The Myopic Optimism of the ‘Good’ Asylum

Date: 03/2015

In recent weeks, both the New York Times and the Journal of the American Medical Association published articles that call for a return to asylum-style care for people with serious mental illness. These authors take the stance that the decades-long effort to reform mental health services – a movement away from custodial institutional care and toward community-based supports – is a failure, citing the high numbers of people who have ended up homeless, incarcerated, or receiving inadequate care in understaffed emergency rooms and nursing homes. Christine Montross, in the New York Times, also extends the institutional care possibility to people with intellectual disabilities – a group whose outcomes in the community have been largely positive. The JAMA article focuses on treatment for people who are too “unsafe” for community services. But this overstated link between mental illness and violence is unsubstantiated: research shows that people with serious mental illness are 10 times more likely to be victims than perpetrators of violent crime.

The solution, these writers argue, is a 21st-century version of the 19th-century notion of the asylum. But any student of history can tell you that the retreat-style ideal at the heart of this model rapidly deteriorated from sanctuary to warehouse in a matter of decades. The scandalous results of isolation, stigma, and inadequate expenditure of public resources associated with the institution model have been chronicled by reformers as early as Irving Goffman and continue to this day.

Christine Montross’s empathy with her patients’ suffering and her frustration with the challenges of providing appropriate quality care—both of which are due to the inadequacies of community services—are apparent and understandable. However, her proposed solution, though well intentioned, is misguided.  History has repeatedly demonstrated that a policy based on institutional “solutions” to the individual and social problems of mental illness, though attractive in the abstract, are destined to failure, with consequences more deleterious than those of the deinstitutionalization movement.  Ironically, the author’s own facility, Butler Hospital, is a prime historical example of why even the most advanced, high-quality institutions are not adequate solutions to the challenges she identifies.

We agree that deinstitutionalization has left many people in shameful straits. However, we strongly disagree that the solution is to recreate the asylum in any form. Regardless of intention, the proposed “clean, well-lighted place” of healing and safety has yet to hold up to historical realities. Even the authors admit that fully supporting their ideal would require an infusion of public resources that is unlikely to be forthcoming. And we take particular exception to the fact that the authors overlook two significant factors: research that shows the positive outcomes of supporting people in communities and the voices of people with disabilities who have consistently advocated for a system that supports leading real lives in real communities.   

The solution to the legitimate issues these authors raise is to acknowledge that the original advocates of deinstitutionalization did not ensure that alternatives would be adequately funded and to commit to an uncompromising effort to secure funding for evidence-based practices that divert people from prisons and jails, support their inclusion in their communities and jobs, ensure they have access to adequate treatment, and – above all – engage them as partners in the campaign. 

In calling for a return to institutional treatment, the authors ignore the universe of creative, humane, evidence-based services and supports that enable people with even the most severe mental illnesses and intellectual disabilities to live meaningful lives in the community. These services aim to support people as they obtain employment and develop valued relationships, and they foster emotional and physical wellness. Services like supported housing, supported employment, peer supports – and crisis respites when more intensive services are needed – are not only more desirable but also less expensive than institutional care. However, they are underfunded and unavailable to many people who would benefit from them.

Given the current state of funding nationwide (states facing severe financial shortfalls have cut at least $4.35 billion in public mental health spending from 2009 to 2012) it seems naïve to think that resources necessary to maintain improved asylum facilities could continue in perpetuity. Moreover, states alone would largely foot the bill for modernized asylums: whereas most community services are eligible to receive a federal match from Medicaid (with rates ranging from 50% to 75%; Massachusetts receives 50%), institutions for adults are not eligible for this match. To divert more funding from evidence-based supports in order to return to a model with a proven record of widespread and spectacular failures – a model that proved not only ineffective but inhumane – is senseless.

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