Should We Return to the Asylum Era?

In 1955, there were 560,000 patients in psychiatric hospital across the United States.  Today, there are only 45,000.   Since the U.S. population has doubled over that same time period, that means that the number of hospital beds for mental patients has declined to levels not seen in the United States since the 1840s.  And this has remained virtually unchanged over the past forty years despite the clear need for improved mental health care. 

With no beds to care for them and horrendously long waiting lists for the few services that are available, many people dealing with severe mental illness find themselves trapped in limbo created by well-meaning social policies and economic reality.  For people dealing with major mental illness, including schizophrenia and bipolar disorder, receiving proper mental health care is usually made even harder by their difficulty functioning in the community.  Family members often find themselves unable to provide proper care and experience burnout as a result.  Mental patients without families are forced to rely on community care programs (when they exist).  Far too often, these mental patients find themselves either out on the streets or caught up in a prison system that was never designed to accomodate them.  Having seen this myself during the years when I worked in the Ontario correctional system, I can certainly appreciate how desperate the situation can be for them. 

But is there a way out of this dilemma?   A provocative new paper published in the Journal of the American Medical Association investigates an  option that is certain to be controversial in its own right:  rehabilitating the reputation of psychiatric hospitals as places where mentally ill people can really get the help they need.   Written by three bioethicists at the University of Pennsylvania's Perelman School of Medicine, the paper points out that the current disastrous state of mental health care in most countries is due to the long-term trend towards deinstitutionalization that led to the closure or downsizing of most psychiatric hospitals over the past sixty years.   

“It’s really not as radical as it sounds,” says Dominic A. Sisti, one of the authors of the paper in an interview with Quartz magazine.   Not only have psychiatrists been calling for expanding psychiatric facilities for years, but it was largely because of the repressive practices of many asylums in the past that the stigma against hospitals first developed.   By reestablishing hospitals as sanctuaries where people in need might get the help they need, many of the current problems surrounding mental health care might be avoided.

Beginning in the 1940s and 1950s, psychiatric patients were slowly released into the community both as a cost-cutting measure and a misplaced faith in the effectiveness of new medications for controlling mental illness.  During the 1960s, this trend towards deinstitutionalization was boosted by the patients' rights advocacy groups who insisted that psychiatric hospitalization was an infringement on civil rights.   As hospital beds closed, the community care programs that were meant to take their place largely failed to materialize and patients were often left to fend for themselves.

From the 1970s onward, the number of psychiatric hospital beds has remained steady though the need has been steadily growing as mental patients grow older and are less able to care for themselves.  The problem has been aggravated by the practice of "patient dumping" with some hospitals emptying beds by transporting released patients to other jurisdictions where they might be someone else's problem.   In other cases, patients might be transferred to nursing homes or general hospitals that are not equipped to provide the round-the-clock care needed.

There are successful community programs in place for many people dealing with mental illness.   These include the Fountain House program using the clubhouse model of psychosocial rehabilitation.   Beginning in New York City in 1949, there are now over four hundred Fountain Houses worldwide which are aimed at fighting the stigma of mental illness and helping patients live in the community.  Still, not all people with mental illness can handle living independently in the community and may frequently get in trouble with the law as a result.

Though the stigma surrounding psychiatric hospitals is still strong, allowing prisons to become the default option for many people with mental illness is no solution.  All too often, prisons have no choice but to put mentally ill prisoners into solitary confinement which typically makes their condition even worse.  And the costs of housing mental ill prisoners tend to be far higher than prisoners without mental illness.    In Texas for example, it costs $30000 to $50000 a year to house a mentally ill inmate compared to an average of $22000 a year for inmates without mental illness.  This will likely rise in the near future now that the U.S. Supreme Court has ruled that the current state of treatment in most prisons amounts to cruel and unusual punishment.  That means that new facilities must be built to provide better treatment.

Certainly, building new psychiatric hospitals won't be a cure-all for reforming psychiatric services.   High-functioning patients with mild forms of mental illness will continue to function in the community with proper outpatient treatment.   Still, as Dominic A. Sisti and his co-authors point out in concluding their paper:

"Asylums are a necessary but not sufficient component of a reformed spectrum of psychiatric services. A return to asylum-based long-term psychiatric care will not remedy the complex problems of the US mental health system, especially for patients with milder forms of mental illness who can thrive with high-quality outpatient care. Reforms that ignore the importance of expanding the role of such institutions will fail mental health patients who cannot live alone, cannot care for themselves, or are a danger to themselves and others."

Though the cost of building new hospitals will be high, it is a better alternative than what is happening now.  Allowing the prison system to  house the most violent patients while leaving the rest to fend for themselves isn't working.  And, as the past forty years have demonstrated, this is one problem that won't go away if we continue to ignore it.

 

 

 

           

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