Asylum Within and Without Asylums

That asylum for the insane is poorly cared for where the wants of the body are alone abundantly supplied, while the cravings of the heart are left unappeased (1).

In his classic series of lectures on the asylum, "What Asylums Were, Are, and Ought to Be" (2), Scotsman W. A. F. Browne indicated that "the whole secret of the new system and that of moral treatment…may be summed up in two words, kindness and occupation." These principles were shared by Pinel of France and Tuke of England; readers of this journal were reminded of this history in 1984 by Rosenblatt (3).

In the United States, the founding members of the Association of Medical Superintendents of American Institutions for the Insane (now the American Psychiatric Association) directed their asylums under these same principles. In the pages of the official journal of the association, Kirkbride (4,5), Ray (6), Earle (7), and Butler (1) instructed that asylum buildings should be of artful construction that conveyed a sense of "glorious beneficence," have beautiful views and grounds, and contain "home-felt" rooms furnished like private dwellings with excellent ventilation; in no case should the asylum look like a place of confinement. Patients of the asylum should not only be involved routinely in manual labor but also have ample opportunity for pleasures: music, lectures, parties, carriage rides, ten pins, a library, Bible reading and divine worship, and excursions. Patients not only were the beneficiaries of the environment and activities provided by the superintendent but also gained from exposure to other patients: "The desponding are comforted and made hopeful, and the excited are repressed and instructed by the cordial and kindly comments of the convalescent and experienced" (1).

From what was the asylum an inviolable refuge, a retreat, a protective shelter? The asylum was a place to escape from the causes of insanity; these were the daily strains and stresses of life, particularly those caused by the family. The belief was clear: "the insane cannot be usually healed at home" and "hospitals [are] the proper places for the insane" (8). Removal of an individual from his city or town to the asylum was for the purpose of treatment, not for custodial care. The superintendents recognized the importance of being respectful of the patient: "The utmost care…should be taken to act on what remains of the intellect, wisely to direct the impaired faculties of the understanding, and at the same time to cherish and govern the affections by all the resources of compassionate protection" (1).

But the physician's purpose was cure of insanity (8), and very high cure rates were routinely reported by superintendents (5). Contemporarily, perhaps the most fundamentally misunderstood aspect of early American asylums was their purpose: to provide an effective environment to deliver efficacious moral treatment to cure insanity. The salubrious climate was established for its remedial effects, with the goal of discharging the patient to again become a productive member of society.

The role of asylums, described by President Franklin Pierce as "munificent establishments of local beneficence" (9), was unfortunately short-lived. The curability data were refuted by Pliny Earle (10). The asylums received more patients than their treatment capacities could handle, and they became impaled by political patronage. Their mission, despite their vision, moved from curing to mitigating and maintaining.

In the first half of the 20th century, asylums—legislatively renamed "hospitals"—became overrun by persons with neurosyphilis and by the elderly. By becoming the dumping ground for all manner of people who could not care for themselves, the once-grand asylums deteriorated into snake pits and hellholes worthy of exposés (11). By the mid-1950s, every other hospital bed in the United States was a psychiatric bed; at that point a confluence of factors initiated the depopulation of the state hospitals in a phenomenon known retrospectively as "deinstitutionalization" (12). As the downsizing of public hospitals began, experts in the field, such as Ivan Belknap and Milton Greenblatt, were publishing books on the state hospital, yet none called for a resurrection of an asylum function.

As early as the 1960s, some were questioning the eclipsing role of the state hospital. But this was certainly not the prevailing opinion. Rather, the general consensus was that taking the individual out of the institution would take the institutionalism out of the individual (12).

In the 1970s, readers of this journal were exposed to no small measure of emerging alternatives to the state hospital (13). There was, however, Bachrach's (14) reasoned and repeated reminder that "the planning of services for the chronically mentally ill has largely overlooked the necessity for providing the same range of services outside the hospital as inside." A few professionals asked about where the patients whom no one else wanted would be served, how the mental health system would deal with "hospital-philic" or "independence-phobic" individuals, and why long-term institutional care needed to be seen so negatively (12,15). However, these views were but whispers in the tornado-like rush to community-based care and treatment.

The early 1980s brings us to the period in which John Talbott wrote his opinion piece calling for the recognition of and need for the function of asylum. This period saw a declining influence of psychiatrists in the public sector. The quality of care in state hospitals was extremely low, and the morale of state hospital employees was plummeting. New strains on the state hospital census were emerging, including a lower death rate among elderly persons with chronic mental illness, a cohort of new long-stay patients, and an increasing population of criminally committed individuals. Economic factors were mixed but generally did not bode well for the state hospital. And the whole process was so politicized as to be nearing irrationality (12,16).

Talbott's call for asylum, be it in or out of asylums, was not the only such call in the first half of the 1980s. But Talbott's came early in that decade and was the most clarion call from a leader in American psychiatry. To many, such remarks as Talbott's were somewhere along the continuum between radical and blasphemous.

How far have we come in the past two decades in the community care of persons with serious mental illness? Most commentators would agree that we have come a long way but not far enough. Concerns about the exploitation and mistreatment of persons with mental illness who live in the community that rival the worst abuses of the old state hospitals still make headlines in leading newspapers. So Talbott's concerns are still salient, but they have become much more complex in an era in which the population of persons with mental illness has been dispersed so widely in community settings.

State and county mental hospitals, the locus of asylum for many over the past century, have continued to shrink in number and size to about 200 facilities in 2002, with an average daily resident census of about 40,000. This volume accounts for less than 10 percent of the total inpatient and residential care episodes in the specialty mental health sector (17). Paradoxically, as reductions in patient populations have diminished the role of these institutions, the quality of care they provide has improved both from better staff-to-patient ratios and from the adoption and use of technological advances in psychiatric treatment. These facilities still play important roles for forensic populations (primarily insanity acquittees and many who are found incompetent to stand trial) and for patients who require long-term care. Patients in the latter group have special behavioral problems that make them difficult to place and maintain in community settings.

As state hospitals have downsized, the share of state mental health dollars going to community care has increased. In 1981, a total of 63 percent of state mental health dollars, or $4.1 billion, was for hospitals, and 33 percent, or $2 billion, was for community-based programs. In 2001, 32 percent of funding, or $7.4 billion, was for hospitals, and 68 percent, or $15.4 billion, was for community-based programs (17). The flow of dollars to community-based care has dramatically changed the site of care delivery from state institutions to local communities, where multiple providers—mostly not-for-profit outpatient and residential programs—are responsible for serving many persons with serious mental illness who in earlier times would have spent years in institutional settings. Coordination of these services has been assigned to case managers at the local county level under the auspices of the public mental health authorities.

The rapid growth of community-based treatment and care in the past 20 years was also fueled by new funding streams from the broader social welfare and health insurance arenas that soon matched, and then exceeded, state mental health agency appropriations. States have increasingly relied on the Medicaid program to support community-based treatment. As a result, Medicaid is the largest payer for mental health services in the United States. By 1997 Medicaid alone spent more than $14 billion, which accounted for 20 percent of all mental health spending and 36 percent of public mental health spending in the United States. Many older disabled people rely on Medicare for their mental health treatment. Together, Medicaid and Medicare spent $24 billion in 2002 on beneficiary mental health treatment (18).

Today, more than three-quarters of the 4.6 million individuals who have severe and persistent mental illness now live most of their lives in the community, including an as yet unmeasured number who live in independent housing that provides no on-site service supports. Access to social insurance (Social Security Disability Insurance [SSDI]) and income assistance programs (Supplemental Security Income [SSI]) has had a large impact on the living conditions of people with serious mental illness. In 2002, these programs spent $21 billion on behalf of mentally ill persons with disabilities.

The sobering reality is that these monthly income supports are rarely sufficient to lift people out of poverty or to enable them to obtain affordable housing. People who rely solely on SSI benefits have incomes that are only 18 percent of the median national income, and many adults with serious mental illness who receive SSI spend more than 50 percent of their income on housing (18). As a result, many people with serious mental illness live in substandard housing and often face discrimination by housing providers. The shortage of affordable housing and accompanying support services forces many people with serious mental illness to cycle through jails, institutions, shelters, and the streets; to remain unnecessarily in institutions; or to live in substandard housing.

People with mental illness have one of the lowest rates of employment of any group with disabilities—only about one in three is employed (18). High unemployment occurs despite the fact that a majority of adults with serious mental illness want to work and could work with help. But current policies result in loss of Medicaid benefits if income exceeds fixed levels, thereby serving as a disincentive to work. Thus many persons with serious mental illness are trapped into long-term dependence on disability income support that leaves them living below the poverty level.

So although great strides have been made in the past two decades in community living for people with serious mental illness, numerous gaps in policies and supports still exist and limit the quality of life of many. As the President's New Freedom Commission (18) made clear, the current patchwork of programs and policies across levels of government and among many community agencies results in a fragmented or uncoordinated set of services for persons with serious mental illness. Many of the mainstream health and social welfare programs mentioned above are not designed for persons with serious mental illness, even though this group has become one of the largest and most disabled groups of beneficiaries.

In its call to action, the New Freedom Commission advances recovery as the primary purpose of a transformed system of care whereby persons with serious mental illness are able to live, work, learn, and participate fully in their communities. This idea of recovery stands in sharp contrast to the concept of the asylum as a place of retreat but resonates with the deeper functional definition of asylum as a support structure that promotes both kindness and occupation. The challenge is that the population of persons with serious mental illness is no longer concentrated under a single agency umbrella but spread across several different governmental layers and policy sectors. Hopes and expectations are high that this goal will be achieved in the near future, but the challenges of developing a coherent service system and supportive community environment remain formidable.

To meet these challenges we best return to Talbott's pragmatic advice: do not be concrete, overidealistic, or passive. View the loci of care and treatment as sites of services rather than buildings. And create a continuum of services that embraces both recovery and asylum.We salute John Talbott for proposing in the 1980s what our mental illness system of care still needs to provide:asylum within or without asylums.

Dr. Geller is professor of psychiatry and director of public-sector psychiatry at the University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, Massachusetts 01655 (e-mail, [email protected]). Dr. Morrissey is professor of social medicine, psychiatry, health policy, and administration at the Cecil G. Sheps Center for Health Services Research of the University of North Carolina in Chapel Hill. This commentary is part of a tribute to John A. Talbott, M.D., Editor Emeritus, who served as Editor of Hospital and Community Psychiatry and Psychiatric Services from 1981 to 2004.