Tag Archives: deinstitutionalization

Should We Bring Back Mental Asylums?

newer meby Marvin Ross

Dr Dawson provided an excellent history of how much we have regressed in our treatment of those with mental illness in his five part series. Despite better (but not perfect) medications, and greater knowledge of the brain, we have, as he said, “For a significant number of mentally ill people (and their families) we have, over the past 30 years, reversed the reforms provoked by Dorothea Dix in 1843.”

Certainly, the statistics for Canada, the US and the UK, bear this out. The Canadian Journal of Psychiatry pointed out that there was a rapid closure of beds in the 1970s and 1980s but that was offset by an increase in days of care in the psychiatric units of general hospitals. They called this transinstitutionalization. But, by the 1990s the overall days of inpatient care began to decrease. Between 1985 to 1999 there was a decline of 41.6% in average days of care per 1000 pop in psychiatric hospitals and a decline of 33.7% in psych units in general hospitals. Days in hospital declined but there were more frequent stays for patients – the revolving door.

In a document by the Public Health Agency of Canada called the Human Face of Mental Illness, it was stated that “This discontinuity and inadequacy of care after hospitalization is common among seniors who have lived with schizophrenia for most of their lives. After being transferred from psychiatric institutions they may find themselves in long- term care facilities that generally have limited availability of mental health professionals.”

Meanwhile, there was a near-doubling in the total proportion of prison inmates in Canada with mental illnesses between 1997 and 2009. Prisoners often end up in segregation units and without adequate treatment because the prisons don’t have the staff or resources to properly care for them.

In the US according to the Treatment Advocacy Center, in 1955 there were 340 public psychiatric beds available per 100,000 U.S. citizens. By 2005, the number plummeted to a staggering 17 beds per 100,000 persons. And we know that the largest psychiatric facilities in the US are the jails in New York City, Chicago and LA.

The Guardian newspaper in the UK recently reported that more than 2,100 mental health beds have closed since April 2011, amounting to a 12% decline in the total number available. It also found that seven people had killed themselves since 2012 after being told there were no hospital beds for them.

On one occasion last year, there were no beds available for adults in England.

In 2011, Dr Peter Tyrer, a professor of community psychiatry at the Centre for Mental Health at Imperial College, London, wrote in the British Medical Journal that “I am now rueing the success of the community psychiatric movement in the UK, where the inane chant of “community good, hospital bad” has taken over every part of national policy. At some point in the steady reduction of psychiatric beds, from a maximum of 155 000 in 1954 to 27 000 in 2008 the downward slope has to level off or rise.”

Meanwhile, earlier this year, three medical ethicists at the University of Pennsylvania, Dominic Sisti, Andrea Segal and Ezekiel Emanuel, argued for a return of the mental asylum in the Journal of the American Medical Association. They said that their use of the word asylum wasn’t meant to be “intentionally provocative.”

“We’re hoping to reappropriate the term to get back to its original meaning, which is a place of safety, sanctuary, and healing, or at least dignified healing for people who are very sick.”

The United States, they said, now has 14 public psychiatric beds per 100,000 people, the same as in 1850. On average, Sisti said, countries in the European Union have 50 beds per 100,000.

On a personal level, author Katherine Flannery Dering whose book Shot in the Head discusses how she and her 8 siblings cared for a brother with schizophrenia, described the impact of what she called The Great Emptying on one of the talks that she gave. As she says, the number of people needing hospitals did not shrink as much as hospitals did.

Asylums (or psychiatric hospitals) do not have to be evil places where patients are abused or ignored. There is no reason they cannot be caring compassionate places that give patients the necessary time to heal or to protect them from the outside world if that is what they need.


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One Step Forward, Two Steps Back – Mental Illness Treatment Over the Past 150+ Years – Part V of IV

David Laing DawsonBy Dr David Laing Dawson

Since writing Part IV, I’ve read E. Fuller Torrey’s American Psychosis. So there is my historian tracing the manner in which the personal struggles of politicians, the belief systems of leading professionals of the time, egos, idealism, personal tragedies, and, of course, power, politics, and money brought about the disastrous transformation and destruction of the mental illness treatment system from 1963 to present time in the US.

Canada is always a slightly more cautious, reticent, little brother too often lead astray by his risk taking, grandiose big brother. We are not as enamoured with the profit motive; we have evolved a somewhat different social contract; our minimum wages and safety nets are better; our Federal Government dare not (thanks in large part to Quebec) tamper with social and health programs long the responsibility of our provinces (or initiate something unilaterally that would undermine or destroy Provincial Programs). So we still have most of our mental hospitals, and they are mostly linked and associated with our community programs. Our psychiatric leaders and teachers remained a little more grounded in the observations of Dr. Kraeplin than the fanciful extrapolations of Drs. Freud and Laing. We realize, I hope, that privatizing our garbage collection (providing we retain sensible unions) might be both fiscally and socially responsible, but privatizing the care of the mentally ill is not.

Yet in our own slow and cautious way we are following the same path as the US. Completely discredited ideas about the causes, treatments, and “prevention” of serious mental illness, once promoted by the Psychoanalysists who designed the American Community Mental Health Programs of 1960 and 1970 are finding their way into our commissions and planning groups. Our linguistic avoidance of ‘illness’ in favour of ‘issues’ and ‘health’ is just another form of denial of the knowledge that, unfortunately, God help us, no matter how well we conduct our lives, we (and our children) can still be stricken with serious diseases of the body and brain. And, our cherished belief in inclusiveness, our understandable distrust of authority, even of scientific authority, and our wishful thinking and politeness, often allow equal voice to the speakers of nonsense on our commissions and task forces.

Much of the care of the seriously mentally ill has shifted to psychiatry programs and inpatient units of our General Hospitals. These are not for-profit institutions, but neither are they asylums; short stays are the goal; turn-over is rapid, and the doors we unlocked in the 1970’s are once again locked. (Security becomes paramount when the unit is situated on the fifth floor of a General Hospital next to the surgical suite and the Pediatric ward.) Overwrought privacy laws allow health personnel to avoid the onerous task of talking with families and other caregivers. Time consuming and difficult appeal processes facilitate psychiatrists prematurely discharging very ill people who are not, strictly speaking, imminently dangerous to self or others.

We too now have mentally ill homeless, and jails and prisons with burgeoning populations suffering from mental illness.

(I remember being mildly astonished, in perhaps 1990, to find that an Ontario Ministry of Health task force, seeking to determine the optimal number of psychiatric inpatient beds per 100,000 population, was using the State of Georgia as a benchmark. Not The Netherlands, Finland, Sweden, Denmark, but Georgia. It is sometimes difficult to resist American enthusiasm.)

We have had the opportunity of adopting some of the good and effective programs pioneered in the U.S. (the ACT programs) and avoiding some of their bad ideas; we are developing a number of programs to help the police (now often front-line mental health workers by default) in many jurisdictions; we have some means of mandating forced community treatment for those who remain at risk (though it is underutilized).

Still, our development of community programs to service the seriously mentally ill has definitely not kept up with de-institutionalization. We seem to be, once again, inexorably following the misguided steps of our big brother to the south.

But, we have not destroyed our mental illness treatment system, merely hobbled it. So, in theory at least, as a country with a smaller population than California, we should be able to fix it.