Asylums: Back to the Future?

Reading the column by APA President Renée Binder, M.D., titled “Return to Asylums? NEVER!” in the August 21 issue, I was dismayed by the lack of definition of “asylum.” Instead, we should be debating how people with serious and persistent mental illness ought to be cared for, given our inhumane, costly, and morally irresponsible status quo. By creating alternatives, we will begin to shift the expectations of our patients and the public debate about the scope of such possibility.

As an early career psychiatrist working in a public hospital with involuntary severely persistently mentally ill (SPMI) patients and consulting for medically underserved populations, I do not know firsthand the abuses of the state psychiatric hospitals, though they have a history of brutality, victimization, and other excesses with little emphasis on recovery. Many of my hospitalized SPMI patients have told me they prefer jail to the involuntary treatment they receive in the hospital, which is indeed a damning indictment.

However, this need not be the case. Asylum could be defined by open, voluntary, accessible, recovery-oriented residential treatment for many of those now cycling through hospitals and jails and prisons. Such models existed at the intersection of deinstitutionalization and the nascent community treatment that was meant to replace it in the 1960s and are contemporary in the few remaining Soteria model houses in the United States and Northern Europe. It is in large part because of the habituation to violent and involuntary treatment that today’s chronically institutionalized and incarcerated patients are disengaged and hostile to care.

It is only through our own vision and leadership that a new generation of mentally ill patients can have different experiences and expectations of the care offered to them and that alternative models of community care and asylum, rather than involuntary detention (whether hospital or prison), can become viable. Community care will provide part of the solution, but it cannot serve the needs of our most vulnerable patients.

Taylor Mac Black, M.D. (Seattle, Wash.)

Thank you for taking the time to share your comments on my column. I define “asylum” as an institution that provides long-term treatment and housing to people with mental illness. As we all know, asylums in this country were built to separate people with mental illness from the rest of the community and have a long history of providing inadequate or even harmful care, severely limited by a lack of understanding of the etiology of mental illness as well as resources. During the era of asylums, people with mental illness were locked away and warehoused; today, they are warehoused in jails and prisons—a situation that I am addressing through initiatives this year as APA president. However, I don’t think we are far apart in our thinking, because I do believe that this country would benefit from new models of residential treatment that respect autonomy. We also need other models of care and alternatives that include diversion programs, collaborative courts, and increased community treatment with wraparound services, housing, substance abuse programs, and early intervention and prevention services. I appreciate your input and your suggestions. ■