No Modern Asylums

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Emily Ladau

No Modern Asylums: A Response to Dr. Christine Montross

History has consistently proven that the way forward is not to move backwards, and yet, this is exactly what three ethicists from the University of Pennsylvania propose should be done for people with mental health conditions*. Echoing this idea in “The Modern Asylum,”a recent Op-Ed for The New York Times, Dr. Christine Montross reflects on her experiences as a hospital psychiatrist, expressing disappointment with the current status of mental health care. A return to institutional facilities, she argues, would be an ideal alternative to the vicious cycle of challenges faced by those with mental health disabilities who cannot find effective, stable care in community settings.

Truth be told, much of what Dr. Montross addresses in her article is spot on. The mental health care system in the United States is indeed deeply flawed and desperately in need of not just reform, but a complete overhaul. However, Dr. Montross’s belief in accomplishing system change by reinstating widespread existence of asylums is troublesome.

All of the significant problems that the community of people with mental health conditions encounter in the present day – incarceration, homelessness, struggles with inadequate care, endangerment in group homes – can be traced back to the stigmatization and culture of institutions. Institutions have long been society’s “solution” for mental health disabilities, dating as far back as the 8th century, and rarely, if ever, have they been humane places to be. In spite of continuous movements pursuing reforms in the 19th, 20th, and even into the 21st centuries, institutions remained places in which people resided in absolute squalor while being grossly abused and neglected.

Obviously, Dr. Montross isn’t advocating for a return to prison-like confinement and mistreatment. In fact, her vision sounds rather ideal in a sense. She believes institutions can be modernized to better serve mental health care needs and ensure well-being by providing thoroughly trained support staff, vocational training, and accommodations for sensory needs. The issue? Dr. Montross’s idea for a shift in mental health care sounds pretty darn similar to what community living is already supposed to be – a safe, supportive environment.

Unfortunately, the fact that conditions remain less than ideal for most people with mental disabilities is a direct remnant of asylums, as well as the fear and stigma that clouds them. Even though, as Dr. Montross notes, the current “rigorous regulations” developed as safeguards “to ensure patient safety and autonomy” in community settings have “backfired,” the answer is not to return to a system that was largely the impetus of this problem. And, since regulations are failing within the current mental health care model, reverting to institutionalization runs an even bigger risk of regulations being ignored.

Abuses against disabled people go unchecked around the world every single day. I fear a “modern asylum” would be an open invitation for abuse rates to grow. Moreover, history has been known to repeat itself far too easily, compounded by media constantly perpetuating cruel stereotypes of institutions and mental health disabilities. As such, the failures of the U.S. mental health system to provide safe, supportive environments for the people who need them cannot and should not be remedied by returning to a model that already failed.

Consider, for example, the infamous case of the Willowbrook State School in New York. Inhumane conditions went unchecked in Willowbrook for years on end, until the problems were finally cracked wide open to the public in a 1972 expose reported by Geraldo Rivera. In the present, I’d like to believe that if an institution was abusive or neglectful in any way, word would spread much faster and something would immediately be done about it, but the reality is: decades after the horrors of Willowbrook came to light, New York still hasn’t fully completed their action plan to phase out the existence of such terrible places.

So, rather than pulling away already limited funding to develop new institutions, funds should be allocated specifically so that group homes and other community living environments can actually properly serve their intended functions. But, money is not the only issue.

It’s undeniable that the main obstacle in the way of improving the mental health care system is the way stigma continues to be ingrained in so much of society. For instance, Dr. Montross calls for modern asylums to provide residents with vocational training, but how would such training account for the fact that far too many employers still harbor discriminatory mindsets? Or, would there be no goals for residents to ever get to the point where they could leave the institution equipped with vocational skills that they could use to contribute to their community?

The mental health care system absolutely abandons people, but I don’t believe it’s “in the name of autonomy.” Or rather, blaming it on autonomy is missing the bigger problems at play. I have seen people I care about grappling with the devastatingly broken mental health care system, left to fight their battles with limited access to care and deep senses of shame as they try to sustain their daily lives. If autonomy is truly the goal, the mental health care system has a long way to go. What, then, can be done? The answer, I believe, is at once simple and complex, and it doesn’t involve relegating people to institutions. Problems cannot be fixed by reintroducing problems. Instead, we must focus on improving healthcare practices and coverage, recognizing the importance of mental health care, and working to end stigma, once and for all.

*Please know that I researched and discussed with several advocates the preferred terminology and have discerned that there does not seem to be overall consensus. “Mental illness” seems to be accepted, but there is a leaning towards “mental health disability/condition.” Any and all variations of terminology used in this piece are written with the utmost respect and I hope to maintain an open dialogue about it.

Emily Ladau is a writer and disability rights activist whose passion is to harness the powers of language and social media as tools for people to become informed and engaged social justice advocates. She maintains a blog, Words I Wheel By, as a platform to address discrimination and to encourage people to understand the experience of having a disability in more positive, accepting, and supportive ways.