Psychiatric Institutions Are a Necessity (I swear to God he says that….)

http://www.nytimes.com/roomfordebate/2016/05/09/getting-the-mentally-ill-out-of-jail-and-off-the-streets/psychiatric-institutions-are-a-necessity

I really hope Donald Trump doesn’t get hold of these article. He might decide to build something else in addition to his wall. (I know he will say we will do a great job of it….)

Seriously this article shows why ivory tower wisdom is not the same thing as wisdom. It basically says we don’t hospitalize enough people for long enough times and if we will do it in a kinder way everything will be okay. Psychiatric hospitals will actually work if we are kinder. They will not be so traumatic if we are kinder. And as long as we are kind about it some people just don’t need human rights. It gets in the way of what is good for them. Remember only as long as we are kind.

The idea that we can do anything we want to do to someone as long as it is for their own good is the mother of all kinds of atrocity. The author is an ethicist and you would think he would know that when you divorce ethics from the choices a person makes for his life how much of ethics is really left? The history of mental health in the United States is that the pursuit of the greater good has been the real madness with which we have lived. The author gives us a romance novel theory of asylum and asks us trust him that it will be okay.

The rest of this post will be somewhat difficult to read. I try to take an almost paragraph by paragraph look at what he says. There is just so much to react to any other kind of approach seemed lacking.

“Behind the bars of prisons and jails in the United States exists a shadow mental health care system where nearly half a million inmates have a serious mental illness like schizophrenia. In hospitals, severely mentally ill patients languish for months in acute care units, which are designed to stabilize patients, not to help their long-term recovery.”

He starts off with rhetoric that would make Rep. Murphy proud. “A shadow mental health care system where nearly half a million inmates have a serious mental illness like schizophrenia..” There are a bunch of assumptions implicit in the picture he paints.

1. He implies for those with “serious mentally illness” criminal behavior is in some way a defiency of psychiatric hospitalization. He ignores the fact that many states have cut their mental health budgets to the bone and that for many people it is the lack of community support rather than the use of community support that is problematic.
2. The assumption that criminal behavior is simply a symptom of serious mental illness is naive at best. It ignores the context of a person’s life and in doing so acts as apologist for all kinds of factors like poverty, racism, drugs, gangs, childhood trauma, homelessness and several other things.
3. Math is also an area of deficit for the author. He quotes a figure of nearly half a million “inmates.” His asylums are supposed to solve this issue. (I actually think he is talking about a lot more people than that.) If you assume that most asylums would be in the neighborhood of 100 patients or so you are talking about 5000 new asylums. Most state hospital beds cost about $1000 a day. I assume his asylums will probably cost more than that since they are so “improved.” But even being optimistic and assuming the cost is in the neighborhood of $1000 a day you are talking an expense of $500,000,000 to run these asylums. How much to build them and staff them I don’t think anyone truly knows. The other thing to realize is that this would change the way current patients are viewed. People who may only be there for days would now be there for months. Since census for most hospitals is based on people staying a few days beds would have to be increased just to deal with current demand. Insurance largely doesn’t pay for what he is talking about. Most of the people he is talking about don’t have insurance anyway. The federal government is not going to pay for it. The expense would have to go to the states. You are talking millions of dollars per year from each state. What he writes is simply fantasy. Bad fantasy. He makes it sound like the only thing lacking is moral commitment to the poor mentally ill. He seems to have his own deficit in reality testing. And none of this even begins to take into reality of the legal, financial and political decisions that it would take to even begin to make this a reality. Apologies to the author but the real world leaves a lot of “good ideas” stupid.
4. The last sentence in the paragraph just confuses me. I am not exactly sure what it means or if it even means anything at all. He talks about people languishing in acute care units for months. First of all acute care units is not months. Not anywhere I no about anyway. Secondly does he not just say long term hospitalization sucks? Is that not what “languishing for months” means? Did he just negate his whole argument? Then he criticizes these units as being about stabilization and not long term recovery. In the real world of what psychiatric hospitals are actually about what does this even mean? I really don’t know if that is even a real distinction. I think it is like an argument for good brussel sprouts or good liver. Some things are just what they are regardless of how bad you want them not to be.

“To give these people the care they deserve, we need to bring back psychiatric asylums. Not the dismal institutions that were shuttered in the past, or settings of gothic fiction, but asylums based on the true meaning of the word: places of sanctuary and safety for vulnerable people. The current system too often fails to protect and care for individuals who have serious mental illness in the appropriate place and at the appropriate time.”

This is my favorite paragraph. “To give these people the care they need…..”
Does anyone, anyone, anyone believe long term psychiatric hospitalization is (in Rep Murphy’s favorite term) an evidence based practice? There is a fancy psychological term for this…. “confirmation bias.” My layman’s definition of it would be “the chronic inability to see the nonsense in what you are saying because that nonsense fits your preconceived notions of what you think should be true.” Perhaps “these people” need to decide what they need.

“Not the dismal institutions…. ” He is arguing that we need to go back to something we have never done. That is really the essence of his argument. We don’t need psychiatric hospitals. We need psychiatric hospitals with all the bad stuff taken out. We need to go back to what we have never done. Ask anyone who has ever been in a psychiatric hospital. For that matter ask anyone that has worked in one. They will tell you. This is a scam.

“Mental health treatment should be provided in a seamless continuum that ranges from outpatient care, to community services and supportive housing, to inpatient medical care. But the system is so utterly disjointed, uncoordinated and poorly funded, that those who need help, instead end up in jails and prisons, or warehoused in nursing homes and other group housing facilities.”

Psychiatric hospitalization is the great gobbler of money that could be used to pay for some of these things he talks about. The average state hospital system in this country serves about 10% of the people served by the community system at an equal or greater sum of money. In the real world mental health systems don’t print their own money. They must make choices. Too little bang for way too many bucks.

“The few state hospitals that remain, though, have months-long wait lists, and private psychiatric facilities cost tens of thousands of dollars per month. The dramatic decline in psychiatric beds has been well documented.”

State hospitals have months long wait list….. That is simply not true. It also reveals a profound misunderstanding of state hospitals. In Tennessee all state hospitalization is committal. Someone is judged a danger to themselves or others. There is no come back later ticket for people who are supposedly current risks.

Private psychiatric hospitals cost tens of thousands of dollars a month…. And…. His proposal if anything would increase it. I wonder on a long term basis of following his prescription for mental health heaven would not end up killing his asylum by making them financially unsustainable.

“In any other branch of medicine, such a dearth of services would stoke public outrage. Yet in mental health care, it is routine for sick individuals to cycle through the same emergency rooms weekly — or find themselves in jails and prisons — only to be sent on their way with a blister pack containing a week’s worth of medication before they deteriorate again.”

A short word about public outrage. Many people he talks about lack access to services because they lack the insurance needed to access the services they need. I don’t think the author realizes the impact of that. Millions of people lack the ability to access any kind of medical care. Sometimes public outrage is hard to find.

“High quality, ethically administered psychiatric asylums would provide the seriously mentally ill with a place to stabilize and recover; they are a necessary part of a comprehensive mental health care system. In contrast to those of the past, modern asylums would be settings that restore hope, support recovery and provide an array of treatments. Their quality and costs should be fully transparent and they should be integrated into the broader health care system, perhaps as a part of an accountable care organization.”

It is fitting that we end here. Perhaps I pay too much attention to words but is he saying the major problem with current psychiatric hospitals is that they are not ethically administered? Again he would have us go back to a kinder and gentler hospital which has never existed. His faith is touching but somehow not very inspiring or convincing. I wish he cared as much about the people he claims to want to help as the asylums he tries so hard to sell.

This article is living proof that much that is found in the newspaper is neither very important or very real. I wish he had talked more about the hope many have found. I wish he said better life is not beyond reach or expectation. I wish he had talked about peer support and the value some people have found in the lived experience of others. I wish his ethics were more than the greater good for the greater amount of people. I wish I matter and you matter to him but he seems a system guy.

I wish his ideas were important and well said. It was just one more important person being important. Such a shame.

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