By Paul Gionfriddo
The JAMA headline is pretty sensational: Improving Long-term Psychiatric Care: Bring Back the Asylum. And the article itself is generating a lot of discussion and debate.
But headlines can be misleading. As the authors write:
“A return to asylum-based long-term psychiatric care will not remedy the complex problems of the US mental health system, especially for patients with milder forms of mental illness who can thrive with high-quality outpatient care.”
They are right about this. We should be focusing on high-quality community-based care, not putting people in asylums. But they are not the first ones to make this point. Our founder, Clifford Beers, made it more than a hundred years ago.
However, sensational headlines attract attention and sometimes take the air out of the actual arguments being made.
So who will really pay attention to the fact that what the authors are arguing for is a balanced approach to building a system – adding more beds and more community services?
Or that the real fault in their logic is rooted in their too-narrow perspective:
“For persons with severe and treatment-resistant psychotic disorders, who are too unstable or unsafe for community-based treatment, the choice is between the prison–homelessness–acute hospitalization–prison cycle or long-term psychiatric institutionalization.”
That’s only the choice for people who are trapped in Stage 4 thinking about mental illness, who believe that people magically become seriously mentally ill all of sudden one day, and who fail to understand that it is a chain of neglect that leads them to prisons, homelessness, acute hospitalizations, and long-term institutionalization.
We’re not really offering people a choice today, because we are waiting too long to diagnose and respond to mental illnesses instead of intervening as soon as symptoms emerge – and we are failing to offer a full menu of treatments and supports.
So what the authors are really arguing for is a path to institutionalization in the guise of compassion.
“Reforms that ignore the importance of expanding the role of such institutions will fail mental health patients who cannot live alone, cannot care for themselves, or are a danger to themselves and others.”
Who says they “cannot”? That assertion is indefensible, and that path to institutionalization for long-term care services is a well-traveled one that has proven expensive and inadequate for people with every chronic condition. The evidence for this exists both in this country (in historical Medicaid long term care spending, for example) and throughout the world.
But that doesn’t stop the authors from making an argument that made its home in the 19th century.