President Donald Trump has acknowledged what once might have been done about the volatile behavior of the 19-year-old suspect before the Feb. 14 mass shooting at a Parkland, Florida high school that left 17 people dead:
“In the old days,” Trump told state governors attending a meeting on gun safety at the White House on Feb. 26, “you would put him into a mental institution.”
The old days would have been 1953 when the number of state psychiatric hospital beds in the United States peaked at 559,000. That was before new antipsychotic medications and the rise of the civil rights movement led to a shift toward community-based outpatient treatment for individuals previously considered lifelong hospital cases.
Today, there are only an estimated 40,000 state and county psychiatric hospital beds, according to a 2017 report by the National Association of State Mental Health Program Directors.
Deinstitutionalization emptied hospitals but ultimately filled prisons, jails, and the streets with people with serious mental illness when adequate funding for community mental health care never materialized.
Trump’s public comments mirror renewed interest in the role of mental institutions in American society, despite the history of abuses like those portrayed in the classic film, “The Snake Pit.”
Among those advocating for a rethinking of asylums is Dominic Sisti, Ph.D., an assistant professor in the Department of Medical Ethics & Health Policy at the University of Pennsylvania where he directs the Scattergood Program for Applied Ethics in Behavioral Health Care.
Safe and Humane?
Sisti published a paper in JAMA in 2015 titled “Improving Long-term Psychiatric Care: Bring Back the Asylum” arguing that “safe, modern and humane” psychiatric asylums make both financial and moral sense.
The original meaning of asylum was a place of refuge where people with mental illness could live and heal and receive humane treatment, Sisti said.
“The idea isn’t to rebuild Willowbrook or the awful snake pits that were in documentary films in the 1950s and ‘60s at all,” Sisti said in a recent phone interview. “It would be extraordinarily foolish for anyone to say we should go back to those places. They were not asylums. They were snake pits.”
Initial reaction to the paper was negative as people got hung up on the subtitle, Sisti said. Then he started hearing from others who were more favorable.
“People didn’t really read the paper. They saw screenshots and tweets and things without actually reading the actual rationale,” he added. “Over the months, I started to hear from family members and patients and even judges and law enforcement folks saying this is exactly right.”
Asylums alone are insufficient but represent one component of a continuum of care, Sisti said. He cited the 320-bed Worcester Recovery Center and Hospital which opened in 2012 in Massachusetts as an example of a full range of treatment services.
The facility is located on the campus of the old Worcester State Hospital that closed in 1991 and consolidated beds lost when the state of Massachusetts closed the Westborough State Hospital in 2010.
Deinstitutionalization, Sisti argues, really became trans-institutionalization as patients with chronic mental illness were moved to nursing homes and general hospitals where they received short-term treatment and at much higher cost.
Many ended up homeless while an estimated 20 percent of the U.S. incarcerated population are now individuals with serious mental illness.
The suicide rate in the U.S. increased 22 percent between 1999 and 2013, while the number of psychiatric beds decreased from 34 to 22 beds per 100,000 residents during that 15-year span, according to an August 2017 paper by University of Chicago researchers published in JAMA Psychiatry.
The non-profit Treatment Advocacy Center estimated the number of last-resort psychiatric hospital beds in the U.S. fell to 11.7 per 100,000 population in a June 2016 report. The Arlington, Virginia- based center said 50 per 100,000 are necessary to provide treatment to individuals who need inpatient care.
Among New England states, Connecticut has 17.1 state hospital beds per capita, followed by Rhode Island at 12.3, New Hampshire at 11.9, Maine at 10.8, Massachusetts at 8.9 and Vermont at 4.0.
Clearly, the numbers don’t show a trend toward reversing de-institutionalization any time soon. The numbers do show the prison system continuing to absorb a large and significant number of mentally ill patients.
For example, in Rhode Island in October 2011, an average of between 10 and 15 percent of state Department of Corrections inmates were moved to the Eleanor Slater Hospital because they were found incompetent to stand trial, according to the state figures. By March 2018, 46 percent of patients were found incompetent.
“I think this number’s very striking to show that’s what happened with state hospitals limiting the number of beds across the country,” said Louis Cerbo, Ph.D., a clinical psychologist and director of behavioral health at the Rhode Island Department of Corrections.
Devoting resources to adding more state psychiatric beds makes sense in states that have very few of them, Cerbo said. “There are some states in the country that might look at bringing back certain types of state institutions,” Cerbo added. “It’s a state by state issue.”
But he doesn’t consider more state hospital beds the answer to improving long-term psychiatric care. Rather he said the focus should be on strengthening community mental health centers, diversion programs and supportive housing.
There is a critical need for group homes, especially for hard to place populations like sex offenders and those with a history of arson, Cerbo said.
“In the long run, those programs can be cheaper than a state hospital,” Cerbo said.