Monday, November 30, 2015

A return to the asylum?

In The New York Review of Books, Aryeh Neier and David J. Rothman write:

Although few people are satisfied with the quality of mental health services in the US, it is still startling to find physicians and psychiatrists enthusiastically calling for a return to asylums. One might think that the grim history of confinement would have precluded such advocacy. Whether in popular imagination (think of The Snake Pit or One Flew Over the Cuckoo’s Nest), historical literature (Michel Foucault’s Madness and Civilization), or legislation (exemplified by the Americans with Disabilities Act), the asylum seemed to represent yesterday’s nightmare.

Nevertheless, last winter, The Journal of the American Medical Association ran an editorial titled in part “Bring Back the Asylum,”1 and a few weeks later, a New York Times Op-Ed piece endorsed it.2 In this same spirit, Massachusetts recently invested $300 million in a new mental hospital, the Worcester Recovery Center and Hospital. Are the failures of community services so extreme and beyond repair as to justify recreating asylums?

Nejer and Rothman concede the shameful inadequacy of the current state of affairs, where the mentally ill often wind up in prison or on the street. But they argue:

Still, returning to the days of the asylum would be an egregious mistake. As daunting as it is to assure quality of care in community settings, it is far more difficult to assure that people will be treated decently in closed institutions. To assert, as the authors of the JAMA commentary did, that the asylum was “a protected place where safety, sanctuary, and long-term care” was provided and that “it is time to build them—again” is to turn a blind eye to the established facts of asylum life. To give asylums priority over community settings would send the unmistakable message that the disabled are first and foremost a public hazard, best managed by incarceration. As stingy as legislators may be in providing for facilities in communities—whether in families, adult homes, or private apartments—they are still more stingy in appropriations for sealed-off institutions. Out of sight is out of mind. The likelihood that asylums will be adequately funded and monitored is low, and none of their proponents has suggested policies that might produce a different outcome.

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