Open Minds Joins Critics of Asylum Proposal

By Cory W. Thornton, M.S.  Open Minds  March 5, 2015

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Asylum – “an institution for the care of the destitute or sick, and especially the insane.” The idea of “asylum” and the reality of asylums in the history of care for individuals with mental illness, are not exactly in sync – and definitely not without controversy. But over the past several decades the concept of institutions as the primary place of care for these individuals has fallen out of favor socially, clinically, and legally.

So there was no small degree of surprise when an article by Dominic A. Sisti, Ph.D., Andrea G. Segal, MS and Ezekiel J. Emanuel, MD, Ph.D., entitled Improving Long-term Psychiatric Care – Bring Back the Asylum) appeared in the January 20 edition of TheJournal of the American Medical Association. Their premise – re-create long-term hospitalization through public hospitals because persons with both severe and treatment-resistant psychotic disorders, who are unsafe for community-based treatments, are being forced into a cycle from prison, to homelessness, to acute hospitalization, and back to prison. Dr. Sisti argues that “The financially sensible and morally appropriate way forward includes a return to psychiatric asylums that are safe, modern, and humane.“

Not surprisingly, there were a wide range of reactions to the article. These are just a few:

1. Mad In America – Bring Back the Asylum?
2. Mental Health America – Bring Back the Asylum?
3. Psychology Today – Bring Back the Asylum? Bioethicists have right idea, but wrong label
4. The Atlantic – Should the U.S. Bring Back Psychiatric Asylums?
5. The National Council For Community Behavioral Health – Asylum or Warehouse?
6. The Practical Psychosomaticist – The Mental Health Asylum: The Pendulum Swings Back?

To get our team’s perspective on the issue, I turned to two OPEN MINDS senior associates, Robert Dunbar and George Braunstein.

Robert Dunbar – “I have to ask…is the reduced availability of ‘asylums’, state hospital beds, or other long-term care options really the solution to a broken mental health system? The World Health Organization (WHO) proposes that an improved mental health care system would consist of a mix of services with the availability of select services tied to frequency of need as well as to cost. Proposed services would include self-care, peer support, a continuum of community mental health services, general hospital-based mental health services, mental health services integrated within general hospitals, and a very “limited” number of mental hospital beds….The mental health service system will have the opportunity to invest in a continuum of evidence- and community-based services. There is no need to revert to the times when the mentally ill were isolated from their communities and loved ones because “recovery” was not deemed possible.”

George Braunstein – “Dr. Sisti calls for developing new, more humane long-term care hospitals that serve people who need those services. While I think the article is well written and makes a compelling argument, this approach to addressing a serious and well-documented problem regarding the availability of appropriate services for people with a serious mental illness is simplistic, and ignores some important issues and new developments in health care that will impact service quality and access issues. The article also ignores the most important premise of civil and human rights, the right to choose. [The] obvious key to successful service delivery, requires effective public policy that recognizes the rights and the aspirations of people with a serious mental illness to have a choice where they live, and the treatment they receive. Secondly, the funding for any program, institutional or not, needs to be sufficient to achieve the stated goals. If those two issues are adequately addressed, then an effective community-based system with newly effective technology, vertical service models, and the availability of housing and job training will be possible.”

For more on their perspectives, you can read the full interview piece, Should The U.S. Bring Back Psychiatric Asylums?, in the February 2015 OPEN MINDS Management Newsletter. And for more on long-term care issues, check out these resources form theOPEN MINDS Industry Library – Commission on Long Term Care: Mental Health and LTC, Roadmap to Medicaid Reform: Long-Term Care, The Changing Mission of State Psychiatric Hospitals, More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States, and State Mental Health Program Directors Recommend Integrating Public Psychiatric Hospitals Into Continuum Of Community-Based Care.