Platform—Open Door Dilemma

How are hospitals supposed to cater for patients who are a security risk and still pursue a progressive, 'open door' policy with the majority of their patients? Dr. Norman Imlah, medical director of All Saints Hospital, Birmingham, puts the case for closed special units. advances in the treatment and management of the mentally ill in Britain have brought problems for the legislators, but none more pressing than the policy of sending offenders from the courts to the mental hospitals under Sections 60 and 65 of the Mental Health Act. This Act, generally conceded to be enlightened, contains an archaic anomaly; that hospitals pursuing open-door policies, developing various kinds of therapeutic communities and embarking upon community mental health programmes, at the same time are expected to contain patients who, for security reasons, require restricted supervision more akin to prison than a hospital. This anomaly has produced a dilemma for most hospitals?whether to provide the type of restrictions that the court expects for the cases they send, to the detriment of the therapeutic atmosphere of the hospital, or to pursue a totally progressive policy and risk the harm that may result from insufficient security precautions. Most hospitals try to achieve an unhappy and unsatisfactory compromise between the two extremes. Unhappy, because staff today do not think they can promote good, therapeutic relationships in an atmosphere of restraint for some and non-restraint for others, particularly so when the existence of restraint is viewed by both staff and patients as a punishing sanction. Nurses do not regard the function of warder as compatible with their role as nurses. Unsatisfactory, because the system does not work. Security in the old mental institution was preserved by a system of discipline that drilled the nurse /attendant into the efficiency of a prison warder. Nurse training is no longer intended to equip the nurse to be a warder and any attempt to do so would be rightfully resisted. The result is that the form of security which exists is an inefficient one, far short of the requirements needed to provide adequate detention of many Section 60 and 65 patients. Even the retention of the locked ward, still favoured by some hospitals, is more of a 'token security' the main consequence of which is to increase the motivation of the patient to escape and is more indicative of the prevailing attitude to patients in the hospital than it is …