Should We Bring Back Public Psychiatric Hospitals?

Consider for a moment this situation: Your adult daughter suffers from a serious mental illness. You have tried to get help for her, but it has not worked out, and you were told that unless she’s a danger to herself or someone else, she can’t be hospitalized.

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Now she’s living on the street and you have no idea how she is faring. You worry constantly and dread getting a certain phone call. You wish desperately there was some sort of safe haven for her, but you know you cannot afford a private care facility.

Maybe at this point, a publicly funded psychiatric hospital sounds like a good idea — as long as it isn’t what they were known for back in the 1950s and 1960s.

The closing of psychiatric hospitals began during those decades and has continued since; today, there are very few left, with about 11 state psychiatric hospital beds per 100,000 people. That’s the same ratio we had in 1850, according to a 2012 report by the Treatment Advocacy Center. Do we need more public psychiatric hospitals?

This question recently drew a standing-room-only crowd at Fountain House, a nonprofit community and social services center for the seriously mentally ill in New York City, where a panel of experts discussed the issue. (Watch a video of the discussion here.) The question exists within the context of a mental health crisis in the United States, and the related statistics are disturbing:

• Having serious mental illness, such as bipolar disease or schizophrenia, will shorten your lifespan by 25 years. This is not because of suicide, but because many health issues (diabetes, heart disease, obesity, smoking) go untreated in the mentally ill, according to the National Alliance on Mental Illness (NAMI).
• In nearly every U.S. state, people with serious mental illness are more likely to be jailed than sent to a hospital. In 2014, the number of mentally ill people behind bars was 10 times that of patients in state psychiatric hospitals, according to a study by the Treatment Advocacy Center, a national nonprofit based in Arlington, Va. New Hampshire is currently facing a backlash for placing into jails seriously mentally ill people who haven’t been arrested.
• Some jails are inhumane for mentally ill people, and they are extremely costly. Incarceration can cost $100,000 per person per year, according to a 2014 Washington state survey.
• One quarter of mentally ill people are homeless, according to NAMI. Some are discharged directly from jails, emergency rooms and mental hospitals to the streets.
• Only about 63 percent of adults with serious mental illness received mental health services in the past year, NAMI says.

To treat this rising crisis, some experts argue for reinstituting mental health/psychiatric asylums — though the word “asylum” is loaded. In the strict sense of the word, asylums are meant to be places of safety and sanctuary. But for most people, the term conjures images of some of the worst state psychiatric hospitals of America’s past, including lobotomies, electric shock treatments and restraints for people locked up against their will.

None of the panelists at the Fountain House discussion were in favor of bringing back the old asylums. Instead, they want to create compassionate places where people with mental illness can heal and return to society.

If you are a family caregiver of an adult with a serious mental illness, you are among a large population in the United States, and many of these caregivers are 50 or older. This is according to a 2016 study by The National Alliance for Caregiving and NAMI, which found that mental health caregivers are 54 on average, and typically tend to an adult son or daughter, providing 32 hours of care each week. About half of these caregivers report that their child lives with, and is financially dependent on, them. Few have plans in place for their child’s care once they can no longer provide it. And 62 percent of these parents said caregiving has made their own health worse.

“A parent shouldn’t have to be a caregiver who provides what amounts to mental health care because our system won’t do it,” said John Snook, a panelist during the Fountain House discussion and executive director of the Treatment Advocacy Center. Snook said mental illness should be treated — and covered by insurance — like any other illness.

Snook added that although some excellent mental health facilities exist, they are tremendously expensive and beyond the reach of many. Not all people with serious mental illness need to be in an institution, but there does need to be some sort of long-term care for those who do, he said.

The panelists agreed that there is a crisis in the United States and an urgent need for solutions so people with serious mental illness receive proper treatment and shelter. The problem, the experts said, comes down to what society and government are willing to do, and government funding doesn’t come easy, said Dr. Ralph Aquila, medical director at Fountain House and the Sidney R. Baer Jr. Center in New York City.

“When it comes to resources and allocating funds, there are other priorities,” he said.

The discussion included the “clubhouse model” of mental illness rehabilitation, of which Fountain House is an example. These organizations are local community centers that support people with mental illness in a variety of ways, including help in finding mental health treatment, safe and affordable housing, employment and socialization.

Fountain House members are free to come and go as they wish. They are evaluated and prescribed medications when needed. They can work in the kitchen or horticulture department, create artwork to be sold in the Fountain House gallery and get help going back to school or finding a job. Most of all, they have a place to go that’s safe, where they have friends and community.

The clubhouse model is far more cost-effective than a psychiatric hospital.

For example, New Yorkers with mental illness have an average of a 50 percent rehospitalization rate, which costs $28,000 for a two-week stay in a psychiatric facility. Members of Fountain House have a rehospitalization rate of just 10 percent. And for about the same cost as that two-week hospital stay, the program -- which is free to members -- provides one year of housing, community support services, employment, as well as educational and social opportunities. Fountain House covers these costs through public funding and private donations. With members working and paying taxes, they are not draining public funds, Fountain House says.

Joel Corcoran, executive director of Clubhouse International, a nonprofit that helps people launch and grow clubhouses around the world, attended the Fountain House event and facilitated a small-group discussion afterward. He said clubhouse programs work because they provide a much-needed community to their members.

“People need a safe place, a feeling of being needed and wanted, something to do on a Friday night — and someone to do it with,” he said.

The model has taken off. Since Clubhouse International spun off from Fountain House in 1977, it has helped start about 300 clubhouses in more than 30 countries.

Clubhouses work well for many people with mental illness, but the panel agreed that the United States needs a variety of solutions to match the diversity of mental health needs among the population.

For many people, inpatient psychiatric care is necessary, and bringing back public hospitals might be the solution for those who cannot afford private institutions.