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.

We were alarmed by the basic premise of "Improving Long-term Psychiatric Care, Bring Back the Asylum,” as published in the Journal of the American Medical Association, which advocated for the return of what the modern behavioral health community hoped would remain buried in the past. Asylums in their best practice separated individuals from families and communities and supported the notion that people cannot recover from serious mental illness. Asylums in their worst practice created harmful and dangerous living conditions similar to prison camps. A return to asylums is actually contradictory to the current science and practice within the field and what we know is required to improve the health status of individuals, communities, and the City of Philadelphia.

The authors note that many people find themselves trapped in a cycle formed by incarceration, homelessness, and acute hospitalization. We disagree that homelessness is an unavoidable consequence for many struggling with a serious mental health disorder. People experience homelessness quite simply because of a lack of housing. When housing, along with appropriate support services, is made available to people experiencing serious mental illness, we know that homelessness is eliminated. For example, Philadelphia has created a unique partnership led by the office of the Deputy Mayor for Health and Opportunity that includes the Philadelphia Housing Authority, the Office of Supportive Housing, the Department of Behavioral Health/Intellectual disAbility Services (DBHIDS), and provider agencies that offer housing through vouchers for individuals with serious mental illnesses and substance use conditions. Since 2012, 792 individuals have moved into permanent supportive housing. Over 350 of them came from mental health residential programs, primarily congregate care settings, with the remainder being people who were experiencing long-term street homelessness. Approximately 94% of these individuals remain in their housing and are doing well living in the community.

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.

Further, more and more research shows that medical care is responsible for only 10-20% of our our health status. Where we live, work, and play greatly shape our health and well-being. In fact, lifestyle factors such as eating, smoking, and physical activity, and our social and economic well-being, largely determine how healthy we are (see County Health Rankings and Roadmaps). As the Robert Wood Johnson Foundation has eloquently stated, our zip code may be more important to our health than our genetic code. So any strategies to address serious mental illness must include economic and social supports, including housing.

DBHIDS administers the City of Philadelphia’s behavioral health system, providing supports and services through a network of providers throughout the city, addressing the needs of 1.5 million people. This year marks the 10th anniversary of our system transformation efforts, which have involved the aligning of how people receive services with a new vision of helping people lead productive and fulfilling lives in their communities informed by what we know: people can and do recover from even the most serious mental illness or addiction. Courtenay Harding and her colleagues’ seminal 1987, The Vermont Study Longitudinal Study of Persons With Severe Mental Illness, which has been replicated numerous times, has indeed found that the majority of people can and do recover; only a small minority of people with serious mental illness need long-term intensive supports. For most people, these supports can be successfully and cost-effectively provided in community-based settings.

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.

In addition to free and anonymous online screenings and regular public engagement at health fairs or other major events and campaigns, DBHIDS is committed to innovative initiatives like Mental Health First Aid, a free training program designed to help people recognize someone experiencing a behavioral health challenge and offer support. Over 8,000 Mental Health First Aiders have been trained in Philadelphia, with over 190 Philadelphia instructors leading the trainings. Satisfaction with the training has been overwhelmingly positive. As a member of the faith community shared: “I learned so much today that I feel I may be able to help others.”

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.

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