It is not much -- just a 6-foot-by-12-foot space with a few chairs, a barbecue, and pots of basil and pink flowers. But to 47-year-old Gigi Alley, the garden she has built on the porch of her Medford home symbolizes everything she did not have during seven weeks of constant confinement in a psychiatric unit at Cambridge Hospital.
"Even in times of real distress, I can find moments of calm just by listening to the wind blow in the trees and seeing squirrels," said Alley, who suffers from depression and multiple personality disorder.
That is the idea behind a bill pending in the Legislature that would require psychiatric hospitals to provide patients like Alley with a right long enjoyed by prison inmates: daily access to the outdoors.
Dubbed the Fresh Air Bill and sponsored by Senator Patricia Jehlen , a Democrat from Somerville, and Representative Frank Smizik , a Democrat of Brookline, the legislation has met with opposition from medical centers and raised questions about the proper balance between patients' autonomy and doctors' clinical judgment.
"It's not that we're against fresh air, it's that we cannot guarantee safety," said David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems, which represents the majority of the state's private psychiatric institutions. "Many patients are in the hospital because they are dangerous to themselves and to others."
Massachusetts Department of Mental Health policy states that all public psychiatric hospitals should allow residents outdoors as long as it is safe.
But the guideline does not apply to the state's 64 private facilities, which range from high-rise, acute-care units in congested urban areas to a working farm in Western Massachusetts where people with severe psychiatric disabilities shovel hay and make cheese.
Consumers of mental health services and their advocates packed a hearing late last month before the Joint Committee on Mental Health and Substance Abuse, which is considering the bill, to make their case that sequestering patients indoors amounts to discrimination. It will be months before the bill reaches the floor of the Legislature -- if it ever does.
"I think in a way this is one of the last frontiers of the civil rights movement," Jonathan Dosick, founder of the Coalition for Fresh Air Rights, said in an interview afterward.
"Psychiatric patients in the larger picture are not being treated with decency and humanity. In our laws, prison inmates are guaranteed time outside per day, and then to have this population of people who are often labeled as violent and unstable and don't enjoy this right really angers a lot of people," he said.
Proponents and critics of the bill differ on how many hospitals would be affected. Matteodo says only two of the hospitals in his group completely ban fresh air breaks.
But many allow them infrequently, only when enough staff is available, or for patients who behave well, smoke, or stay for long periods. Advocates say such restrictions can make it all but impossible for residents to get outside.
"I have talked to parents who are getting calls from an adult child in a psychiatric unit who is told they cannot go outside because they don't smoke," said Dori Hutchinson , director of services for the Boston University Center for Psychiatric Rehabilitation. "Their child takes up smoking just to be able to go outside. To me that's outrageous."
Mary Milgrom, senior director of nursing at Cambridge Hospital, where Alley stayed, said the hospital works to provide patients with fresh air on a case-by-case basis and is currently reviewing its policies.
While few researchers have explored whether being outdoors speeds recovery, many mental health professionals see the idea as common sense -- especially practitioners of ecopsychology, a budding field that examines how the natural environment influences human behavior.
"People without psychiatric conditions seem to cope better and feel more hopeful when they have access to even a small amount of landscaping," Frances Kuo , an ecopsychologist at the University of Illinois at Urbana-Champaign, wrote in a letter to the committee. "Why, then, should people in a more vulnerable state be subjected to an often barren, institutional setting?"
A century ago, wealthy eccentrics flocked to sanatoriums in the countryside to recover from stress, while poor patients spent years on state farms where they got plenty of exercise even as the government exploited their labor.
In recent years, however, advances in medication and shrinking insurance payments have led to shorter hospital stays, usually indoors in urban environments.
With an average length of stay of nine days, some private hospitals argue, fresh air becomes less of an issue.
Administrators worry they will have to construct costly outdoor courtyards for patients, or else parade them through the hospital to reach the street, potentially endangering them and the public.
"We would never want in the name of fresh air to jeopardize a life," said Dr. John Herman , director of clinical services for the psychiatry department at Massachusetts General Hospital.
Those arguments do not convince patients like Alley, who called the unit where she stayed from February to April as insular as a space station.
Even the window blinds were kept closed at all times, she said.
Returning to the outside world was so jarring, she said, that every sound grated on her nerves.
"It's easy to feel freakish and different when you're locked inside," she said. "If I had been able to go out, it would have made me feel less disconnected."
(Correction: Because of a reporting error, a story in the July 8 City & Region section about psychiatric patients being given access to the outdoors incorrectly described state law. A Department of Mental Health policy mandates that state-run hospitals provide psychiatric patients with access to the outdoors if it is safe, but such access is not required by law. All but one of the department's five inpatient facilities have secure outdoor areas for patients.)