Co-authored by Linda Beeber, Ph.D., RN, CS, FAAN, professor at the University of North Carolina at Chapel Hill, and Madeline A. Naegle, Ph.D., PMHCNS-BC, FAAN, professor at New York University
Does the U.S. need more "asylums" to treat or house persons with severe mental illness? A recent article in the Journal of the American Medical Association (JAMA) authored by three ethicists calls for improved psychiatric care by returning to psychiatric "asylums" of the past ("asylums" that are "safe, modern, and humane"). Persons with mental illness are now straining the capacity of our jails and prisons, hospital emergency departments, nursing homes and other long-term care facilities.
Others seem to agree. Psychiatrist Christine Montrose wrote an op-ed in the New York Times titled "The Modern Asylum," going beyond by calling for more "asylums" to house and treat persons not only with severe mental illness, but also those with chronic neurological/developmental disorders such as disorders on the autism spectrum. Recent letters to the editor in the NYT responding to "The Modern Asylum" had mixed reactions to the idea of returning to "asylums," yet they all agree that we need to do more for persons with severe mental illness and those with neurological/developmental disorders.
Asylums were initially conceived as refuges where individuals with mental illnesses could be cured if they had healthful, low-stress, protected surroundings. Over time, the key elements of protection and healthful living were lost, and asylums became places of abuse, infringement on human rights, stigma and confinement in lieu of treatment. The authors of this op-ed would like to emphasize that while we support the need for new models of care, we emphasize that "new" must be predicated on a completely different paradigm that doesn't isolate people with severe mental illness from society, and instead embodies recovery in vibrant, nurturing communities within the larger society.
The Substance Abuse and Mental Health Services Administration (SAMHSA) is making strides to incorporate principles of recovery into mental health care, and we applaud this agency for leading the charge to create a very different blueprint for care. SAMHSA's four major dimensions to support recovery from mental illness are as follows:
• Health -- overcoming or managing one's disease(s) or symptoms -- for example, abstaining from use of alcohol, illicit drugs, and non-prescribed medications if one has an addiction problem -- and, for everyone in recovery, making informed, healthy choices that support physical and emotional well-being.
• Home -- having a stable and safe place to live.
• Purpose -- conducting meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society.
• Community -- having relationships and social networks that provide support, friendship, love, and hope.
The authors of this op-ed are psychiatric mental health nurse researchers, educators, and practitioners with many years of experience providing mental health care to persons with mental illness, in inpatient and community settings. We applaud the authors of the JAMA commentary, the NYT's op-ed, and the subsequent NYT's letters to the editor for bringing the issue of inadequate comprehensive psychiatric mental health care to the forefront and proposing an alternative. We also applaud psychiatric mental health nurses for caring for those in need now and the nursing educators who continue to teach the importance of complex relationship skills needed to assist people with serious mental illness.
Further, we advocate for a federally-supported national summit convening consumers, mental health professional organizations, and providers to assess progress to date by reviewing existing services such as Assertive Community Treatment (ACT), community mental health services, peer support services, alternatives to emergency departments (such as The Living Room), and looking toward new models of care. The community mental health concepts of 1965 that failed due to inadequate funding, resulted in a compromised and flawed, haphazard array of services. We are not in favor of a return to that cobbled together array of services, often not tailored to population needs. Rather, we are calling for a new conversation about alternative approaches that "institutionalize" all dimensions of recovery.
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