We Need the “Asylums” Again Believe It Or Not

On January 16, 2015 the American Medical Association issued a press release giving notice of an article that asserted the current model fo treating the mentally ill as “ethically unacceptable and financially costly.” It was walking about the decades old failure of “de-institutionalization” that in in its second or third cycle of failure, being re-enacted in states all over the country once again, with similar and predictably disastrous results. I have the feeling that its title and byline in the press release was a little bit intentionally inflammatory to call attention to the importance of this issue.

This article was startlingly timely in that this author had just this week launched this blog on the broad topic of “mental health reform” and the state by state and national debacle it has become since the 19990’s in Michigan and since 1999-2000 since the same dishonest cruel blueprint was foisted upon the naive and desperate legislators in those states to save monies. Michigan by the 1990’s was in accelerating economic swandive mode because of the near bankruptcy of the Big Three American auto makers at the end of the second George W. Bush Presidency, forcing the surprisingly opposition to the bail out first of the two USA life saving bailouts that were left to the the new Obama administration. One would think that the Republicans would remember the satirical but emblematic motto of the character of “General Bullmoose,” in the old “Lil’ Abner” cartoon series by the great satirist Al Capp, “What’s Good for General Bullmoose is Good for the USA!” General Bullmoose was a character who represented the auto (GM–get it?) and military interests that dominated the country in those decades from the 1950’s onward. Business was supreme and has always been the organizing ideological center of the Republican Party. Michigan was one of the Rust Belt States losing population by the thousands yearly as families fled the loss of jobs in the auto and allied industries foretelling a trend that continues to this day.

Meanwhile North Carolina in the late 19990’s suffered enormously from the precipitous “Dot .com” bust of overvalued darling companies of stock hucksters on Wall Street that were innovative but made no money and somehow a free Internet based serviced equalled or guaranteed riches in the future. Conservative economists and stock experts who warned in ever darker tones in those years about that folly were lampooned unwisely by the upstarts of the New Economy that no one could define as old fuddy duddies with their economic heads in the sands of progress. North Carolina was perhaps the third most important “Dot .com” economic engine in the country after Silicon Valley and the Boston Corridor because of North Carolina State University’s technical powers and the graduation of the RTP (Research Triangle Park”) into the tech Big Leagues with dozens of start up tech companies who went bust as funding vaporized when results never appeared and tight money clamped down. Then North Carolina got hit with Hurricane Floyd which devastated an Eastern part of the state and cost the state in short order between one and two Billion dollars to helps its citizens rebuild. Then North Carolina lost a very important legal economic case in the early 1990’s that went all the way to the Supreme Court and cost the state over $900B in one year. North Carolina lost its contention that it could, as it had been for 9 or 10 year years, taxing the federal retirement pensions and benefits of retired federal workers living in the state. The loss meant the state had to refund almost a billion dollars swiftly as NC is a state that requires by its own Constitution that its annual state budget always be balanced, no matter what, no funky borrowing or issuing junk bonds as a way out. So the General Assembly was desperately looking for a way to save approximately two billion dollars quickly and fell sucker to the pitchmen from Michigan and before that Massachusetts in the 1980’s who had saved those states huge amounts of monies but slashing the budgets and costs of the mental health systems with a new plan that was called euphemistically “Mental Health Reform.”

Its basic tenet was to close ‘expensive’ out dated state hospitals and their beds, since everyone knew by that time that being in the state hospital environment was bad for your because of the three decade long promulgation of the modern fallacy of “institutionalization.”

The four state hospitals in Nor Carolina, Dorothea Dix Hospital in Raleigh, Cherry Hospital in Goldsboro, John Umstead Hospital in Butner outside of Durham, and Brougthon Hospital in Morganton in the western third of the state and the largest, had their beds reduced by roughly two-thirds each. The bogus reform plan, a several hundred spreadsheet program utilized in other states notably Michigan, promised the building of comprehensive outpatient services as it dismantled and destrroyed the well functioning local county by county mentalh health services. It was also suppposed to build for a start, sixteen smaller, more regionalized (read local and closer to families) less “isntitutional” smaller “mni” state hospitals. None were built for years by the state except one which was placed in the outskirts of the western town of Sylva without a large enough supportive psychiatric cohort staff of practtioners in an old, converted, rennovated nursing home and one unit housed in a small community hospital in Linville NC.

And the results were predictable, patients lost their long trusted psychiatrists and clinicians by the droves and it took years to replace those. Crises with patient ended up in the ERs of small hospitals all over the state, many with any psychiatrists on their staffs OR any inpatient psychiatric units. Patients also ended up in even greater numbers in the jails, at the country and state levels. Counties suddenly had to find staff, resources and medication budgets to care for at least 10-20 times more mental patients than they had ever had, Jail suicides dramatically increased. And the mental health reform took years to try to catch up.  A prominent then Duke faculty psychiatrist in the mid 2000’s stated publicly for the media in an interview that it would “take 10 years for the state to replace what we had [in state mental health capabilities] ten years ago. A more damning indictment of the the state’s mental health reform effort could not have been verbalized except the description by a Dr. Steve Crane MD a teaching physician for the family practice residency program in Hendersonville and Asheville as “the disaster that just keeps on giving,” which was a satirical take-off on the then current circulating satirical description of Hurricane Katrina and the failure of the Bush Administration to respond to it in a timely fashion which is now a classical study in government and business schools on how NOT to handle a crisis.

To quote the article in the Journal of the American Medical Association published January 20, 2015, “As the United States population has doubled since 1955, the number of inpatient psychiatric beds the United States has been cut by nearly 95 percent to just 45,000, a wholly inadequate equation when considering that there are currently 10 million U.S. resident with serious mental illness.

Continuing, the authors of the article, Dominic Sisti Ph.D., Andreas Segal MS, and Exekiel Emanuel MD Ph.D, wrote “For the past 60 years or more, social political and economic forces coalescent to ove severely mentally patients out of psychiatric hospitals.” They went on to say that the psychological civil rights movement propelled deinstitutionalization and resulted in “transinstitutionalization” which meant the severely mentally ill hit the ERs, jails and homeless shelters and streets around the country in huge numbers.  To further quote, “…most disturbingly, U.S. jails and prisons have become the nation’s largest mental health facilities. Half of all in mates have a mental illness or substance abuse disorder; 15 per cent of state inmates are diagnosed with a psychotic disorder.”

Instead, to quote the press release itself, “the authors suggest that a better option for the severely and chronically mentally ill, and the most ‘financially sensible and morally appropriate way forward includes a return to psychiatric asylum that are safe, modern and humane. They argue the term ‘asylum’ should be understood in its original sense–a place of safety, sanctuary and healing,” and I would add long term care, and long term rehabilitation to permit development of the current mantra ideal goal of “recovery.”

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Author: Frank

I am a older child, adult, geriatric teaching psychiatrist with over 30 years' practice experience in North Carolina, first at Duke as clnical teaching faculty, then in Western NC as a primary child psychiatry specialist. I have taught and supervised child psychiatrists and psychiatrists in training and many other mental health professionals and taught at two medical schools. I have served in many public and private practice settings. My primary interest is in observing and documenting the ongoing mental health reform efforts in the State of North Carolina and documenting its sucessess and failures at all levels. My favorite pastime among many others is spoofing my friends and kids with my deadpan sense of humor.

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