From a Contributing Editor, Colleague and Friend of the Editor
This week’s reading is a provocative companion piece to the recent review of efforts to reduce involuntary admission to hospital. It is the environmental expression of the legal deprivation of freedom of movement: the locked door. Locked doors have a powerful symbolic meaning in psychiatry; outpatients coming for elective consultations sometimes tell me they are afraid if they “say the wrong thing” that I will “lock them up”. Asylum superintendents carried large rings of keys that embodied power and control.
Having spent half my career working on inpatient units, I am, like almost all of you, familiar with the locked doors that distinguish our wards from all others found in a hospital. And I know the reasons for their justification: prevention of elopement by people at risk of harm to themselves and others. And that prevention is intended to serve not only the patient and family but also the clinicians and the institution in terms of risk management. And yet…people do elope. Sometimes they return and sometimes they do not. Sometimes they attempt or complete suicide and sometimes they do not.
There is, as always, a tension between safety and risk, between freedom and protection, between autonomy and control. Locks are ubiquitous but not universal on psychiatric wards. What do we know about whether they make a difference? And what would be the ethically acceptable methodology for determining it?
– David Goldbloom, OC, MD, FRCP(C) Continue reading