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Legislating a Coalition for Fresh Air?

by Jonathan Dosick

In Massachusetts, a unique initiative is being considered: One that affirms the essential connection between psychological well being and the healing effects of nature. This effort is named CFAR: The Coalition for Fresh Air Rights. We have filed a bill in the State Legislature to make daily access to fresh air and the outdoors a fundamental right.

At issue: The denial of fresh air and outdoor access to patients in psychiatric facilities. Most psychiatric hospitals are ‘locked’, and most have limited access to the outdoors, some none at all. Outdoor access is mainly governed by ‘privilege’ systems, and fresh air is often restricted as a punitive measure for ‘bad’ behavior.

Everyone, to some degree, agrees that fresh air is important. But we think access to the outdoors is extremely important to basic psychological well being. To deny it to people who, by no fault of their own, are suffering acute emotional and spiritual crises, only exacerbates their pain.

The push for greater equality and dignity for the ‘mentally ill’ can arguably be said to be one of the last frontiers of the Civil Rights movement. As ‘consumers’ (persons with mental health concerns), we are experiencing a groundswell of empowerment and newfound respect, the logical result of all great civil rights efforts.

Still, we start out at a loss in a society that seems to have lost track of how to be well. Rampant abuses of power by treators, tremendous media stigmatization, and a broken health care system are challenges faced by us all.

For example, in this state, prison inmates are mandated time outdoors, yet consumers are not. We seek to change this.

As a ‘consumer’ myself, I have experienced the profound pain of mental illness. I’ve been lucky to come from a supportive background. But I and countless others have been victimized by a system that takes those in crisis and locks them inside for very short stays (a week or so on average - sometimes months in state facilities), in cold, institutional settings.

The isolation felt in this situation is compounded by staff members who are frequently disdainful and seriously overworked, and ‘privilege’ systems that treat people like helpless children. Being indoors 24/7 only makes things worse.

Despite the common refrain from insurers that “if people are well enough to go outside, they are well enough to go home”, staying inside distances people from the outside world and stifles their preparedness for discharge. There is no escape from the dismal settings and others’ pain.

I have been hospitalized 11 times in my life, and looking back over the diaries I’ve kept, I see a pattern. Going outside was something that I looked forward to – it spiritually nourished me, even in the ‘dead’ of winter. Again, I was lucky – my hospitalizations happened in places where outdoor access was allowed. I don’t think I could handle staying in all day, breathing stale air.

The ‘privilege’ systems that exist in many places punish patients for noncompliance with treatment plans or disagreeing with staff. Privileges such as outdoor breaks are therefore revoked.

An exhaustive survey of hospital policies at 72 hospitals across the state has yielded mixed results. Some are very supportive of the idea; and some have severely limited access. Some administrators become indignant at the very idea of providing outdoor access. In addition, some state hospitals do not evaluate patients for 30-40 days for privileges, keeping them inside for that duration.

How many of us just ‘don’t feel right’ if we don’t go outside each day? It’s a very human condition. Scientific studies (many of them available through ICE), have shown over and over that exposure to nature directly correlates with lowered stress levels, decreased frustration and violence, and an increase in overall well being. In the 19th Century, the Quakers ran psychiatric hospitals based on ‘moral treatment’: Patients enjoyed fresh air, good food, and a remarkably tolerant system where they were considered ‘brethren’.

But current trends in an increasingly restrictive and ‘managed’ healthcare system show we are moving backwards. People in need of acute care are being kept in hospitals that are more and more restrictive, for shorter lengths of time. Emphasis is on ‘stabilization, not treatment’. The units are basically holding areas where patients’ medications are monkeyed around with - far less emphasis is placed on holistic types of treatment plans. This creates a ‘revolving door’ situation, where consumers become more and more reliant on medication, perceived as the only approach.

The bill faces large obstacles, despite the fact that it has been endorsed by organizations such as the National Association of Social Workers, the National Alliance for the Mentally Ill, 14 legislative co-sponsors, and hundreds of fellow consumers and disability-rights activists and advocates.

The primary opponents to the bill are hospital industry lobbyists. They argue that allowing access to fresh air will cost large amounts of money, possibly leading to the closure of units. Understaffing due to economic hardship is a concern, as is safety. The hospitals worry that escaped patients, some of whom are prone to dangerous behaviors, threaten their own safety and that of the general public. They fear public outrage and multimillion-dollar lawsuits.

But we believe progress can be made, and with some capital expenditure and creative thinking, compromises can be reached. A clause in the bill allows for the superintendent of a facility, in limited cases, to revoke a person’s outdoor access if that person is deemed too serious of a threat.

As Coordinator of CFAR, I feel extraordinarily lucky to be able to spearhead a campaign that touches on a subject that is important but often overlooked. When our bill was heard in front of the Joint Legislative Committee on Mental Health and Substance Abuse in July, the consumer turnout was very impressive. Consumers and advocates alike testified passionately about the importance of their connection with nature. This was awe-inspiring and incredibly encouraging. Thanks to groups like ICE, I now have the chance to ‘spread the word’ on a national level. I hope this effort will be a seed of enlightened thinking, and a movement toward the true freedom nature offers.


Jonathan Dosick is the Coordinator for CFAR, The Coalition for Fresh Air Rights. He lives in Watertown, Massachusetts and works for the Disability Law Center in Boston.

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