Don’t Bring Back the Asylum: Recovery, Not Re-institutionalization
Amid the current opioid crisis, high-profile events of mass violence and suicide, mental health parity implementation, and continued efforts to expand Medicaid for childless adults, never has behavioral health featured so prominently on policy agendas. Industry experts are scrambling for solutions, including a serious proposal to reintroduce the “asylum” as described in the Journal of the American Medical Association (JAMA) in January of this year. The JAMA article argued for the expansion of institutionalized settings for people with mental illness who cannot live alone, cannot care for themselves, or are a danger to themselves and others. Surely the solution to tackling the incredibly complex problem of mental illness and substance misuse has to involve a broader dialogue than whether or not we need more inpatient psychiatric beds.
It is undeniable that mental health care faces centuries of discrimination to catch up with our physical health care counterparts. However, reinforcing a delivery model that is asylum-based only takes us backwards. Recovery itself does not – and never will – take place in institutionalized settings. Indeed, “recovery” is mentioned only once in the JAMA article, describing prison settings as an “environment anathema to the goals of psychiatric recovery.” What the JAMA article does not go on to explore is that recovery is only truly successful, and sustained, when achieved in the community.
A reduction in the number of inpatient psychiatric beds doesn’t have to end up as a game of “Whack-a-mole” with the same individuals popping up in different settings, including prisons and emergency rooms. With targeted investment in robust social wraparound supports, the evidence is clear that it is possible to achieve recovery for almost all individuals with severe and enduring mental illness in community settings. However, achieving a 21st century model of mental health care means paying for more than just inpatient beds.
In Massachusetts, several initiatives – such as REACH (Recovery, Education & Access to Community Health) – have demonstrated that it is possible to provide alternatives to inpatient admissions. The REACH program was driven by an innovative reimbursement model, more of which are needed to drive improvement in mental health care. However, the challenges faced by this sector are not solely about reimbursement. In one of the great ironies of US healthcare, those with serious mental illness are “lucky” to have a Medicaid benefit versus a commercial insurance benefit. Since the early 1990s, state Medicaid programs and departments of mental health have invested heavily in community-based flexible supports that focus on non-medical interventions to reduce social isolation, increase self-management skills, and improve an individual’s ability to live independently. Community support workers, targeted case management, day programs, transportation supports, clubhouse services, and in-home therapies are all examples of services that focus on the unique circumstances of each individual to execute a “person-centered recovery plan.” Few, if any, commercial carriers include such flexible interventions in their benefit structures. Persons with serious mental illness must be either poor enough or disabled enough to avail themselves of such recovery services. These interventions work for some of the most treatment refractory populations, yet the JAMA is suggesting that the answer for the 180 million Americans who get their health insurance through employers is to increase access to inpatient beds?
It’s hard to imagine a future state where inpatient mental health beds are no longer required at all. There will likely always be a need for a small number of acute emergency inpatient psychiatric beds, but we need to focus our energies on the many currently underutilized alternatives that exist – and not on asylums. Indeed, the very word “asylum” suggests treatment that, by its very definition, can go unseen and therefore unchecked by society at large.
Such alternative settings include Crisis Stabilization Units, which provide a short-term residential setting to de-escalate the severity of an individual’s distress through providing 24-hour observation and supervision (SAMHSA, 2012). Internationally, there is a growing evidence base that “Crisis Houses” are as effective as care provided in inpatient settings with higher user satisfaction as well as more cost-effective (Hayes et al. 2012). For a significant proportion of people in psychiatric inpatient beds today, many of them have nowhere else to live and are otherwise homeless. For such individuals, Housing First is an example of attempts to end homelessness through rapid rehousing. People with mental illness are more likely to require access to these crisis services when other factors, such as poverty, unstable housing, coexisting substance use, and other physical health problems, co-occur.
In a “big data” world of predictive analytics and risk stratification models, there is more we can do to identify those most at risk and target limited resources accordingly; it doesn’t have to be a game of “Whack-a-mole.” Failure to innovate care for the most vulnerable individuals who need it most risks stepping back to a 19th century asylum mentality of containment. Indeed, the very suggestion hints at defeat during a time when our understanding of mental illness is unprecedented. It is our obligation to look forward, not backwards.
Sisti, D.A. (2015). Improving Long-term Psychiatric Care: Bring Back the Asylum. JAMA. 313, (3).
Binelli, M. (2015, March 29). This place is not designed for humanity. The New York Times Magazine.
Hayes, J. Gibbons, R. Outim, F. Tang, S. Chakraborty, A. (2012). A new model for quality improvement in acute inpatient psychiatry: observational data from an acute assessment unit. JRSM Open. 3, (9) 65.