Healing is Found in the Outdoors
Homecoming had its birth in 2015. I had just been appointed medical director of a brand new assisted living center, designed specifically for people with dementia. This center had neighborhoods of 16 people each connected to each other by a Main Street. Residents would walk along this Main Street as they visited each other’s neighborhoods. On the way, they could stop in at the movie theater to see what was playing, the pub to grab a pint, the library to check out a book and the general store to stock up on supplies. All of this was fine, but what really interested me was the door in the middle of Main Street. Off to one side, it opened into a nice courtyard with pathways extending to other courtyards on the right and the left. I was very excited about this door - my previous medical directorship was in a facility with a very small concrete pad surrounded by fencing, a left over “smoking area” from the days when we used to let residents smoke. In that other facility, residents with dementia would have to get on an elevator (not a chance of this, unless you could figure out the combo), make their way down a hallway and then enter another combo to the smoking area. There, you could enjoy the sun from about 10a -3p when it cleared the surrounding 2 story brick walls and listen to the soothing sounds of the HVAC system. In other words, my patients in that building only went outside when they were being wheeled to the ambulance for a trip to the hospital. So this new facility, with its door to the outside right there in the center of Main Street was more exciting to me than any of the other amenities.
Within a few months, though, I noticed a curious thing about the door and the courtyard – the door was locked and the courtyard was usually empty. Turns out that one of the residents had found that the aluminum fencing surrounding the courtyard would bend pretty easily. She was able to slip out between the bars, sparking a frantic search of the neighborhood before she was returned to facility. Although there were some vague commitments to improving the sturdiness of the surrounding fence (and adding cameras to monitor the long walkway around the back of the building), the courtyard was off limits from then on unless a staff member was on site, making sure any potential escapees would not test the strength of the slender aluminum railings separating them from freedom.
The calls started coming in “Mr. Johnson has been roaming the hallways and is very difficult to redirect. He hit one of the CNAs this morning and is now trying to break through the courtyard door! We need something to calm him down!” I had been so hopeful, when I started this position, that I would be able to avoid prescribing the nerve pills and anti-psychotics that I had to use at my other facility, the one without outdoor access. I was finding out that instead of being of great benefit, that door and the visible courtyard just beyond it became a liability, a focal point, especially for new residents, of potential escape. Teasing our residents with the tantalizing proximity of outdoor space, fresh air and sunshine only available in small dollops simply increased restlessness and in some cases, enraged our residents.
The unfettered access to the outdoors that I wanted for my patients was not a new idea. In fact, it was common in the early 1900s. In the days before Thorazine, there were very few medications available to help calm an agitated person living with mental illness. Methods such as padded cells, strait jackets, cold showers and restrictive cages were used with little regard for the human dignity of those with mental illness including those with dementia. In the late 19th and early 20th centuries, an approach to care called “Moral Medicine” emphasized the benefits of beautiful surroundings and access to open space. Here in Virginia, the old, grand buildings of Western State Hospital in Staunton can still be seen surrounded by acres and acres of what were once manicured lawns and gardens. Borne from necessity and a sense of obligation to the human dignity of every person, outdoor space became the main way asylums would help people with mental illness cope with their anxiety and confusion. The freedom to wander among many acres of lawns, gardens and pastures was not only a way to help people expend energy and decrease aggressive behavior, it was a recognition of the dignity of each person in offering them the freedom to choose their path, to offer them an autonomy that they otherwise would not have. This was the “morality” of Moral Medicine, recognizing the value and rights of each patient.
But the only place to find mental health facilities with acres and acres of expansive grounds are in the history books. Beginning in the 1950s, the field of psychopharmacology reduced the need for wandering among lawns and pastures. With Thorazine and Haldol, Ativan and Xanax, wandering and agitation could be controlled with injections and pills. Beginning in the 70’s, antipsychotics such as Haldol and then Seroquel and Risperdal were commonly used to help calm agitated residents, especially those with Schizophrenia and Bipolar Disorder. And although there is no FDA approval for their use in people living with dementia, the lion’s share of antipsychotic use in assisted living and long-term care are by those people living with dementia. As the 20th century wore on, mental institutes with expansive grounds disappeared, a victim not only to the emphasis on providing community-based services to the mentally ill, but to economics: it’s simply cheaper to give a dose of Risperdal than it is to provide acres of space.
Most facilities, and ultimately doctors, are caught in a bind these days. Regulations now limit antipsychotic and benzodiazepine use in long term care due to their dangerous side effects. On the other hand, with the lack of substantial outdoor space, few tools exist to help a memory unit handle agitated residents. If a 70-year-old physically robust person with dementia recognizes the cruel injustice of that locked door to the courtyard, no amount of bingo or crafting is going to calm him down. Thus, the calls – “Mr. Johnson hit another CNA, and is wandering into Mrs. Smith’s room again!” Although I always explore other methods – caregiver training, distraction, activities – I use these chemicals more often than I wish.
And so I dreamed – what would happen if my patients were able to open that door and walk into the courtyard? Even better, what would happen if the first thing they saw when they opened the door was not the walls and fence of a small yard, but a green expanse of lawn, of trees, of woods and paths wandering over the hills beyond? Would I ever be called for a prescription of Risperdal again?
This is where the concept of Homecoming began – as a plea from my patients to return to the “Moral Medicine” of the past and to once again take advantage of the healing that can be found in the outdoors.
