update

News Update

Congressional Proposal Aids Families of Persons with Severe Mental Illness: Helping Families in Mental Health Crisis Act; “Bring Back the Asylums”

By Carmen Lee, PWDF Program Coordinator for Public Awareness and Education

The promise of the Community Mental Health Act of 1963 (CMHA) to provide for community-based care, as an alternative to institutionalization, has not been fully realized due to lack of adequate funding.  Since the enactment of CMHA, 90 percent of beds have been cut at state hospitals, while only half of the proposed community mental health centers have been built. ¹  Deinstitutionalization accelerated with new treatment options (antipsychotic drugs and outpatient therapy) and the civil rights movement, which resulted in state laws limiting involuntary hospitalization to people with severe mental illness (SMI) considered to be a danger to themselves and/or others.  Unfortunately, these developments have resulted in high levels of emergency hospitalizations, incarceration and homelessness.

More recent proposals affecting people with SMI include “Helping Families in Mental Health Crisis Act” and the provocatively named proposition to “Bring Back the Asylum.”

Helping Families in Mental Health Crisis Act

In June 2015, the Helping Families in Mental Health Crisis Act, H.R. 3717 (discussed in PWDF’s Spring 2014 e-newsletter) was revised as H.R. 2646.  National Alliance on Mental Illness (NAMI) prepared a comparison chart of the old and new versions of the bills. This latest version of the bill still does not adequately address PWDF’s concerns about consumer privacy and civil rights protections relating to HIPAA, Assisted Outpatient Treatment (AOT) and advocacy provisions.

At the NAMI Convention in San Francisco on July 9, 2015, Angelica Almeida, PhD, AOT Care Director at San Francisco Department of Public Health, participated in a panel discussion on “Treatment Engagement in San Francisco: Humane or Coercion?”  Dr. Almeida emphasized AOT’s focus on community-based services that allow multiple opportunities for an eligible person with SMI to engage in voluntary treatment, and include a Care Team (a psychologist, a peer who has lived experience with mental health treatment, and a family liaison who has a relative with mental illness) and intensive outpatient services to prevent decompensation.

“Bring Back the Asylum”

On July 22, 2015, Commonwealth Club President and CEO Gloria Duffy moderated “A Debate on Treating Mental Illness: Should We Bring Back Asylums?” featuring Dominic A. Sisti, PhD, of University of Pennsylvania, taking the affirmative position, and Renee Binder, MD, of UCSF and American Psychiatric Association President, taking the opposing position. ²

Dr. Sisti explained that the “asylum” idea reflected a proposal to include inpatient psychiatric settings as part of the continuum of care, for people with SMI who need to get “stabilized in place,” including more strict compliance with medications. Dr. Sisti regarded AOT as a euphemism for compulsory treatment, including forcing people to take medications.  He emphasized that the Olmstead case ³ provided for the least restricted setting if appropriate, but it would be a tragedy to de-institutionalize some persons who are not capable of living on their own; his position is that community care for all is ideal, but we do not live in an ideal world.  Dr. Sisti favored a return to asylums based on the Quaker model of moral treatment and safe sanctuary for healing.  He proposed structured residences on college campuses, so persons with SMI can get jobs and interact in the community to decrease stigma, while those in the healing professions have opportunities for training.

Dr. Binder stated her opposition to “bring back the asylum,” which she viewed as convenient to make people with SMI “disappear” so that, as a society, we do not have to deal with “them” anymore.  Based on her experience as former Director of Langley Porter Psychiatric Institute at UCSF, she related the dangers of institutionalization as studied by Erving Goffman, who found that people who were institutionalized were infantilized in a paternalistic and highly regimented culture.  Instead of using funding to bring back asylums, Dr. Binder said funding should be increased to provide more evidence-based community care, including prevention, early intervention and diversion programs (e.g., behavioral health courts, as discussed in PWDF’s Winter 2008 e-newsletter).  She regarded AOT as an “extra tool” in San Francisco for a small population of people with SMI who do not comply with treatment, with the objective of their reintegration in the community as soon as possible.