Medicine: Hospitals Without Locks

In Western countries, mental hospitals are big and numerous—yet crowded beyond capacity; they cost too much—yet cannot get enough psychiatrists to staff them. The solution to these paradoxes, says British Psychiatrist Joshua Bierer: tear down most of the hospitals.

With a prophet’s zeal, the modern Joshua who wants the walls to come tumbling down has preached his doctrine more than 120 times in the last three months to hundreds of U.S. and Canadian psychiatrists and mental health workers. Many of his hearers sputtered, “You don’t really mean it!” But Dr. Bierer does. He seriously proposes the wiping out of most of the present mental hospitals, and certainly the big ones where patients are kept round the clock for months and years (though the number of patients in hospitals has been dropping since 1956).

Night Shift. Since 1946, Austrian-born Dr. Bierer has been running the Marlborough Day Hospital in London. Patients come, unsupervised, by public transportation, for a 7½-hour day, and return home at night. Then the night shift comes on: patients who have daytime jobs, and especially those whose family situations have had a major part in their illness. Dr. Bierer will soon open his “shift hospital” for weekend stays as well.

At Runwell in Essex, Dr. Bierer directs a “therapeutic community” of about 20 houses with 40 to 100 patients. He says: “To lock people up. one needs more rather than less staff; to keep people in chains, one needs other people to keep them clean. It is much less expensive to let them walk about and work and clean the place up for themselves. It is much less expensive to run day hospitals, workshops and hostels than to lock people up.”

In Britain, nearly 90% of mental patients are in unlocked hospitals; in the U.S.. less than 50%. Britain has 70 day hospitals; the U.S. only 25. The usual reaction of North American psychiatrists to the bearded Bierer’s preachment is that U.S. legal and public opinion is not yet ready for a drastic change. The same arguments were advanced when a few progressive U.S. hospitals began to unlock their doors (TIME. Nov. 16, 1959). Yet patients free to come and go have committed no more crimes, caused no more trouble than the general population. The more freedom they have, the less likely they are to be violent, and the more likely to get better.

To Save a Billion? Dr. Bierer, who has a doctorate in economics as well as in medicine, also makes a dollars-and-cents argument. In the U.S., he says, 85% of the psychiatrists, concentrating on lengthy analytic methods, can treat only 15% of mental patients, leaving only 15% to treat the 85% of patients who are in hospitals. Day, night and weekend hospitals, intensively using group psychotherapy, make the ratio nearer even and incidentally enable psychiatrists, handling many more patients, to make more money. Potential savings in unlocking hospitals: $1 billion a year.

Britain’s hardheaded Ministry of Health does not buy all the Bierer doctrine, but it goes a long way with him. It has just announced a plan to shut down 70,000 mental-hospital beds, or about half the nation’s total, within 15 years. And Bierer gets support for his theories from two distant lands that have never had big hospitals: Nigeria and India.

Psychiatry in Abeokuta. Resplendent in gold-crusted headdress and flowing robes, Nigerian Psychiatrist Dr, Thomas Adeoye Lambo appeared on TV (Open End) last week to tell how he turned four villages in Abeokuta into a therapeutic community. Each patient is accompanied by a family member, who rents a hut to care and cook for him. The kinsman goes with the patient to all treatments, so that he learns what psychiatry is and does. In Abeokuta it incorporates many aspects of the tribal cults, including religious sacrifices. Patient and kinsman also learn to accept and tolerate illness in other patients, so that when they go back to their villages, they become missionaries for mental health.

The same group principle applies in most of India, where the family provides emotional and material support for the mentally ill. Dr. Werner A. Kohlmeyer reports that the Christian Medical College at Vellore in Madras has built a modest mental health center, designed not to frighten patients or kin by bigness or strangeness. A family member rooms in with the patient, cooks and cares for him. When all beds are full, the new admissions are treated as outpatients.

In Boston, where one of the first U.S. day hospitals has been running since 1952, Dr. Bernard M. Kramer suggests: “The day hospital may become the major primary psychiatric facility of the future.”