Abstract
Treating persons with serious mental illness is a complex and challenging endeavor. One intervention that has received little attention in recent years is the need for asylum. Asylum means a sanctuary, a place that lowers levels of stress and provides protection, safety, security, and social support, as well as an array of treatment services. The concept of “asylum” may have lost favor because it was equated with the abysmal conditions found in the state psychiatric hospitals of the past. Among the reasons persons with serious mental illness have been arrested and incarcerated is society's failure to provide adequate levels of asylum. With the release of tens of thousands of mentally ill inmates from state and federal jails and prisons, it is time to revisit this concept, not only for these persons but for those who have not been criminalized. Asylum can be found in various settings, including with family in the patient's home, in a board-and-care facility, or in a psychiatric hospital if necessary. Not all persons with a major mental illness are capable of achieving high levels of social and vocational functioning; however, living in a place that provides asylum can promote a higher quality of life. The value of asylum for many persons with serious mental illness should not be underestimated.
There is no higher priority in mental health than successfully treating persons with serious mental illness. To do this, it is important for us to identify these persons' needs and also to recognize that their needs vary in both nature and intensity. Moreover, we have to be open to re-embracing concepts that have lost their currency, such as that of providing asylum and sanctuary when the demands of the world overwhelm the person.
Because the former state mental hospitals were called asylums, the word “asylum” had an unfavorable and negative connotation during much of the past century. But, what does the term asylum really mean with regard to persons with serious mental illness? Generally, it should mean a sanctuary; that is, a place that provides protection, safety, security, and social support.1 For those who are experiencing a considerable amount of stress, an asylum can be a place that provides relief. Clearly, a place of asylum or sanctuary must lower the level of stress. Places of asylum for persons with serious mental illness give protection and social support and do not require performance that is beyond the capabilities of the person. Asylum can be provided in the home by the patient's family or in a community facility, such as a board-and-care home; however, in many cases, the structure of a psychiatric hospital is needed.
Achieving asylum requires not only offering sanctuary, but providing adequate treatment services, specifically for those with serious mental illness, as well as those who have co-occurring disorders such as substance abuse. The importance of supports and funding to provide a system of services for those with mental illness cannot be overemphasized.
Persons with serious mental illness (that is, schizophrenia, schizoaffective disorder, bipolar disorder, and major depressive disorder) and other severely disabling mental disorders, such as posttraumatic stress disorder, have many needs. For example, it is easy to understand that these persons need psychiatric medications and psychological treatments2,3; however, they are not enough. We must also identify the same person's needs in terms of environment. For instance, if a person has a limited tolerance for stress, then reducing stress is crucial, but if he cannot cope with the ordinary demands of the world, then he should be in an environment where there are fewer demands.
Another need of individuals with serious mental illness is that of structure.4 Structure is provided in mental health settings by such means as adequate housing with the appropriate amount of security, a low staff-to-patient ratio, close monitoring of medication adherence, having the person engage in therapeutic activities that organize much of the day, and staff who are willing and able to set limits on inappropriate and violent behavior.
In making the case for asylum, we must not forget the past. For many hundreds of thousands of mentally ill patients, state hospitals were generally places of abysmal living conditions. However, advocating and promoting discharge from these institutions placed many more thousands in circumstances that were no better.5 For instance, it is estimated that there are now more than 350,000 persons with serious mental illness in U.S. jails and prisons6 and 250,000 persons with serious mental illness who are homeless in the United States.7
Reasons that have been suggested for this occurrence of criminalization and homelessness relate to a lack of asylum for persons with serious mental illness in the community, which include housing, financial assistance, and therapeutic programs. Their living situation and mental health treatment, if any, do not offer sufficient structure, such as assertive community treatment (ACT), forensic assertive community treatment (FACT),8 and psychiatric hospital beds.9 Nor is there adequate relief from stress to provide the sanctuary they need.
Correctional facilities may be places that provide structure, as does a psychiatric hospital, but jails and prisons should not be perceived of as places of sanctuary, because they do not operate according to a therapeutic orientation and do not necessarily provide relief to persons in distress.10 Correctional institutions have been established to mete out punishment and to protect society and are not designed to be therapeutically oriented settings.11 The discipline is often harsh and the correctional staff are not always skilled in recognizing and managing persons with serious mental illness. Another consequence is that the inmate-patient is doubly stigmatized as both a person with mental illness and a criminal.
In again recognizing the need for asylum, both in the community and when necessary in accredited, high-quality psychiatric hospitals that provide a full range of treatment services, we must develop our knowledge about when and how to support and protect the person with serious mental illness to avoid the tragedies of the past.
Recognizing the Need for Asylum
The early architects of deinstitutionalization often made the serious error of destroying the “function” of asylum, for many persons with serious mental illness, when they dismantled state hospitals.1 When planners and caregivers disapproved of the abuses they saw inside places called asylums, they often rejected the entire concept of a need for asylum. Consequently, very little was written about the importance of asylum and sanctuary. Currently, there is gathering support in the professional literature for providing asylum as an essential aspect of care for those with serious mental illness.12,13 If we are to improve our system of care, not only must the importance of asylum for persons with serious mental illness be recognized, but there should also be cost analyses for their incarceration versus hospitalization; for comprehensive community support systems, including housing; and, for those with comorbidity, substance abuse treatment.
Serious problems will most likely arise whenever a community lacks adequate equivalents for the full range of functions traditionally served by state mental hospitals.1 This includes the provision of asylum to those patients who need it. Indeed, it is apparent that many of the problems plaguing deinstitutionalization today derive, first, from our failure to recognize that some psychiatric patients with serious mental illness still have a need for asylum and, second, from our failure to offer that asylum, even when we recognize the necessity.
The disabilities associated with long-term, serious mental illness can include social isolation, vocational inadequacy, and exaggerated dependency. Although many persons with serious mental illness can eventually attain high levels of social and vocational functioning, a sizable proportion find it difficult to meet even the simple demands of living. Many are unable to withstand pressure and are apt to experience incapacitating psychiatric symptoms when confronted with a common crisis of life. Thus, for some persons with serious mental illness, finding asylum from many of life's demands can make all the difference.
Some persons with serious mental illness are particularly aware and insightful; they recognize that they become anxious and overwhelmed in social or vocational situations.14 With varying degrees of reluctance, they make a conscious decision to limit their exposure to pressure and, in some cases, to avoid pressure of any kind. Because some persons with serious mental illness may have a limited tolerance for stress, avoidance of stress is one way of attempting to survive outside of a sheltered setting such as a psychiatric hospital. Patients may also need medications and other community supports to ensure that they are able to remain in the community.
Persons who have found refuge at home or in facilities, such as board-and-care homes, have come to what might be called “adaptation by decompression.”14 They have found a place of asylum and sanctuary from life's pressures; but, at the same time, a place where there is support, structure, and some treatment, especially in the form of psychiatric medications.
The Relationship Between Asylum and Rehabilitation
In discussing the need for asylum, the relationship of asylum to vocational and social rehabilitation programs should be clarified. Vocational and social rehabilitation programs can significantly enhance the quality of life for many with long-term mental illness. Rehabilitation adds a function beyond that of simple asylum and may reduce the need for it. The supportive and protective elements of asylum are built into some rehabilitation programs. When these elements are not offered by the programs, such as during the evenings and weekends, they should be provided elsewhere: by families, by halfway houses, by board-and-care homes, or in other settings.14
For some persons with serious mental illness, rehabilitation leads to an ability to have satisfying social relationships and to work in competitive employment at various levels; the person no longer needs a high degree of structure and protection to live productively. For many others, although they may attain increased vocational ability, increased autonomy, and increased social functioning and lead fuller lives, they may be able to do so only within a sheltered vocational or social structure. Along with a growing recognition of the importance of vocational and social rehabilitation is the acknowledgment that the elements of asylum often need to be supplied concurrently if rehabilitation programs are to achieve maximum results.
Accepting the Limitations of Many Persons With Serious Mental Illness
There are mental health professionals, administrators, and other observers of the scene, for whom it is difficult to accept the limited social and vocational abilities of some persons with a major mental illness. For example, there are patients who can be maintained in a board-and-care home who remain passive, cannot initiate and sustain social interactions, and cannot carry out vocational activities, even with capable assistance. Some mental health professionals and others find such a situation discouraging and even unacceptable. They cannot believe that rehabilitation cannot make these patients achieve a level of functioning that would cause this placement to feel like a “normal” environment. These mental health professionals and others may underestimate the value of the services that make it possible for such persons to live in a community setting (even though their lives may be constricted). Clearly, this would be preferable for those who otherwise might need to live in a psychiatric hospital or who might find their way into the criminal justice system.
Likewise, it is difficult for some to believe that there is a sizeable group of persons with serious mental illness who need therapeutic psychiatric facilities where a high degree of structure is provided and the door may be locked. They believe that, if we only had a more optimistic philosophy, these facilities would not have to be locked and highly structured, and these patients would be transformed. Such beliefs may result in the advocacy and funding of facilities and programs in the mental health system that do not provide sufficient structure and do not adequately serve these persons. There can be powerful political pressure, when new services and facilities are being considered for persons with serious mental illness, to make these services voluntary and unlocked. A possible consequence of this for those who fail to obtain the high degree of structure they need may well be incarceration in jails and prisons or living on the streets. Moreover, for persons with serious mental illness who are released from or who have been in correctional facilities, there may be a reluctance to place them in locked, secure psychiatric settings, even though prior community stays have demonstrated the need for a high degree of structure.
There are persons, both inside and outside of the mental health system who do not accept the therapeutic value of assisted outpatient treatment and extended psychiatric hospitalization for some persons with serious mental illness.15 Absent is the belief that such a setting or treatment is necessary to meet the needs of some persons with serious mental illness. In our opinion, we should not attribute to a group of people with serious mental illness a predetermined set of unrealistic expectations regarding their capabilities and needs. Rather, we should be astute clinicians and try to understand what the behavior and symptoms of each person are telling us and strive to treat them accordingly.
For some persons with serious mental illness, too many demands, and for others, any demands at all, will reactivate symptoms and perhaps necessitate a psychiatric hospitalization. Conversely, too few demands and too low expectations may result in regression. In his seminal work, Wing16 suggested that many patients who have experienced schizophrenia remain vulnerable to two extremes of social stimulation. On the one hand, too much stimulation, may lead to an acute relapse. On the other hand, too little stimulation will solidify tendencies toward social withdrawal, underactivity, and apathy. Thus, patients have to walk a narrow line between the two types of danger; clinicians must recognize both in deciding how much and in what ways to support and protect patients.
Normalization of the patient's environment to the greatest extent possible should be the goal of treatment. Attention to the environment should include consideration of the social milieu, the living situation, and the work situation. However, this ideal of normalization cannot be achieved for every person with serious mental illness. Each patient should be given every opportunity to reach it, but we must realize that some will fall short. If we persist in fruitless efforts to push people to adjust to a lifestyle beyond their capabilities, not only may we cause them anguish, but we run the risk of contributing to the emergence of overt symptoms of psychopathology.
Institutionalism and the Schizophrenic Process
A major obstacle to understanding and addressing the problems of deinstitutionalization has been a failure to recognize that persons with serious mental illness are a heterogeneous group who vary greatly in their capacity for rehabilitation. Patients differ in their motivation and their ability to cope with stress and pressure, ranging from tolerating almost no stress at all, to those who can, with some assistance, and usually with medications, achieve recovery and cope with most of the demands of daily life. Some who are amenable to social rehabilitation cannot handle the stresses of vocational rehabilitation and vice versa; however, some can handle the stresses of both, even at a high level.17,18
Moreover, it has been hypothesized that people who spend long periods in psychiatric hospitals develop what has come to be known as institutionalism, a syndrome characterized by lack of initiative, apathy, withdrawal, submissiveness to authority, excessive dependence on the institution, and feelings of worthlessness and dehumanization.19 This syndrome was once thought to be entirely the outcome of living in and adapting to the institution; we now know that, at least in part, it is probably characteristic of the schizophrenic process itself. Many patients who are vulnerable to institutionalism may develop dependence on any way of life that provides minimal social stimulation and allows them to be socially inactive. Many gravitate toward a lifestyle that is low in stress and will permit them to remain as free as possible from disturbing psychotic symptoms and dysphoric feelings.
A place of asylum should include treatment interventions that increase the individual's ability to tolerate stress. Testing these interventions in a safe and supportive environment can assist in assuring a successful transition to less structured settings in the community. It should be recognized and accepted that, for some persons with serious mental illness, there may always be a need for asylum; however, the setting where it is provided may vary according to the individual's needs. Some persons may periodically require the safety and security of a psychiatric hospital for relatively short periods of time, while others may need asylum in a psychiatric hospital for an extended stay.
Asylum for Released Mentally Ill Offenders
The need to recognize the importance of asylum and how it contributes to stability and the treatment of persons with serious mental illness is going to become an even more critical concern now that decarceration is occurring in many states.4 Jails and prisons are currently releasing large numbers of incarcerated people, including those with serious mental illnesses, into the community because of overcrowding and unsustainable fiscal costs. Unfortunately, appropriate community residential and treatment services may not be keeping pace with the need. Many of these individuals have been in correctional facilities for years and are not able to navigate community living successfully unless they are closely monitored and supported. When the community fails to provide an appropriate system of care for these released offenders with mental illness, their risk for reoffending as well as decompensation increases. Persons with mental illness released from correctional facilities need a host of treatment and supportive services, such as mental health treatment, including psychiatric medications; substance abuse treatment; appropriate housing; financial and vocational assistance; close supervision, as needed by both mental health and criminal justice personnel; acquisition of skills to live in a world that may have changed considerably during their incarceration; and intensive social support.
Clearly, we do not want to repeat the kind of adverse events that occurred after deinstitutionalization. Realistic and individualized expectations should be applied to those persons with serious mental illness who are released from jails and prisons. They may not have the benefit of family support and may not have the skills to socialize, or even to communicate their needs effectively. For many, the stressors may overpower their ability to cope and can very well lead to their decompensation. These formerly incarcerated persons may be a challenging group and will require a significant amount of resources that should include understanding the need for and providing asylum in patients' homes and in such facilities as board-and-care homes and high-quality psychiatric hospitals.
Conclusion
Treating persons with serious mental illness requires more than just making the correct diagnosis, prescribing the right medications, and providing the appropriate psychotherapeutic approach. There should be an in-depth understanding of patients' needs for structure and their ability to cope with stress, as well as an assurance that they are in suitable living situations. Above all, the importance of asylum and sanctuary cannot be underestimated.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2016 American Academy of Psychiatry and the Law
