Beware return of 'asylums'

By Mark Salzer

and Robert Meek

The Journal of the American Medical Association (JAMA) recently published an opinion supporting the reinstitutionalization of millions of Americans with serious mental illnesses. These putative experts claim that "these individuals cannot help themselves or live independently," and imply that most chronically lack insight and cannot be effectively helped by treatment, while playing into pernicious fears of violence.

The authors conclude that it is time to revert to the original intent of "asylums" as sanctuaries and places of healing and call for a return to institutionalization in psychiatric hospitals of those citizens who are currently in jails or sleeping on our streets, or at risk of such outcomes.

We are perplexed as to why lessons from the past about the costs, ineffectiveness, harms, and moral challenges associated with "asylums" have apparently not been learned.

What do we know?

First, the evidence. Over the past 20 years, there has been a great deal of evidence showing that people with serious mental illnesses are highly capable of leading meaningful lives in the community. They are able to live independently, work, go to school, be loving partners and parents, volunteer, be powerful peers and advocates, and generally do the same things as anyone else, especially if provided the proper resources and supports.

Engaging in these activities is good for their physical and mental health. The problem is that the available resources and supports in these areas are woefully inadequate, partly due to lack of funding. For example, state-based funding (solely state dollars) for community mental-health services in Pennsylvania has decreased a staggering 20 percent over the last two years. Meanwhile, despite a declining state hospital population, state funding for institutional care has risen 6 percent over the same period.

Adequate funding of community-based services is needed, not more institutions that are more expensive per capita and for which no federal Medicaid dollars can be drawn down, a funding source sorely needed to provide adequate services.

Second, the perceptions. The argument for returning to "asylums" is partly predicated on misperceptions.

The homelessness and criminal-justice issues that people with serious mental illnesses experience are primarily due to poverty and substance abuse. Illusory ideas about the role of mental illnesses in these social problems lead to illusory solutions.

The JAMA article also plays into fears of a link between violence and mental illness. The reality is that there is a link, but not in the direction that draws the attention of the media and creates exaggerated fears in the populace. Individuals with severe mental illnesses are 2.5 times more likely to be attacked, raped, or mugged than the general population and 14 times more likely to be victims of a violent crime than to be arrested for one. The solution is to effectively address violence, prejudice, and discrimination against people with mental illnesses, not perpetuate it with misguided viewpoints.

Third, the reality of "asylums." Anyone who knows their history or understands their features appreciates that the original intent of "asylums" cannot be achieved. They were never, and never can be, pleasant sanctuaries of healing, let alone settings that uphold fairness, dignity, respect, rights, and capabilities, all key ethical principles.

Moreover, "asylums" clearly can cause harm, as described in, for example, Albert Deutsch's classic book Shame of the States or the documentary Titicut Follies. Numerous theorists and researchers conclude that these institutions are inherently flawed. Relapsing to such an approach in the name of treatment is most certainly regressive thinking.

Effective and accessible community-based services can be one-tenth the cost of incarceration in an asylum and have been shown to enhance the quality of life of these valuable American citizens. That is clearly the solution.

Fourth, it is important to maintain the advances that have been made in mental health care.

Great strides in knowledge about effective mental-health services and policies have occurred over the past two decades. But a backlash is afoot, seemingly driven by stereotypes, prejudice, and skewed interpretations of data that threaten this progress.

We were buoyed by President Obama's State of the Union speech, in which he said he wants "future generations to know that we are a people who see our differences as a great gift, that we are a people who value the dignity and worth of every citizen," specifically mentioning "Americans with mental illness" along with people of different races, ethnicities, and class.

This is the first time we can recall a president explicitly declaring the worth and dignity in our society of people with mental illnesses. Let us hope that this is the ethic that is kept in mind in the development of mental-health policies for decades to come.