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Philadelphia succeeds without 'asylums'

If we were able to create health-promoting communities and expand the services we already provide there would be no need to call for a return to "asylums."

This is one in a mini-series of posts about the state of mental health care in America, and how to fix it.

As far as health issues go, matters of behavioral health present unique challenges, both for those struggling with disorders and for the broader community as well. The majority of people with behavioral health issues never receive treatment and for those that do go to a behavioral health provider, the majority of people never return for a second visit. This means that people often wait until a psychiatric emergency develops before accessing care. This is equivalent to people never getting a physical health check-up and then discovering they have Stage IV cancer.

One problem is the stigma that surrounds these serious but common and treatable health issues which unjustly places shame on those who are affected by them including their families.

A second challenge to behavioral health is misinformation. Stigma can cast a veil that obscures truth and makes possible the spreading of fear-based myths and what are ultimately dehumanizing stereotypes. The veil promotes unhealthy and hostile attitudes in communities and shames a tragic many from considering seeking the help they need.

Successes in our community-based approach extends to treatment for youth. In 2006, Philadelphia had 1,588 youth in residential treatment, seen as the only option available and appropriate to them. Since that time, however, DBHIDS has created strategic and significant community-based treatment opportunities, which have resulted in real cost savings to taxpayers – and better results for youth. As of 2014, we have seen a 74% decrease in youth requiring residential treatment.

Over the past 10 years, through unprecedented collaboration with our providers, community stakeholders, academic partners and other agencies, DBHIDS has seen the impact of what a recovery-oriented system can have on a city. We are continuing to build upon this work, including enhancing our public health approach, to increase awareness of these common and treatable health issues and reduce the stigma that prevents far too many to seek help.

Programs like Mental Health First Aid (now mandatory for all Philadelphia police cadets), online screenings, and the numerous behavioral health-themed mural projects across the city, all serve the goals of prevention, early intervention, and reducing stigma, which are key to reducing crises and increase the capacity for communities to support people.

We should not be asking for the return of asylums in our behavioral health care system, but rather communities that are safe from violence, prejudice, poverty, food deserts, and inadequate educational and economic opportunities. We need places for children and families to thrive and for systems to support health. This means a comprehensive recovery- and resilience-oriented behavioral health system that can support individuals and families living in communities. This will lead to a greater likelihood of people learning, working, and contributing to their community. This is in contrast to asylums that rely on paternalistic care in settings that do not support independence and a life in the community. Recovery and a life in the community can be accomplished in many ways. We have examples of this right here in Philadelphia, including Journey of Hope, which provides community-based treatment for individuals with histories of chronic homelessness and substance abuse conditions. These specialized treatment programs support people in their recovery and do not require sobriety to access care.

Another successful community-based program for individuals with serious mental illness has been the transformation of Philadelphia's Day Treatment or Maintenance programs to Community Integrated Recovery Centers. Instead of having vans pick up and drop off people every day at centers, where they would often sit idly in front of televisions and smoke cigarettes, the these integrated recovery centers now teach daily living skills such as taking public transportation, and prepare people for educational and job opportunities. The data shows that for those with at least 1 year in the program, we see a 36% decrease in the need for crisis services. We have remarkable evidence of people succeeding, such as person who was once considered mute to now speaking and being employed as a recovery peer specialist.

If we were able to provide more services like this and create health-promoting communities, we guarantee that 21st century care would learn from our history – and not include a call for 'asylums'.

Arthur C. Evans Jr., Ph.D., is the Commissioner of the Philadelphia Department of Behavioral Health and Intellectual disAbility Services. Samantha Matlin, Ph.D. is Special Advisor to the Commissioner and Senior Director for Health Promotion. Matthew O. Hurford, M.D. is the former Chief Medical Officer.

Read more about The Public's Health.