Bring Back The Asylum? Really?

This article will discuss the surprising but necessary and growing realization in this country that in order to adequate repair our broken national mental health care delivery system, we have to “bring back the asylums.” Instead of continuing to downsize and abolish inpatient beds, and close more and more state hospitals, we need more beds, more specialized units and more new, modern replacement state hospitals to replace our ageing physical plants of state hospitals that are on average, almost all over 100 years old!

I must also apprise/warn the reader that I have violated the big rule of blogging that I have read in every tutorial on blogging in the last three years, to keep your piece to say, 300-500 words maximum. I have ten-tupled that out of necessity to cover this complex and controversial subject fairly and adequately. I do not believe the batted about insulting Internet based concept that suddenly all American Internet readers have suddenly developed incredibly short attention spans. The blogging books and authorities all would hold me up, I am sure, as the Greatest Violator of Blogging Rules Ever. I would answer that if you are not interested in the crisis of mental health care, and/or mental health reform in this country, quit now, stop reading this piece, save yourself time and do something that fits and pleases you better. I will not mind. But if you are, I would hope you will find this piece informative, motivating and encouraging. I do not write from a pessimist’s heart, and am not the old character from the cartoon strip of Al Capp’s, Little Abner, now long out of print and unknown to anyone under 40 years old or so; this character was called “Joe #@?!” or something like that. He was a total gloom and doom guy, worse than Eyore of Winnie the Pooh. He was illustrated so well pictorially by Al Capp to give any reader of the comic strip an immediate recognition of this character’s constant and unfailing pessimism and even constant expectation that misfortune was waiting for him at any second, by drawing with a little black cloud just above his head that was already raining on him and no one else wherever he went. I am hoping to write and promote change in the opposite, optimistic, we can gradually make things better mode. And fortunately in my state of practice in North Carolina, no matter our present hurdles, we are working diligently on them, I think in the last few years we have turned a number of big policy and implementation corners, and I am proud of this state’s efforts under very very adverse circumstances. I also hope that by writing from that perspective, and by picking up and publicizing in my own small way, successes, victories and advances I find through my professional collegial grapevine of four decades of colleagues from my training years, different places I have practiced, and the wonders of my cool little Google Internet keyword army of helpful search bots, I can spread some good news of mental health reform efforts in other locales that are also fostering improvement and progress against the daunting odds and difficulties we face commonly all over this country. So get your favorite beverage, get you thinking and pondering cap on, and undertake to read [in as many sittings as it takes] this massive blog “missal” on “bringing back the state hospitals,” not exactly a popular or politically correct concept perhaps these days.

I feel I must add another disclaimer prior to getting into the meat of this article on the undeniable necessity of retaining and continuing to improve state mental hospitals, those much maligned “institutions:” I am now a state hospital psychiatrist, having now worked in one in my mostly home practice state and where I originally trained in psychiatry, North Carolina. These are no one’s views but my own. I am a state employee and support the efforts of mental health reform in NC even though like many other states, this has been a “rocky road,” and in its earliest years of MH reform, NC made many mistakes and I was a critic. I trained at Duke and had training rotations at the then existing John Umstead (state) Hospital outside Durham in Butner NC north of Durham and I worked there for three years as an adolescent psychiatrist helping to start its first shorter stay crisis adolescent unit in the late 1970’s till 1981 or so. I also “moonlighted” at another state hospital in NC doing admissions on weekends to supplement my earnings to help pay for a growing young family and also my then hefty psychoanalytic training expenses which literally took almost all my earnings since my training analysis was not covered by health insurance. At no time in any of those earlier stints of working in supposedly the latter days of abuse in state hospitals, did I EVER see any abuse in the three of the four NC state hospitals that I ever rotated through or worked in. I only say compassionate treatment that was up to date with the state of the art and science of  psychiatry at the time and better in many ways since the state hospitals then, and still are now, in NC closely and wonderfully affiliated with the major medical schools and many of the staff state hospital psychiatrists are actually medical school department of psychiatry teaching faculty as was I.

With that in mind it is undeniable that much of the history of state hospitals in this country was some of the most sordid, horrific, hidden instances of institutional abuse imaginable, comparable to the forced entry of Native American Indian youth from the late 1880’s on until before WWII in this country. My wife is Cherokee and in decades of our marriage and untold dozens of visits to her home and extended family in Cherokee NC, on the reservation, properly named, the “Qualla Boundary,” gradually as her relatives came to trust me, I began to hear of the “historical trauma,” suffered by those who were literally kidnapped off the streets/lanes of the reservations and shipped off without notice to their parents to “Indian Schools,” in the West, my wife’s maternal grandmother for one, to one in the Plains of the Midwest, and who escaped and returned home. My wife’s own mother was hidden for a period of time by that maternal grandmother to escape being Shanghaied when the Bureau of Indian Affairs “recruiters” would appear in Cherokee. So I have a sort of bilaterally based feel, acquaintance with and interest in institutional abuse. As a college student I read as did most everyone else interested in or taking any introductory psychology class the famous book that started the entire “de-institutionalization” campaign in this country to abolish the then reviled state psychiatric hospitals and its entire movement and system, Erving Goffman’s book, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates which you can review at its sale site on [Note: I am NOT an affiliate of Amazon’s, and do NOT get a royalty if you buy it, I merely use that site as it is a good place to read about the book if you are not familiar with it]. This book had the best of intentions as it documented the bad conditions of state hospitals but it was a product of its time, when psychiatry was more an exercize of detention of psychotic persons for whom there were no effective or humane treatments; and so that author documented the result. It result was that it become a political social cause as we are so free to do in this country (thank God and the Founding Fathers) to abolish state hospitals in toto. By the early modern era of psychiatric treatment, the 1970’s when a number of somewhat effective medicines were in use and permitted the exit of hundreds of thousands of the previously largely institutionalized for life patients, the movement had captured the ideology of politicians, social policy planners, the early mental health advocacy groups, etc. Not that this was entirely bad, it was inevitable, and in many ways needed, overdue and helpful in some ways. Transparency was growing long before that social codeword gained widespread use. State hospitals that were fortunate enough to have enlightened leadership, to be located close enough geographically to be affiliated with centers of psychiatric research, teaching and training such as departments of psychiatry in medical schools, offered the best they could and by and large were worthy treatment facilities. But many others had been secret horror houses for many many years.

So as policy reforms that later evolved into our present last decade and a half at least of national mental health reform, state hospitals started to be downsized in bed numbers in the 1970’s or so, accelerating especially in the last 10 to 15 years or so, also with many very old dilapidated neglected physical plants of state hospitals closed for safety reasons but largely without replacement services in the form of new public hospitals. The social national policy answer was the establishment of local usually county based “mental health centers” starting in the 1960’s under President Kennedy’s comprehensive community mental health centers legislation of 1063, championed by the late Hubert Humphrey, and continued under the Great Society auspices of Lyndon Johnson’s presidency. Nowadays most still operating state hospitals have been downsized greatly on average perhaps by my own personal estimation from my reading of the literature on the subject, of an average of two-thirds in the last 30 years. construction of new state hospital sized or even regional smaller psychiatric public facilities, have been almost non-existent. For instance, in North Carolina’s own comprehensive original mental health reform plan of 1999-2000 only two of sixteen such regional facilities have been built and one of them serving western NC is an old, but very well maintained, converted nursing home. The only one built to my knowledge in Raleigh which was added to the county hospital of Raleigh as an inpatient public psychiatric unit to serve the under- or uninsured of Wake County after that county got tired of waiting for the state to make good on its pledge and took its own initiative to start its county equivalent. In this regard, it is an old story, mental health resources are cut, shut or underfunded and few or no new replacement services are put in their place or funded. This is somewhat of a misleading and in many ways, now false statement if applied to North Carolina, as this state has made enormous efforts to facilitate the start of privatized mental health agency providers in the last almost 16 years of effort, and to some degree, replaced some of the lost services, but still not enough. But suffice it to say, it truly IS a work in progress and continues to the credit of this state which is doing this in the face of state-wide recession since the “” bust of 1991 which hit this state hard in the Research Triangle Park economic engine, and the crippling of the state’s major agricultural sources of income, tobacco, textiles, and the almost total loss of the furniture manufacturing industry. The latter was as if North Carolina were the center of the Big Three auto industry, and equal to what would have happened to Michigan if all Three auto-makers had simply left that state entirely. North Carolina lost virtually all its furniture manufacturing to Mexico and China; and until NAFTA, NC had been the furniture capital truly of the entire country and to some extent of the world. The Hickory Furniture Mart, still an enormous convention center even by Las Vegas standards hosted twice a year at its convention for furniture buyers of the world, over 160,000 buyers twice a year.

Better But Not Well: Mental Health Policy in the United States since 1950

The Eclipse of the State Mental Hospital: Policy, Stigma, and Organization

Asylums: Essays on the Social Situation of Mental Patients and Other Inmates

So through the 1970’s on, state mental hospitals began to be closed as documented in several books I would offer for free review on their respective sites on Amazon: By John Gray Abandoned Asylums of New England: A Photographic Journey, Asylum: Inside the Closed World of State Mental Hospitals, The Lives They Left Behind: Suitcases from a State Hospital Attic really a fascinating book that research the lives of actual patients from Williard State Hospital in NY and worth a read), The Architecture of madness: Insane Asylums in the United States (Architecture, Landscape and American Culture, and of all things, a website devoted to abandoned asylums which is actually a fascinating read and a labor of love of forgotten architecture: Abandoned Asylums,

Nationwide, whether the efforts were termed ‘mental health reform,’ or not, the policy mistake was the same, close the labelled as bad state hospitals, without providing adequate replacement resources in any venue except the outpatient mental health county based centers. De-institutionalization was felt to be the right thing to do and again, very understandable in the context of the times. Patients were no longer actively psychotic, and could function in acceptable ways–up to a point. But new ‘state hospitals’ in a host of different forms to suddenly house these unfortunates, many of whom had no jobs, no income except paltry SSI or disability income, no pensions as they had been and were still unemployable except in sheltered workshops which had begun, with a few exceptions in dedicated communities, begun to disappear nationwide, and could not by and large return to live with their families or parents. Often their parents were themselves elderly, retired and on limited retirement incomes themselves. So what happened? In large urban areas such as New  York City, the mentally ill were housed in crowded unused, abandoned former hotels, often in the seedy, crime and drug ridden areas, as attempts to build, erect adequate housing with supervision in real neighborhoods tried early in the process under the Fair Housing Act of the Nixon Years (though passed in the Johnson era) were shut down nationwide, actively resisted all over the country as no one wanted “mental patients” living in abandoned motels or small apartment complexes or group homes in THEIR neighborhoods. So the mentally ill suffered de facto housing segregation to poor housing, crowded poorly maintained “welfare hotels,” as they were derogatorily called, with largely absentee landlords who made large profits and of course usually did not re-invest in property maintenance. So they gradually became hell-holes of crime, drug abuse, victimization and preying upon the largely defenseless mentally ill (mostly quiet isolative fearful folks often WHO DID NOT BELONG TO GANGS, so they did not have “protection,”) And their outside the state hospital lives were often far worse, far more dangerous than anything they experienced in state hospitals, even those that did have a culture of abuse and neglect. The welfare hotels of large cities all over the country became the new “Cabrini Green” projects like in Chicago tailor made for predation by the individual and organized criminal elements. Patients were afraid to leave their apartments except for the most essential necessities such as food, and gradually a pattern of “non-compliance,” with mental health service follow up started to manifest itself, a pattern not seen in such large numbers before. So patients chose to not keep appointment to avoid running the “crime gauntlets” of the halls and stairways and walks, bus or subway rides to their clinics, and relapsed into their recurrent psychoses or severe depression and had to be re-hospitalized almost always after an acute emergency episode of dangerous acting out the behaviors of their illness. This was the beginning of the now constant flood and presence of actively mentally acutely ill, poorly served  masses of psychiatric patients we have seen flooding large and small hospital ERs all over the country for nearly two decades, but far worse as the numbers continue to rise faster that systems can be radically reconfigured to serve them, and constitute our “sudden new” crisis. Bah humbug, this has been coming and developing under our noses for more than 30 years, ask any hospital administrator or medical director of any ER.

In the smaller urban and near rural areas, abandonded or cheap for sale nursing homes were utilized by surrounding small, less financially “rich” communities as they sought to house the now increasing numbers of discharged state hospital patients that had not existed in most communities across the entire country. These were by and large much better solutions than the urban horrid welfare hotels of the big cities. Local mental health centers could do local follow up, even do visitation based pre “home nursing” follow and schedule appointments in one day for the entire patient cohort of the more modestly sized facility. I remember doing this in the 1970’s and 1980’s, even through the 1990”s as part of my long ingrained commitment to “social” or “community psychiatry” sense of service ethics, thankfully instilled in me by my enlightened training program and mentors at Duke. I felt comfortable going into such facilities and enjoyed it. Visiting patients in their personal setting almost always a terrific personally satisfying experience both my patients and me. I dedicated at least two days a month happily to the “cause,” as I saw and did it financially on a mixed private practice basis for those patients with insurance, and under contract with the local mental health centers for patients who were under or uninsured. It made NO difference to me at all, the patient all deserved and received the same care from the cadre of private psychiatrists and social workers who did this type of practice “back in the day.” And it work great. Patients looked on the appointments as visits and enjoyed the chats and “socialization” as some therapists would rightly call the interactions. I got to know these folks personally and it was wonderful. They trusted me/us and when we had to make difficult treatment decisions, even to bring them back into the hospitals, we caught the symptoms early, the hospital stays were almost always SHORTER and therefore less costly and they came right back to their same outpatient familiar cadre of mental health practitioners and support. This was real community psychiatry. And it worked so much better in some ways than what we have now but that is a story for another post that i guarantee will appear in the coming weeks. I remember being the psychiatrist half of a two doctor team to a large multi-level of care “nursing home” that was private, affiliated with a large national religious Protestant denomination in Durham, and thankfully is still there, doing great care still always. I fell into it accidentaly. I was asked by one of my fabled psychiatric mentors and supervisors to treat his elderly father who was housed at the facility as he had been a minister in the denomination that started and supported the large facility. I was surprised and flattered to be asked. His father clearly needed psychiaric treatment and fortunately I did well with his father and enjoyed geting to know him. He was a man full of colorful stories in spite of his nascent early dementia and I loved spending time with him and he responded in kind. After I passed that “test” of whether I was going to work out, monitored unbeknownst to me, by the patient’s father, my supervisor, and the facility’s nursing staff and administrator who had been apprised by my psychiatric mentor and the son of the patient, who of course was his father’s guardian, giving consent for me to see his father as required, I then was asked to be the facilities’ ongoing consulting psychiatrist. I jumped at the chance since I had been trained in geriatric psychiatry at Duke and loved working with the elderly as they were always full of history that was as I called it, “off the books.” I then learned that I would be teamed with the consulting internist, the fabled Dr. Eugene Stead MD, then chairman emeritus of Duke’s Department of Internal Medicine, who had been brought from Johns Hospkins in the post early days of Duke’s existence as a medical school, to whip the department into shape, and to make into a national and internationally respected medical school and he did just that, and is one of the now revered, and deservedly so, legends at Duke University School of Medicine. So I had a second chance to jumpt at work at the “retirement home,” as it was called then. I had a chance to round with Dr. Stead about half our mutual time there when we came on a co-scheduled basis to see patients. Where we usually rounded together was the large inpatient medical “hospital” of over 170 beds that was in a two story hospital type building attached to the retirement home part of the complex. This entire facility for its day was way ahead of its time and I did not realize this at first. It has individual and couples apartments out back, some with kitchens, some without, a big dining room for those who did not cook, individal large but dorm like rooms for widows/widowers, nursing stations in multiple locations serving each part of the floor they were located on as each floor would have dozens of apartments and rooms, and at least four hallways, and then the full ‘continuum of care’ which meant residents could be transferred to the hospital part next door but actually physically connected to the big building, all making for a really unified, coordinated facility that was darn near perfect, Records even though they were not computerized in those days, followed the patient easily to their next station of care and nothing was lost or miscommunicated. “Hospital based errors” were rare to say the least. Care was safe. As the consultant psychiatrist I got to indulge in another of my favorite kinds of psychiatric practice that unfortunately still half of private practice psychiatrists avoid like the plague, “hospital consult liaison” psychiatry on medical/surgical units. And I had the precious opportunity to often do with at the side of the giant of Duke Medicine, Dr. Stead. I was only a few years out of training and this was a golden opportunity to work with the best. I learned more medicine from him almost than I had in all of my medical school rotations and was privileged to kick cases around and discuss riddles of diagnosis and management with every day that we rounded together every two weeks or so for almost 15 years. And at least 10% of the ordinary residents at this large facility had had mental illnesses before admission and the facility due to its commitment to its designated church population, took them in wihtout discrimination another wonderful and somewhat unusual compassionate stance that I later found and learned elsewhere over and over was the exception.  So why do I include this vignette? This is the way it is supposed to be for the post state hospital discharged mentally ill. A decent place to live, on site supervision, good consistent follow up with familiar practitioners that do not change every so often because they are underpaid, undertrained, know nothing about the elderly and overworked and under appreciated, the news serfs of mental health care and reform. In the Durham-Raleigh-Chapel Hill (I can be accused of naive idealization here for the ‘good old days’) we had a surplus of nursing homes also a rather unusual situation. In those days many of them were willing to take psychiatric patients that were reasonably stable. Both private and public mental health center based psychiatrists in a way, divied up the facilities needing psychiatrists and provided coverage literally each psychiatrist or call group providing care exclusively to one or more nursing homes. Some of the nursing homes were purchased by the early entrepeneurial forerunners of the now standard model of privatized owners of free standing post discharge ex-nursing home facilities for “ex-mental hospital patients,” and provided care, housing and retained one form or another of mental health consultants and coverage. Some of them to be sure, were poorly run and maintained and some of my colleagues literally having to rub Vicks Varo-Rub menthol ointment under their noses to stand the stench of urine and such to go into these facilities and see patients with psychiatric crises or those needing their periodic standard follow up. But not everyone is a good guy or gal and sufficiently social morally motivated and so there were some awful facilites worse than any state hospital I ever heard of. But we did what we could so patients did not go without.

But keep in mind this was a unique area: There were therapists and psychologists and psychiatrists as I always used to joke to make a point, “under every rock and behind every bush.” This was because in the :RTP” area of Raleigh Durham Chapel Hill, we had two medical schools with departments of psychology each, one with a school of social work, two state hospitals within 15 minutes driving distance each of these massive and high quality training centers/meccas, with their own medical school affiliated psychiatry training programs! We have enough mental health person power to cover almost anything. The only areas I know of such sufeit of mental health resources in the country were parts of LA, Cambridge-Boston MA, Ann Arbor MI, and maybe a few other places in the country with not such big populations but perhaps a little too many such mental health training programs in those areas  because of historical flukes of having more high quality universities and graduate/medical training programs than they should.

In such a situation as I have described above, you could drive 30-60 minutes away from these ideal meccas and find shortages of everything, small understaffed county mental health centers, most of whom still did good work as most of their staff over the years had come from the NC meccas of traning. But the chronically mentally ill tended more and more to have substandard, less frequent care and even less than a modicum of decent housing out in the more rural areas which were not rich enough to buy old motels and turn them into decent housing for the chronically but stable mentally ill.

Finally in the 1990’s and the 2000’s the inevitable, predictable tragedies occurred that reminded the system that had gotten away with the pretense that it was alright to more cheaply house the post hospital discharge, yet chronically mentally ill (as almost all of them are, another truth the planners and bureaucrats in effect had ignored to their and others’ peril but long foreseen by us “troops on the ground.” We started having violent tragedies in the urban big mental patient welfare hotels, in NYC, and other huge populations centers where the mentally ill housed in huge building that were converted hotels, often being more than 10-25 stories high with hundreds and hundreds of mentally ill, mixed in with indigent chronic addicts who still used drugs but could afford to live nowhere else. Follow up and ongoing treatment was predictably abysmal as the ever increasing numbers from the 1980’s especially onward, of discharged “CMI” ]chronically mentally ill] increased at a steady and increasing rate for over two decades. Robberies, rapes of the elderly, and of course murders began to happen to the defenseless in ever increasing numbers. It was a repetitive news story in the more sensationalistic newspapers such as the New York Daily News and the New York Post and thankfully so, as they did their journalistic duty with emphasis pointing out a growing system problem, a solution that was just creating suffering, new kinds of hardship and tragedies with growing regularity. But little was done. Then the more sensational crimes started when the mentally ill who were being shoved out of state hospitals too soon, were still dangerously psychotic and paranoid, started for instance shooting people publicly, like on subways and commuter rail roads in which the wealthy Madison Avenue and Wall Street types communted in addition to middle class poor who had to use those modes of transportation. Then the overdue hue and cry started. And perhaps thankfully these new stories got the attention they finally had deserved all along, the incessant hyping and 24 hour a day “this is a CRISIS! ” cable news networks for all their flaws, gave these stories. Suddenly the planners and state budgeters and officials could no longer ignore these issues until the solutions started to disintegrate as clinicians everywhere knew they would.

The most infamous early case was that of Colin Ferguson who committed “The Long Island Rail Road Massacre” in December, 7, 1993, suddenly pulling a pistol and for no apparent reason, as the reason was all in his delusional head, killed six people and injured 19 others. He was quite psychotic but still convicted and given a 315 year sentence so he would never be released.

Then in the mid and late 2000’s around the country, murders by unstable post hospital discharged state hospital patients housed in nursing homes for the elderly had a rash of murders, presumably committed while delusionally driven and psychotic. This called into the question the several decades old practice of placing discharged CMI state hospital patients without a home, or accepting or any family, into ordinary nursing homes. This also became a national and notorious news story especially when within a period of two years or so, several of these tragic bizarre murders were committed against defenseless elderly nursing home patients. By 2009 many states had passed laws either prohibiting altogether placement of the CMI patients in ordinary nursing homes, or that no more than 50% of the residents of a nursing home could be mentally ill to the extent of requiring ongoing care/follow up. These were expectable reactions but again had unintended complicating consequences. It suddenly became much harder in the 2000’s to find placements for even stable CMI patients from state hospital nationwide. Bizzarre solutions, though somewhat rare started. One private hospital in Nevada started “exporting” and transporting [read “dumping”] discharged homelss mental patients to Sacramento CA to let the state of California with better benefits, i.e., higher Social Security benefits, etc., to deal with them. This went on until California caught on, complained, sued, and the hospital in question in Nevada received onerous and well deserved notoriety, really bad PR and was censured and the practice stopped.

Thank you for reading this VERY long lead up to the essence of this article, the question of “bringing back the asylums,” a provocative title to grab the reader’s attention but a very genuine issue. All of the above article has set the state and array of developments, the description of the decades old ideology of de-institutionlization that has unfortunately been another belief that has led us to the jungle and morass of “untended consequences,” the reality that we as a society have still not solved the issue effectively of what do we do with the CMI patients after we extrude them from the all encompassing state hospitals? The above raft of solutions have worked somewhat but have broken down as insufficient support and treatment services afforded these needy patients with a chronic illness just like diabetes that needs very frequent close monitoring and management, have overwhelmed these interim substitute solutions.

Now considered thought is being given to bringing back the state hospital systems, expanding and/or preserving the still existing ones, improving them where needed in order to effectively manage the CMI that likely can not live easily in outside society as the idealists have hoped for decades. Their clinical needs have rendered that hope back to the scrapbook of ‘good idea but no cigar.’ It has worked up to a point, but the point is now bursting, tragedies are mounting and the systems, i.e., nursing homes and unsupervised converted motels for the mentally ill without on site 24 hour a day, skilled supervision and clinical personnel [because that is what it really takes all you ‘cost hawks’] are being asked to do what they are not staffed for. Try having the Boy Scouts of America, who would try hard, defend us against tht terrorists. The analogy is unkind and overdrawn but makes the point. Just Google “murder in nursing homes by mental patients and see the reams of articles, analyses and especially the sordid new stories going back decades but STILL occurring this year!

One seminal and very important call to reconsider the mess of de-institutionalization emerged January 16, 2015 [this year] from the think tank, the department of Medical ethics and health Policy in the Perelman School of Medicine at the University of Pennsylvania, and was published as an editorial in the Journal of the American Medical Association bestowing upon it national attention and legitimacy. For a summary the “Viewpoint” published in JAMA January 20, 2015, Volume 313, Number 3, pgs. 243-244, entitled “Improving Long term Psychiatric Care: Bring Back the Asylum,” please read the news release Penn Medicine Bioethicists Call for Return to Asylums for Long-Term Psychiatric Care.

Among the startling and dismaying statistics cited are, :As the United States population has doubled since 1955, the number in inpatient psychiatric beds in the United States has been cut by nearly 95% to just 45,000, a wholly inadequate equation when considering that are currently 10 million U.S. resident with serious mental illness. The authors, Dominic Sisti PhD, Andre Segal MS, and Ezekiel Emanuel MD PhD of the above name group in the Perelman School of medicine, wrote tellingly, “For the past year years or more, social, political and economic forces coalesced to move severely mentally ill patients out of psychiatric hospitals.” After listing the last several decades’ forces driving “de-institutionalization,” they write that “de-institutionalization has really been transinstitutionalization,”  Now quoting the press release itself, it is stated, “Some patients with chronic psychiatric disease were moved to nursing home or [other hospitals]. Others became homeless, utilizing hospital emergency department for both care and housing. But [and here the quote is from the JAMA editorial text itself: “most disturbingly, U.S. jails and prisons have become the nation’s largest mental health care facilities. Half of all inmates have a mental illness or substance abuse disorder; 15 percent of state inmates are diagnosed with a psychotic disorder….this results in a vicious cycle whereby mentally ill patient move between crisis hospitalization, homelessness and incarceration.”

And again to quote the derivative text of the press release, “Instead the authors suggest that a better option for the severely and chronically mentally ill, and the ‘financially sensible and morally appropriate way forward includes a return to psychiatric asylums that are safe, modern and humane.” And furthermore, “They argue that the term ‘asylum,’ should be understood in its original sense–a plae of safety, sanctuary and healing.”

The text of the editorial puts it even more strongly, “Asylums are a necessity, but not sufficient component of a reformed spectrum of psychiatric services…reforms need to expand the role of these institutions to address a full range of integrated psychiatric treatment services–from providing care to patient who cannot live along or are a danger to themselves and others, to providing care to patients with milder forms of mental illness who can thrive with high quality outpatient care. The fully-integrated, patient centered facilities do exist in the U.S. today, but more are needed to provide 21st century care to patient with chronic, serious mental illness.”

There you have it. We still truly need comprehensive state psychiatric inpatient hosppitals that can provide thorough going vocational rehabilitation and real work placements, avenues to suitable and supervised transitional housing programs, that coordinate even more fully with the local provider agencies and families if there are involved families for these clients, ongoing regular cognitive behavioral and dialectical behavior therapy outpatient programs that are proven to be very effective, comprehensive committed requiring or routinely court mandated LONG TERM substance abuse counseling, education and self recovery efforts, in home medication administration and supervision, increasing funding support for the still expensive monthly depot injectable anti-psychotic medications that largely handle the chronic 85% incidence rate of CMI patients stopping their oral medications and relapsing, and regular, “often enough,” psychiatric contact and evidence based high quality psychopharmacologic medication treatment to maintain the remission of interfering and disabling symptoms,  tragedies and the ability to participate in the many recovery programs and resources more reliably than at present. Nothing else will suffice.


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