A RETURN TO THE ASYLUM: STEP AWAY FROM THE CRACK PIPE. “Improving Long-Term Psychiatric care: Bring Back the Asylum”

Improving Long-term Psychiatric Care:  Bring Back the Asylum

Dominic A. Sisti, PhD1; Andrea G. Segal, MS1; Ezekiel J. Emanuel, MD, PhD1

[+] Author Affiliations

1Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
JAMA. 2015;313(3):243-244. doi:10.1001/jama.2014.16088.
During the past half century, the supply of inpatient psychiatric beds in the United States has largely vanished. In 1955, 560 000 patients were cared for in state psychiatric facilities; today there are fewer than one-tenth that number: 45 000.1 Given the doubling of the US population, this represents a 95% decline, bringing the per capita public psychiatric bed count to about the same as it was in 1850—14 per 100 000 people.1 A much smaller number of private psychiatric beds has fluctuated since the 1970s in response to policy and regulatory shifts that create varying financial incentives

As a result, few high-quality, accessible long-term care options are available for a significant segment of the approximately 10 million US residents with serious mental illness. This population includes adults who are assessed as lacking insight and chronically psychotic, unable to care for themselves, and potentially dangerous to themselves and the public. These persons frequently have refractory schizophrenia and bipolar disorder. The void is both ethically unacceptable and financially costly.

For the past 60 years or more, social, political, and economic forces coalesced to move severely mentally ill patients out of psychiatric hospitals. The opening of the “back doors” of state hospitals in the 1940s and 1950s marked the first phase of deinstitutionalization, as long-stay chronically ill patients were discharged.2 In the 1960s and 1970s, the civil rights movement propelled deinstitutionalization. Shocking reports about abuses at hospitals, such as Massachusetts’ Bridgewater State Hospital, offended the public consciousness and added momentum to closures of psychiatric hospitals. Formerly institutionalized patients who self-identified as “psychiatric survivors” had developed alternative models of peer-facilitated community treatment such as Fountain House in New York City. These models seemed like viable alternatives to institutions. New drugs, especially chlorpromazine, made outpatient options and the ability to live independently seem both liberating and promising.

Macroeconomics and federal policies accelerated the transformation. Outpatient therapy and drug treatment were less expensive than inpatient care. In an effort to reverse the long-term hospitalization of mentally ill patients in inadequate facilities, the Community Mental Health Centers Act and the advent of Medicaid created an environment that allowed states to close or limit the size of so-called institutions for mental diseases. Progressive reformers, consumers, civil libertarians, and fiscal conservatives all advocated for a similar goal—the closure of publically funded psychiatric institutions.


Deinstitutionalization has really been transinstitutionalization. As state hospitals were closed, patients with chronic psychiatric diseases were moved to nursing homes or to general hospitals where they received episodic psychiatric treatment at significantly higher costs. Others became homeless, utilizing hospital emergency departments for both care and housing. Indeed, the current crisis in Nevada—where the lack of psychiatric beds has resulted in overcrowded emergency departments filled to capacity with psychiatric patients—may be a harbinger of the future. Most disturbingly, US jails and prisons have become the nation’s largest mental health care facilities. Half of all inmates have a mental illness or substance abuse disorder; 15% of state inmates are diagnosed with a psychotic disorder.3

These are not new problems. Dorothea Dix, Moses Sheppard, Thomas Scattergood, and other 19th-century reformers had decried transinstitutionalization of the severely mentally ill into jails and almshouses. They called for a new kind of refuge in which mentally ill persons could live and heal, built on principles of humane and moral treatment. This was the original meaning of psychiatric “asylum”—a protected place where safety, sanctuary, and long-term care for the mentally ill would be provided. It is time to build them—again.

At the moment, prisons appear to offer the default option and an inexpensive solution for housing and treating the mentally ill. In Texas, for instance, costs for an inmate with mental illness range from $30 000-$50 000 a year compared with $22 000 a year for an inmate without mental illness.4 Prison and jail costs will soon increase because the US Supreme Court has ruled that the quality of states’ treatment of mentally ill inmates amounted to cruel and unusual punishment.5 New housing units must be built and better treatment provided for mentally ill inmates.

However, correctional psychiatry is rife with legal, ethical, and clinical challenges. Although the minimal statutory and legal standards of care can be met, it is difficult to imagine how ethically sound treatment of mentally ill prisoners can be delivered. It may be impossible for prison psychiatrists—who may have dual loyalties to the patient and the institution— to provide inmates with compassionate, private, and patient-centered care.6 Mentally ill inmates live in an environment anathema to the goals of psychiatric recovery; it is often unsafe, violent, and designed to both control and punish.

Once released from prison, mentally ill persons are left with little support, because their access to public assistance is suspended and requires reenrollment—a confusing and onerous process. Recent studies show that prisoners with a serious mental illness are 2 to 3 times more likely than prisoners without serious mental illness to be reincarcerated.7 High recidivism generates a vicious cycle whereby mentally ill patients move between crisis hospitalization, homelessness, and incarceration, making it difficult to accurately determine the total cost of psychiatric care for this population.

A better option for a person with serious mental illness is assisted treatment in the community. For potentially dangerous patients, there is early indication that mandated outpatient treatment saves states money. In New York City, after 2 years of mandated outpatient treatment, service costs for individual patients were reduced by half.8 Available data on health outcomes, social functioning, well-being, and quality of life of patients receiving compulsory outpatient treatment are more equivocal.9

However, comprehensive, accessible, and fully integrated community-based mental health care continues to be an unmet promise that originated with President Kennedy’s New Frontier. At best, community treatment can provide high-functioning mentally ill persons a foundation for recovery. At worst, severely mentally ill persons drawing Medicaid and Supplemental Security Income risk becoming “commodities” in a profit-driven conglomeration of boarding houses reminiscent of the private madhouses of 18th-century England.10

Even well-designed community-based programs are often inadequate for a segment of patients who have been deinstitutionalized. For severely and chronically mentally ill persons, the optimal option is long-term care in a psychiatric hospital, which is costly. A Joint Commission–accredited state psychiatric institution in Michigan, for example, costs more than $260 000 per patient annually. The annual rate at St Elizabeth’s Hospital—a forensic psychiatric hospital in the District of Columbia—averages about $328 000 per patient annually.

For persons with severe and treatment-resistant psychotic disorders, who are too unstable or unsafe for community-based treatment, the choice is between the prison–homelessness–acute hospitalization–prison cycle or long-term psychiatric institutionalization. The financially sensible and morally appropriate way forward includes a return to psychiatric asylums that are safe, modern, and humane.


The public’s perception of institutionalized mental health care remains dissonant. It is characterized by beliefs about the dangerousness of persons with mental disorders, combined with images of abuse and institutional warehousing. Realistically, the deployment of both private and public resources is now imperative to provide appropriate care and refuge for seriously mentally ill persons. These individuals cannot help themselves or live independently, and they deserve a safe place to live with proper supports—not cycling between the streets, emergency departments, and prisons.

Asylums are a necessary but not sufficient component of a reformed spectrum of psychiatric services. A return to asylum-based long-term psychiatric care will not remedy the complex problems of the US mental health system, especially for patients with milder forms of mental illness who can thrive with high-quality outpatient care. Reforms that ignore the importance of expanding the role of such institutions will fail mental health patients who cannot live alone, cannot care for themselves, or are a danger to themselves and others.

Fortunately, new models of fully integrated, patient-centered long-term psychiatric care now exist in the United States. For instance, a transformed state hospital that is now the Worcester Recovery Center and Hospital provides a full range of integrated treatment services, psychiatric research, and medical education programs and has been at the forefront of using electronic medical records and patient-centered treatments. With its 320 private rooms and recovery-inspired residential design and treatment programs, the hospital cost $300 million to build and has a $60 million annual budget. More facilities like this one are needed to provide 21st-century care to patients with chronic, serious mental illness.

what kind of fuckery is this


Corresponding Author: Dominic Sisti, PhD, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 3401 Market St, Ste 320, Philadelphia, PA 19104 (sistid@upenn.edu).

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank Paul Appelbaum, MD, and Phyllis Solomon, PhD, for their helpful feedback on earlier drafts of this Viewpoint. We also acknowledge the support of the Thomas Scattergood Behavioral Health Foundation.


Torrey  E, Fuller  D, Geller  J, Jacobs  C, Rogasta  K. No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals. Arlington, VA: Treatment Advocacy Center; 2012.
Morrissey  JP, Goldman  HH.  Care and treatment of the mentally ill in the United States: historical developments and reforms. Ann Am Acad Pol Soc Sci. 1986;484(1):12-27.
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James  DJ, Glaze  LE. Mental Health Problems of Prison and Jail Inmates. Washington, DC: US Dept of Justice, Office of Justice Programs, Bureau of Justice Statistics; 2006.
Torrey  EF, Kennard  AD, Eslinger  D,  et al. More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States. Arlington, VA: Treatment Advocacy Center; 2010.
Brown v Plata, 131 1910 (Supreme Court 2011).
Dlugacz  HA, Low  JY, Wimmer  C, Knox  L. Ethical issues in correctional psychiatry in the United States. In: Konrad  N, Völlm  B, Weisstub  DN, eds. Ethical Issues in Prison Psychiatry. Berlin: Springer; 2013:49-75.
Baillargeon  J, Binswanger  IA, Penn  JV, Williams  BA, Murray  OJ.  Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Psychiatry. 2009;166(1):103-109.
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Swanson  JW, Van Dorn  RA, Swartz  MS,  et al.  The cost of assisted outpatient treatment: can it save states money? Am J Psychiatry. 2013;170(12):1423-1432.
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Kisely  SR, Campbell  LA, Preston  NJ.  Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev. 2011;(2):CD004408.
Scull  A. Institutionalization and deinstitutionalization. In: Pilgrim  D, Rogers  A, Pescosolido  B, eds. The SAGE Handbook of Mental Health and Illness. London, United Kingdom: SAGE Publications Ltd; 2011:430-452.


New Peer Initiative – February 3 Deadline


Application Deadline: February 3, 2015

The ACMHA Peer Leadership Interest Group (PLIG) is doing meaningful and important work for the field. If you have not seen it, the tool kit that arose out of our discussions and input is available and being promoted to the members. The PLIG has another opportunity to do some really valuable work…but the deadline is very short. We have received sponsorship funding to support the development of a program or product that collects and shares information about how peers are supporting At Risk Individuals (ARI) who, for these purposes, are defined as:

  • Individuals in Rural and Frontier areas where resources are geographically hard to access
  • Justice Involved Individuals
  • Individuals experiencing multiple ongoing hospitalizations
  • Individuals with multiple physical and behavioral health issues
  • Homeless individuals

A work group is being put together to create the project.  Individuals in the ARI PLIG work group will be asked to commit to the following

  • Attend the 2015 Summit (funded) and listen to and consider activation and health literacy information.
  • Participate in a 2-3 hour post-Summit session where individuals process conference findings, share other best practices, and determine what program or product the group will create to support the field:  An eBook?  A Toolkit?  A Learning Collaborative? A white paper?  A series of webinars? Sessions at Alternatives Peer Conference? Compendium of tools and resources?
  • Receive input from the full PLIG on the content of the program/product.
  • Create, finalize and distribute the selected program/product(s) by December 31, 2015.

Peers who are interested in being a part of the ARI PLIG work group will need to apply by completing an application and returning it to innovations@acmha.org no later than February 3, 2015. This is a hard deadline as all applications will be sent to the reviewers at the same time. We could not act sooner as funding just became available and the board approved the projectUNCA


Issue Proclamation creating National Monument to honor Dorothea Dix

The imminent sale of the 608 acres that remain of the former Dorothea Dix Hospital campus endangers historic buildings and a patients’ cemetery. Pleas to preserve part of the site to benefit those in NC with mental illness go ignored by the Governor and the Mayor of Raleigh.

Dorothea Dix is a person to be emulated today.

Dix visited the poor and found them chained and neglected in jails and prisons. She used her first-hand experiences to successfully lobby North Carolina’s legislature to found its first asylum in 1859. A National Monument honoring her Legacy of advocating for persons with mental illness would not preclude the use of part of the campus for a City Park.

Because time is of the essence, it may be that only by creation of a National Monument can historic preservation be included in the plans for the future of the former hospital’s campus. The Council of State (state-wide elected officials) can approve the proposed plan for developing a park at any time.

By signing this petition, I agree that President Obama should issue a proclamation under the Antiquities Act creating a monument in Raleigh to honor Dorothea Dix and her legacy.

U.S. House of Representatives
and 2 others
President of the United States
http://www.WhiteHouse.gov President Barack Obama
Create a National Monument to honor Dorothea Dix and her Legacy

We the undersigned petition the Federal Government and the President of the United States to honor the life and legacy of Dorothea Dix. We request the creation of a National Monument in her honor on the site of the former Dix Hosptial in Raleigh, NC, which she was largely responsible for founding.

Because of the need to protect the historic McBride Bldg. and the patients’ cemetery, there is a special need for intervention before the state of NC and the City of Raleigh allow the destruction of these important parts of the Dix Campus.


NYAPRS Note: Our ACMHA Peer Leaders Interest Group is very pleased to share this Peer Services Toolkit which is the result of numerous discussions amongst our members and research by primary author Patrick Hendry that were funded by a grant from Optum.

It’s our hope both peer service leaders, states and new payers alike will use these materials to advance the presence of integrity-level peer support across the nation The Toolkit will be the subject of an upcoming ACMHA webinar and also a presentation at the March 24-5 Annual Summit in St. Louis (https://acmha.org/summit).

brave work

January 19, 2015

Peer-run services that promote wellness and recovery from mental health and addiction-related conditions have emerged as an essential key element in new designs aimed at improving health care outcomes and qualities. Accordingly, ACMHA: The College for Behavioral Health Leadership is proud to announce the release of a comprehensive toolkit for increasing the role of peer support in behavioral health. The Peer Services Toolkit: A Guide to Advancing and Implementing Peer-run Behavioral Health Services looks at the nature of peer support, its origins, essential elements, core values, training and certification, outcomes, providing services within peer-run and traditional agencies, state-level advocacy for peer support services, working with managed care companies, and much more.

Thanks to a grant from Optum, more than 25 peer-run service leaders participated in a daylong special seminar at the 2014 ACMHA Summit that was designed and convened by members of the ACMHA Peer Leaders Interest Group (PLIG). The toolkit is based on those discussions and the efforts that followed.

This easily accessible document will aid providers and funders in understanding the unique benefits of peer support and assist them in contracting for these services. It also offers peer-run organizations valuable insight into the essential preparations needed to contract with managed care and other funders. The toolkit provides an in-depth look at the certification process and its importance in expanding peer services throughout the public behavioral health system and into private practice.

The toolkit includes a comprehensive list of reference materials and links to related documents. A living document, the toolkit will continue to be enhanced over the years. The peer workforce is on the edge of tremendous growth as peers learn new ways to provide their unique and powerful support to people moving into and maintaining recovery.

Please feel free to share/distribute this information. More information about the College and its work is available at www.acmha.org.

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