Back to the Future: Asylums for People Living with Severe Mental Illness?

Dominic Sisti, Ph.D.,  an Assistant Professor of Medical Ethics/Health Policy and Psychiatry at the University of Pennsylvania is the principal author of an article, “Improving Long-term Psychiatric Care: Bring Back the Asylum,” in the Journal of the American Medical Association.

Dr. Sisti argues that comprehensive, accessible and fully integrated community-based mental health care continues to be an unmet promise. He argues that deinstitutionalization has really been “transinstitutionalization,” resulting in a vicious cycle whereby mentally ill patients move between crisis hospitalization, homelessness and incarceration. The report cites recent studies that show that prisoners with a serious mental illness are two to three times more likely than prisoners without serious mental illness to be reincarcerated, that half of all inmates have a mental illness or substance abuse disorder, and that 15 percent of state inmates are diagnosed with a psychotic disorder. Dr. Sisti says that new models of fully integrated, patient-centered long-term psychiatric care now exist in the United States and that such facilities are needed to provide 21st-century care to patients with chronic, serious mental illness.

Dr. Sisti will be speaking at the Commonwealth Club of California on July 22nd. He along with others will be answering these questions:

Should severely mentally ill people be integrated within the community? Or should asylums be  revisited? How would individuals come to be placed in such asylums? What civil rights issues come into play? How would such institutions be funded? Who would staff them and how would training and management ensure humane care? How could modern psychopharmacology and neuromedicine be applied? How could such institutions be structured to perhaps have different levels of institutionalization, from semi-independent living to more comprehensive care? How could they be made into places where people want to be, because their lives would be better than on their own?

While I agree with some of Dr. Sisti’s finding on the consequences of “deinstitutionalization” I strongly disagree with his orientation to solving these problems. Over the past 20-30 years, in addition to the problems, we have also seen tremendous improvements in psychiatric and mental health care including advancements in medications; cognitive behavioral approaches; wrap around service models, supportive housing etc. And while Dr. Sisti focuses on the negative results,  I/we have seen and heard many exhilarating stories of recovery and hope here in San Mateo and across the State and Nation that says we can do better than bringing back the asylums.

If we had the resources that would be required to implement an “asylum system of care” I believe they would be far better used and exponentially more effective if directed toward securing safe and affordable supportive housing, supportive employment, behavioral health workforce development, research on medications and treatment interventions, alternatives to State Hospital, building broader peer support networks and services, more direct support for family members, increased and enhanced crisis intervention training and services to name a “few”.

Lets not look to the past for a solution to today’s challenges but rather build on what is working today that meets the needs of those living with mental illness, their families and our broader community.

One comment

  • Thank you, Steve, for your insightful and compassionate response! These types of suppositions made by Dr. Sisti are myopic and and dangerously uninspired. To revert back to a type of “treatment” that criminalizes and marginalizes individuals with severe mental health challenges serves no one and only pushes away the strong need for humane support under the rug… for us to trip over later. I am grateful for your acknowledgment of what’s working and where we can grow from here. Onward and upward!

    Cardum Harmon
    Heart and Soul, Inc.