Seeking common ground in very different views of mental illness

A trio of ethicists from the University of Pennsylvania sparked some controversy last month by publishing an essay that was provocatively headlined "Improving Long-term Psychiatric Care: Bring Back the Asylum."

The authors–Dominic Sisti, Andrea Segal, and Ezekiel Emanuel– are highly respected in their field, and the article appeared in the top-flight Journal of the American Medical Association. Their intent was to call attention to the poor state of long-term psychiatric care in the United States, and for a return to inpatient care in what used to be called asylums. This lightning-rod idea to reestablish asylums has been both rebuked and praised among those mindful of the issues.

The Public's Health is joining the fray. Today we run the first of several articles exploring the state of mental health care in America, particularly how and where to treat people with severe mental illness. This piece includes authors from the "asylum" essay and critics of it, but they start on common ground: a discussion of some agreed-upon strategies to better the lives of those suffering from mental illness. MICHAEL YUDELL

Mental health care in the United States continues to be under-resourced, plagued by fragmentation, subjected to ever-changing political forces, and influenced by public misunderstanding and controversy. Consensus on how to best serve people with mental health conditions remains elusive. Proponents of the medical model of mental illness (diseases that can be treated with biomedical and psychosocial interventions) remain deadlocked with advocates of the recovery model (a personal journey toward potential that leaves the individual in control). The result is an ever-deepening schism.

The current state of affairs and lack of constructive dialogue have both clinical and ethical ramifications: in the end, people with mental health conditions are the ones who lose. Rapprochement is an ethical obligation if we are to improve the lives of these individuals.

This blog post points to possible areas of common ground in order to advance the conversation:

1. People with mental health conditions deserve the care they need, and whenever possible deserve to play the central role in determining what that care consists of. This fundamental ethical claim motivates consumers, advocates, family members, clinicians, policymakers, and ethicists. It is a statement grounded in an abiding respect for human rights and the belief that mental health care—like all health care— is a right that we as a civil society must find a way to provide, particularly to those who are vulnerable. Aside from this being intrinsically the right thing to do, every citizen has a personal and economic stake in the health and well-being of her neighbor.

2. Mental health care must be individualized, age appropriate, and person-centered. Diagnostic categories without context ought not determine treatment or prognosis. Medical treatments that do not address an individual's unique needs are less effective or even harmful. Providers of mental health care must strive to treat the entire person using evidence-based programs and tools. This means deploying, when appropriate and desired by the individual, both recovery-based and biomedical interventions synergistically. Encouraging the widespread use of psychiatric advance directives is another important way to achieve this goal.

3. We need better ways to keep people with mental health conditions out of prison. Just two weeks ago the Vera Institute for Justice published its report on the widespread misuse of jails, which often ensnare individuals with mental health conditions who are too poor to make bail. This report is one of many that paint the same picture. Too many incarcerated individuals have unmet mental health needs. Sentencing guidelines and bail requirements must be revised and mental health courts and other diversion programs must be scaled up to prevent the incarceration of people who have committed minor offenses, quite possibly as a result of a mental health condition.

4. Finally, and most ambitiously: addressing the root causes of serious mental health conditions requires a sustained effort to address the profound disparities between the rich and the poor, and the public health ramifications of poverty, toxic stress, and trauma. While promising new interventions—including both biomedical and psychosocial treatments—are on the horizon, without a transformation of our basic social structures toward those that are more egalitarian, such solutions will be of limited value.

It is true that between advocates of the recovery and biomedical models there are significant substantive and philosophical differences of opinion on several specific issues related to involuntary interventions and the use of assisted outpatient treatment, to name two examples. These differences must be considered and addressed.

In the end, we would do well to remember our common goal: helping and supporting individuals and families who are affected by mental health conditions.

Dominic Sisti is director of the Scattergood Program for Applied Ethics of Behavioral Healthcare and Assistant Professor at the University of Pennsylvania.

Joseph Rogers is Chief Advocacy Officer of the Mental Health Association of Southeastern Pennsylvania.

Michael Brody is President and Chief Executive Officer of the association.

Andrea Segal is research coordinator for the Scattergood Program for Applied Ethics of Behavioral Healthcare and adjunct instructor at Penn's School of Social Policy and Practice.

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