gigantic barracks, usually out in the country, to be out of sight and out of mind.

“Security” was the watchword for more than half a century in 99% of both public and private mental hospitals. Gates were guarded to prevent escapes. An attending doctor or nurse had to go through what Dr. Herman B. Snow, director at St. Lawrence, calls “the ritual of the key” to enter a building. Then, jangling a fistful of hardware, he had to repeat the ritual at the door of every ward, at every staircase and elevator. That this security fetish is an illusion is shown by St. Lawrence’s experience: it never had many escapes compared with most hospitals, but now has only half as many as previously.

Worse even than locked doors was the intimate desocialization and dehumanization of the patients. On admission to most hospitals, they were stripped of their own clothes, allowed only shapeless, unbelted robes and floppy slippers. Wristwatches were locked up (the crystals might be broken and used in suicide attempts). Eyeglasses were removed at night because of the same fear. Even wedding bands were sometimes taken away (the patients might swallow them or drop them down the toilets). Men could not shave themselves. Bathrooms were locked, and patients could not go to them unattended. Knives and forks were banned from the dining halls, so patients had to eat with spoons. No smoking was allowed. Ward windows were barred and curtainless. There were no mirrors, no flower vases, no plant pots, no bottles, no water glasses.

The Sick Society. Only an insignificant number of patients were disturbed enough to justify a fraction of these precautions. It was society itself that was insecure and full of irrational fears of what the mentally ill might do.

The break with insane traditions fostered by the supposedly sane came around midcentury, was pioneered by Dr. Duncan Macmillan at Mapperley Hospital in Nottingham, in England’s Midlands. His program was virtually duplicated by Drs. Thomas P. Rees and Maxwell Jones at two hospitals in London suburbs.

Dr. Robert C. Hunt, born in Egypt of U.S. missionary parents, was assistant commissioner in New York’s department of mental hygiene in 1955 when he went to Europe and first saw open hospitals, including Mapperley. Says Dr. Hunt now: “I saw and was converted. It was like scales dropping off my eyes.” In 1957 he became director of Hudson River State Hospital on the edge of Poughkeepsie, 80 miles north of New York City. Of its nearly 6,000 patients, only 16% were then in open wards.

Not Iron Bars Alone. Says Dr. Hunt: “Our ‘humane’ practice may be almost as brutalizing and degrading as those of past centuries. It is a rare patient now who suffers cruelties to the flesh, but restraints on the human spirit cannot be measured in terms of iron bars and canvas straps alone. They derive much more importantly from the attitudes of people around the patient. For too long, as Maxwell Jones puts it, we worked on the unconscious belief that ‘the role of the patient is to be sick.’ If he senses that we expect him to be suicidal, or try to get away, or to be violent, he will oblige us. The open door is a symbol of our new-found belief that we expect patients to get better. It is only a symbol and not a panacea. It must be used in combination with every other form of treatment we know.”

Dr. Snow, 50, had got a head start at St. Lawrence, partly because it is the smallest of New York’s 18 state hospitals (never more than 2,300 patients), partly because it is the biggest employer in Ogdensburg (pop. 17,000). Many city officials, including the mayor, are on the hospital staff. Ogdensburgers pay little attention when patients with downtown privileges wander through the stores. For Dr. Hunt at Hudson River, it was tougher. Poughkeepsie (pop. 40,500) is all but surrounded by custodial institutions, some for violent criminals, and the people of Dutchess County have a horror of escapes. But Dr. Hunt now has 96% of his patients in unlocked wards.

New Freedom. “There is a spectrum in ‘freedom’ and ‘open’ doors—they are not absolutes,” says Dr. Hunt. “Doors are open, and some patients can come and go freely, but some are so disturbed that an attendant will ask them to wait for a little talk. The important thing is that they are asked to stay in, not physically restrained. Patients on shock treatment are asked to stay in on treatment days, for their own safety. They understand. In all, 80%—or more than 4,000 patients—have full freedom of the grounds, unsupervised, some part of the day, and about 60 have downtown privileges.”

When Dr. Hunt began opening more doors and taking bars off windows, Dutchess neighbors were worried that AWOL patients would commit sex offenses or crimes of violence. In two years, there has been no such incident. Now Dr. Hunt challenges civic groups: “What Dutchess County community of more than 5,000 people has a better record than that?”

Noise in the Sky. At St. Lawrence, soon after one of the wards was unlocked, one patient returned leading another, who was limping. The explanation: “We heard a noise in the sky. We had heard of airplanes, but could never see one from the closed ward. We got so excited looking at this one that we didn’t look where we were going, and Amy fell down.” A man kept going to the parking lots, sitting in unlocked cars. Eventually, he broke a silence of years to explain: he could not imagine how a car would work without a gearshift lever on the floor.

A striking feature at St. Lawrence, which is now 100% open, and in varying degrees at all New York’s other state hospitals (average: 66% open), is the transformation of the wards. Gone are the dreary wooden benches, where patients dressed in Mother Hubbards (when they were not undressing themselves) sat listless, sometimes in their own excrement. Instead there is modern, comfortable furniture. Windows, no longer barred, have gay curtains or draperies with drawstrings. Instead of glaring ceiling lights, there are bridge and table lamps. Glass vases hold cut flowers. Plant stands are loaded with potted violets. Glass tumblers and bottles—potentially lethal weapons—are all over. Each ward has its full-length mirror.

Patients carry matches and lighters, wear wristwatches. Only rings of exceptional value are locked up for safety’s sake. Women use knives freely when cooking in individual ward kitchens, are allowed scissors for sewing. They use electric washing machines, dryers and irons. Men shave themselves in the ward barber shop (though attendants change blades in safety razors), and have full access to cutting and gouging tools in the craft shop. If anything, says Dr. Snow, there are fewer accidents and fewer suicide attempts nowadays.

Near to the Norms. Across the U.S., almost a dozen states are experimenting with open doors, from those unlocked only an hour or two a day to those flung wide throughout the daylight hours. In the early ’50s, Pennsylvania rejuvenated its Embreeville State Hospital near Philadelphia, opened its doors in mid-1956. Says Dr. Eleanor R. Wright: “We’ve had fewer escapes than when the doors were locked. It may not be the best system for every hospital, but it works for us.”

In California, the system got off to a whiz-bang start when Dr. Harry A. Wilmer, inspired by what he had seen in England, began to apply it at the U.S. Naval Hospital in Oakland. There, young fighting men in prime physical condition were carried in, often in a straitjacket and leg straps, sometimes with as many as six terrified corpsmen holding them down. Each time, Dr. Wilmer said quietly: “Get him out of those things.” Staff members protested at first: “But what if he attacks us or another patient?” Confidently, Dr. Wilmer answered: “He won’t.” And no patient ever did. In this “therapeutic community,” the patients lived up to the staff’s revised expectations—”to function as near to the norms of society as possible.”

A hundred miles to the east, in the midst of California’s San Joaquin Valley, is Stockton State Hospital, opened in 1853. The city (pop. 85,000) has engulfed the hospital with residential developments; a high school now stands across the street. Main job of the security officer on the unfenced hospital grounds: to keep rambunctious youngsters from annoying the 2,500 patients. (An annex, five miles out of town, holds 1,500 more patients.)

Internal Controls. “Opening a door isn’t an end in itself,” says Stockton’s Superintendent Freeman H. Adams, 48, “and it must not be used as a device for the staff to shed their own guilt feelings and spread the patients over a wider area—from the wards to the grounds—without doing anything more for them.” Doors are open at various times of day for 1,850 (or 45%) of Stockton’s patients; 68 of the women may go downtown any time, and Dr. Adams realistically declines to issue town passes for the men, because so many (out of 618 with ground privileges) go there without a by-your-leave. It would be easy, says Dr. Adams, to make a better statistical record by unlocking more doors, but it would be meaningless for 1,000 aged patients, mostly bedridden.

Nowhere has a greater effort been made than at Stockton to get patients to develop self-control and some degree of social control over their fellows; e.g., patients act as door monitors, stop others who are too disturbed to go out. Especially striking are the wards’ “town meetings.” In the least disturbed women’s ward last week, two patients volunteered to stage a psychodrama, one acting the submissive wife (her real-life role), the other playing the domineering husband. From patients aged 18 to 78 came keen comments and criticisms, many showing remarkable psychological insight. At the opposite extreme, in the most disturbed women’s ward, some patients had to be led away from the meeting because they caused too much commotion. Even here, each patient rose and began with a punctilious “Madam Chairman,” addressed to one of their number whom the patients themselves had picked. Clearly evident was strong social pressure by the group to make laggard members develop their own “internal controls” more fully.

Locked Out. Private hospitals are generally even more reluctant than the states to unlock doors, for fear of damaging incidents and lawsuits. Yet in San Francisco, at the opposite extreme in size from the giant state hospitals, a tiny (14-bed) unit at Stanford Hospital* applies the open-door system with outstanding success. “When we speak of patients as being ‘locked up,” says the psychiatrist in charge, Dr. Anthony J. Errichetti Jr., “what we really mean is ‘locked out’—we are using lock and key to exclude them from society. When we used to put a patient in seclusion, he remained as agitated as ever—only the staff was tranquilized.” Here, the seclusion room is used only when the patient himself says he wants to go there to be quiet and have a chance to calm down.

The open door on the second-floor psychiatric ward of this old (1908) building does not mean freedom to walk in and out at will—any more than a patient in the adjoining medical or surgical wards can do so. But nobody is restricted because of mental illness alone: he must show definite signs of disturbance. When he does, the patients (at daily meetings) are usually the first to complain of it, vote to restrict him “behind the clock” (on the boundary wall between ward and corridor). It is by the patients’ own decision that razor blades and pointed knives are not left in accessible places on the ward. Collectively, at least, the patients’ internal controls are excellent. Adds Dr. Errichetti: “And every member of the staff has had to learn to control his own insecurity and paranoid feelings.”

It will take a generation or more to clear the state hospitals of the backlog of patients permanently crippled by old-time procedures that, far from making them better, helped to make them worse. But seclusion rooms are being converted into kitchenettes and beauty parlors; camisoles and straps are disappearing. Shock treatment is seldom used, and only for selected patients. Though admission rates are rising, release rates are rising faster, so that in many states there is a net decrease in the numbers of mentally ill confined to hospitals.

“While the open door is no cure-all,” says Dr. Hunt, “it is the most important thing that has happened in treatment of the mentally ill in our lifetimes—not even excepting the ataractic drugs. With this, we can prove to the public as well as ourselves that incarcerated madness is really unnecessary.”

*Formerly Stanford University Hospital, but cut adrift when the university moved its medical school to the Palo Alto campus (TIME, Sept. 28).