Rachel Pruchno Ph.D.

All in the Family

Bring Back the Asylum?

Bioethicists have right idea, but wrong label

Posted Jan 30, 2015

Mental asylum. Picture it. What do you see?

Perhaps visions of creepy abandoned institutions where wild-eyed doctors used ice picks to perform lobotomies come to mind. Or maybe asylum invokes memories of the 1948 movie, The Snake Pit, in which Olivia de Havilland, playing a woman with schizophrenia, is subjected to shock therapy and hypnotherapy. Or maybe asylum makes you think of Ken Kesey’s 1975 movie, One Flew Over the Cuckoo’s Nest, in which Nurse Ratched torments McMurphy. Whatever the association, I’ll bet it’s not positive.

Now, in an article published last week in the Journal of the American Medical Association1, Zeke Emanuel and bioethicists from the University of Pennsylvania say that, to improve long-term psychiatric care, we should bring back the asylum.

Don’t people with mental illness have enough problems? Stigma is rampant. Care is largely unavailable and unaffordable. Medications have horrific side effects. Laws prohibit families from helping.

While the original intent of asylums was to offer protected places of safety, sanctuary, and healing, asylums have had negative associations for decades. They were austere, secluded places where people with schizophrenia and manic depression were abandoned and abused under the auspices of care.

The Penn scholars may as well have encouraged us to build more “Funny Farms” or “Loony Bins.” These bioethicists should recognize the harm in their cavalier choice of words. Couldn’t they have chosen a less provocative term?

The bioethicists are right, however, about the need for more resources and a full continuum of care to treat people with mental illness. We need more psychologists, psychiatrists, and social workers. We need more inpatient beds and integrated outpatient therapies so that fewer people with mental illness are homeless or imprisoned. We need to overhaul the infrastructure for caring for people with serious mental illness.

For the past decade, I’ve had a front-row seat to the horrors of our mental health system. When my 12-year old daughter Sophie couldn’t focus long enough to do 15 minutes of homework, it took 6 weeks to get an appointment with a psychiatrist. When 13-year old Sophie stole from her cousin, cut herself, and pulled hairs out of her head one at a time, it took 4 months to find a competent therapist with available appointments. Getting these two professionals to coordinate care never happened. When a wild-eyed 16-year old Sophie suffered a psychotic break and told my husband and me she had to run off with a pervert she’d met on the Internet or else he would kill us all, my husband took her to the local crisis center where he and Sophie waited 20 hours for a bed in the Child and Adolescent Psychiatric Unit. When 18-year old Sophie, diagnosed with bipolar disorder and borderline personality disorder, threatened to kill herself, she was placed in the hospital’s dual diagnosis ward where she met dozens of drug addicts. Soon after her release, Sophie became a drug addict herself. Although every one of Sophie’s doctors said she was too sick to make competent decisions about her health care, there was nothing they or my husband and I could do to help her. 

For the past four years Sophie has been addicted to drugs, in and out of prison, and homeless. It didn’t have to be this way. Sophie and many other people with serious mental illness could be helped with the support of appropriate resources and policies.

Over the course of her decade long struggle with mental illness, sometimes Sophie has been able to function on her own, sometimes she’s needed community support, and sometimes she’s been so psychotic that she’s needed inpatient care to protect her from harming herself.

To be sure, some mental health advocates shun any talk of inpatient care, contending that even the most seriously mentally ill people don’t benefit from hospital care. Quite understandably, they fear asylums that warehoused and abused people with mental illness as the rest of society forgot about them. But Sophie’s experiences assure me that they are wrong. There is a real need for aggressively expanding the presence of residential mental health facilities.  

Bioethicists have an important role to play in improving life for people with mental illness. Their thoughts about controversial ethical issues, values, and allocation of scarce resources can propel us toward a future in which resources exist to support people with serious mental illness. But bioethicists must understand the shameful way people with mental illness have been and still are treated, choose their words carefully, and stop needlessly stirring the pot. Perpetuating stigma and magnifying the indignities that people with serious mental illness suffer benefits no one.  

1. http://jama.jamanetwork.com/article.aspx?articleid=2091312