Is Cuenca the ideal therapeutic community?

Many years ago, a young consultant and contractor found himself working in psychiatric hospitals in three very different places: Britain, Bermuda, the United States, and, much later, living in Ecuador.

At first glance the four places had almost nothing in common. Britain had its sprawling Victorian asylums. Bermuda had one small hospital serving an island where almost everybody seemed to know everybody else. America had accreditation manuals several inches thick, lawyers around every corner, and apartment complexes with names like The Preserve, The Reserve, or The Sanctuary, all of which sounded borrowed from a wildlife documentary about butterflies. And then there is Cuenca, which turns out to be the odd-man-out making sense of the other three.

After half a century of watching people recover, relapse, succeed, and fail, I have come to suspect that this city may possess many of the therapeutic qualities psychiatrists have been trying to manufacture for decades without much success.

The first serious placement was in one of England’s county mental hospitals. By today’s standards it was old-fashioned. The buildings belonged to the previous century, and many patients had lived there for years; nobody would seriously argue for returning to that model now.

Yet it also functioned as a village, with gardens, workshops, kitchens, sports fields, a chapel, and more green space than most modern housing developments manage. Staff stayed for years. Patients stayed for years. Sometimes more than one generation of staff cared for more than one generation of patients. Everybody knew everybody else, and the young consultant was too busy trying to understand how the place worked to spend much energy criticizing it.

What he noticed was that almost nobody there seemed terribly interested in writing policies. Years later he would discover hospitals with magnificent policy manuals and surprisingly mediocre care, alongside others that appeared to run on common sense, experience, and relationships instead.

Bermuda made the lesson sharper still. Inspectors visiting from overseas once raised concerns that the hospital kept comparatively few written procedures, yet after walking the wards they found patients who were clean, well dressed and groomed, cheerful, and on good terms with the staff. It is difficult to write a policy that explains why people smile at one another.

Hamilton, the capital city, or more accurately capital town, taught him something further. Many psychiatric patients there were known throughout the town not simply as patients but as local characters, complete with nicknames like Cowboy or Socks, and everybody seemed to know somebody’s story.

One man with chronic schizophrenia often found in the park behind the public library had once been the island’s outstanding high jumper at school, and people remembered that. His illness had not erased his identity. Hospital staff often knew the patients’ parents, siblings, or cousins; some had gone to school together, or lived in the same neighborhoods. Confidentiality still mattered, but there was also an unspoken understanding that these were not strangers, only members of the same community who happened to have fallen ill.

America presented an entirely different puzzle. The consultant could never work out why it was considered morally questionable for a long-term patient to spend an hour growing tomatoes in a greenhouse or baking bread in the hospital kitchen, yet perfectly acceptable for the same hospital to fill its lobby with vending machines dispensing sugar, caffeine, and enough artificial coloring to light a runway.

Apparently one activity counted as exploitation and the other as consumer choice. He supported banning smoking from hospital campuses, despite knowing that many patients regarded cigarettes as life’s greatest pleasure, because the medical evidence was overwhelming, but he was considerably less convinced that stopping patients from growing vegetables represented any kind of triumph for human rights.

The old hospitals had never grown rich on patient gardens; the economic contribution was tiny, the pace was slow, and the patients generally enjoyed it. Fresh vegetables turned up in the kitchens, or on open days, bread turned up on the wards, and there was real satisfaction for a patient in pointing to a row of beans and saying, I grew those. That struck him as much healthier recreation than feeding dollar bills into a vending machine.

The bigger surprise lay outside the hospital altogether. Florida’s apartment developments looked magnificent in the brochures, with swimming pools, palm trees, fitness centers, clubhouses, and smiling suntanned couples carrying tennis rackets, arranged to look uncannily like a university campus.

Then if you actually lived there, you soon discovered that buying a pint of milk meant climbing into a car, collecting a medical prescription meant another drive to a pharmacy, and returning your books to the public library meant driving across town. If the washing machine broke, you needed a vehicle, and if you wanted a film or a haircut, same deal again. The consultant sometimes thought these places were engineered so that the only exercise a resident ever got was the walk from the front door to the parking lot.

For practical psychiatric rehabilitation this created a real problem. Many discharged patients could not drive because of illness, medication, poverty, or disability. Community care sounded splendid on paper, but locating an actual community sometimes proved harder, and many people ended up in low-rent trailer parks or aging roadside motels left behind once the interstate highways diverted the traffic elsewhere. These were cheap places to live, but they rarely supplied the ingredients that make a life feel worth living.

Meanwhile, urban planners began promoting the fashionable idea of walkable neighborhoods, and the consultant found himself smiling at how familiar it all sounded: a place where you could walk to the grocery store, the pharmacy, the park, the library, the café, the barber, and the doctor, and likely bump into three people you knew along the way. Strip away the locked wards and the institutional routines, and planners had accidentally reinvented one of the more successful features of the old psychiatric hospital campus.

Which brings us, finally, to Cuenca. Perhaps the city’s greatest attraction has less to do with the climate, the colonial architecture, or even the cost of living than with the simple fact that life here remains manageable. Many retirees can leave their apartment in the morning and, within half an hour, buy fresh bread, collect a prescription drug, pay a bill, drink a coffee, browse a bookstore, sit in a park, catch the tram, and greet familiar faces, all without starting an engine.

Nobody calls this psychiatric rehabilitation, but perhaps they should. After fifty years of watching healthcare systems search for ever more sophisticated solutions, I have begun to suspect that some of the most effective therapies were never invented by psychiatrists at all. They were invented by towns: a town where people know your name, where ordinary errands do not require a car, and where your identity remains larger than your diagnosis.

For a surprising number of retired people, that may be worth more than the most luxurious clubhouse with the biggest pool and the shiniest brochure in Florida.