This is from a pre press editorial in Lancet Psychiatry, behind a paywall, by Prof Tom Burns. He shows how the managerial convergence has not helped the mad.

I started my psychiatric training in the old psychiatric hospitals, then closing, in the 1990s. We had closed wards, yes, but most wards were open. Including the acute award. My clinical work is on an acute ward. It is open.

On June 1, 1972 I started my first job in psychiatry. Dingleton Hospital in the Scottish Borders was renowned for its family approach and outreach (all patients were assessed and treated in their own homes). But its greater claim to fame was as the first unselective catchment area psychiatric hospital in the UK that had permanently opened all of its doors.

It did this in 1948, long before the introduction of antipsychotics, and they remained open until the hospital closed in 2001.

Dingleton was not some isolated Alcatraz, situated on a bleak moor or surrounded by impenetrable marshes. What it had was a culture of strong, confident nurses who prided themselves on really knowing their patients and fully engaging with them, no matter how unwell they were. There was no separate occupational therapy service nor was there a locked nursing station. Relationships were strengthened by shared engagement in day-to-day tasks, such as cooking meals on the ward (more settled patients queued and ate the same food in the same canteen as the staff—the only difference was that they did not have to pay).

How utterly different this is to the psychiatric units of today. Virtually all now have their doors routinely locked, although voluntary patients are reassured that a member of staff (when they can get them to come) will open the doors and let them out. Visitors experience a forbidding and unwelcoming environment—and must also find someone to let them out. 3 m-high wire fences now surround the gardens and outdoor areas of routine admission wards. We have come to accept this dismal Victorian state of affairs as the norm.

The challenges faced by the wards have, of course, changed significantly. There are far fewer beds than in the past so most inpatients now need to be suffering from very severe mental illness in order to be admitted. Most inpatients in the UK are involuntary for at least part of their admission.
The vast increase in the use of street drugs has contributed to disturbance, and in large cities doors are often claimed to be locked “to keep undesirables out” as much as to keep patients in. However, the overwhelming and official justification for locked doors is to protect patients—to prevent them from absconding and to reduce the risk of suicide. As with the introduction of Community Treatment Orders, it has been argued that such technical fixes could be used to replace the more time-consuming commitment to persuasion and therapeutic engagement. This argument echoes wider concerns about the balance between care and control in psychiatry and generates strong feelings.

I have not quoted the entire article, or the paper it refers to. For those who cannot get at this, a comparison of open and closed German psychiatric wards showed no improvement in the adverse outcomes we fear — and for one, suicide, open wards were better.

Because Tom Burns is correct. A lock cannot replace a nurse who knows you, and you know cares for you. There are no short cuts. Most of the safety that exists in mental health is a series of personal relationships.

And in our quest of uniformity, evidence base, and efficiency we may have lost these relationships. If so, we have lost too much. For they are the true shelter.