The Need for Asylum, Not Asylums

Abstract

Editor: John A. Talbott, M.D. Editorial Board: Varda P. Backus, M.D. James T. Barter, M.D. Gail M. Barton, M.D. Ethel M. Bonn, M.D. BurtonJ. Goldstein, M.D. Ezra E. H. Griffith, M.D. H. Richard Lamb, M.D. Robert B. Millman, M.D. Carol C. Nadelson, M.D. Pedro Ruiz, M.D. Herzl R. Spiro, M.D. George Tarjan, M.D. Interdisciplinary Advisory Board: Ann Conway, O.T.R. Sheldon Silk, MS. MarkJ. Mills,J.D., M.D. Lucile Stark, M.L.S. Robert Porter, Ed.D. Gary R. VandenBos, Ph.D. W. Carole Chenitz, R.N., Ed.D. Contributing Editors: Paul S. Appelbaum, M.D., Law & Psychiatry Allen Frances, M.D., Treatment Planning Martin Gittelman, Ph.D., Foreign Psychiatry Martin Kesselman, M.D., Book Reviews Carl Salaman, M.D., Psychopharmacology Steven S. Sharfstein, M.D., Economic Grand Rounds Zebulon Taintor, M.D.. Using Computers Gene D. Cohen, M.D., Ph.D., Practical Geriatrics Editorial Consultants: Leona L Bachrach, Ph.D. John 0. Lipkin, M.D. Theodore W. Lorei, M.S.W. Cover Art Consultant: Sally Webster, New York City Editorial Staff: Teddye Clayton, Managing Editor Betty Cochran, Assistant Managing Editor Joan OConnor, Senior A.r.ristant Editor Vivian Rothschild, Assistant Editor Denise Felix, Production Editor Erica Hunter, Administrative Assistant Lee Tucker, Secretary Advertising Production, Circulation: Nancy Frey, Chief, Periodicals Services Linda Boraiko, Advertising Production Manager Laura Gorham, Classified Advertising Beth Prester, Circulation Manager Glen Grant, Circulation Coordinator Advertising Sales: Raymond J. Purkis MartinJ. Zittel 2444 Morris Avenue Union, New Jersey 07083 (201) 964-3100 American Psychiatric Association: George Tarjan, M.D., President John A. Talbort, M.D., President-Elect Harvey Bluestone, M.D., Speaker, APA Assembly Melvin Sabshin, M.D., Medical Director Donald W. Hammersley, M.D., Deputy Medical Director and Director, H&CP Service The Need for Asylum, Not Asylums When it comes to our institutions, we in psychiatry seem to have a predilection for concrete thinking Community mental health centers seem to be thought of only as federally funded, low-lying, cinder block buildings adjacent to general hospitals, and asylums only as state-run, redbricked behemoths, located hundreds of miles from modern urban cornmunities. However, just as CMHCs were meant to be services rather than buildings, asylums offered more than just four walls. The first asylum in America, the Eastern Lunatic Asylum in Williamsburg, Virginia (pictured on our cover), opened in 1 773. Shortly thereafter, both private and public mental hospitals were established to care for the severely and chronically mentally ill Their underlying philosophic tenet was “moral treatment,” which was intended to encourage patients to recover in bucolic surroundings far from the hurly-burly of the rapidly changing world While even in the 19th century some programs were established outside these institutions, care in freestanding mental hospitals remained the norm. Depopulation of our state hospitals in the rnid-1950s changed all that Some overly idealistic leaders, convinced that hospitals caused mental disease and disability, advocated their abolition, and the nation embarked enthusiastically on such a course. However, two few programs were set up in the community to care for those we discharged or refused to admit, and no provision was made for those who needed ongoing protective shelter or custodial care. As we approach the 30th anniversary of this depopulation movement, we have come to realize that while good community care may benefit the majority of the chronically mentally ill, a small minority, estimated to be between 2 and 5 percent, need some form of humane asylum. Ironically, however, there are currently no strategies to implement or fund this concept of asylum. The Veterans Administration has long provided domiciliary care for patients not in need of active care, and some states have piloted the use of small locked facilities in the community. But for most of the chronically mentally ill, there are no alternatives to acute hospitalization or care in nursing homes. We must no longer be so concrete in our conceptualization of the asylum, or so overidealistic and passive. Until we can cure psychotic illnesses, some of our patients will require asylum, and we need to pursue reimbursement mechanisms that will enable us to provide it. What we call the places where these patients reside-asylums, sheltered settings, or long-term secure residences-is immaterial. What is important is that we find ways to offer humane asylum in our communities for the frail, inadequate, and inept mentally ill who need it.-JOHN A. TALB0TT, M.D., Editor