Do We Need More Hospital Beds?

Jonathan Keyes
51
169

In an article published by the Treatment Advocacy Center, The Shortage of Public Hospital Beds for Mentally Ill Persons, the authors (D. J. Jaffe and E. Fuller Torrey) present the idea that we have far too few hospital beds in this country, and because of that there has been a dramatic shift towards the diversion of people labeled with mental illness into prisons and homelessness. Their answer to this issue is that we should radically increase the amount of hospital beds and we should also dramatically increase our reliance on outpatient treatment in the form of mandated involuntary medication programs. As many people know here, the TAC has been highly influential politically and the authors of this paper have been instrumental in getting laws passed that mandate the outpatient use of psychiatric drugs for people who have been civilly committed.

As I have written before here, I think it is simply unethical and frankly unconstitutional to mandate that any population be forced to take neuroleptic drugs — drugs that are known to damage health and shorten lives. Furthermore, numerous studies have shown that long-term use of neuroleptics augments the long-term potential for psychosis and elongates the length of the “illness.” Forcing people into a state of permanent sedation may work as a form of social control, but ultimately harms large groups of people while positing the false belief that these drugs correct an illness.

But in this post I mainly want to address the issue of hospital beds. Since the 1960’s there has been a shift towards deinstitutionalization and an increasing reduction in hospital beds in favor of community programs for helping people in emotional distress. In 1955 there were over half a million hospital beds available to the public. Now there is about a tenth that amount at just over 52,000. This has happened while the population has nearly doubled. Essentially, we have gone from about 340 beds per 100,000 people to about 17 beds per 100,000, a massive reduction in available psychiatric beds.

Deinstitutionalization has happened for a number of reasons. On a simple political level, conservatives supported the process as a way of saving money and liberals and libertarians supported the process as a way of promoting civil liberties and greater agency for people labeled with a mental illness.

Because of this enormous drop in available beds, the number of people civilly committed and kept under the guardianship of the state due to “presenting a danger to self or others” has dropped dramatically. In essence, the commitment process has started to phase out except for a very small group of people. This is almost entirely due to financial considerations. States do not want to pay for the high cost of housing patients, so hospital stays have become increasingly short. Many leave the next day and most leave within a few days.

In essence, the hospitals are radically reducing beds due to not being adequately funded by State and Federal coffers. With this massive reduction in beds, there have been wide side effects. Many more people are “boarding” in emergency departments and sometimes stay there for days in small cubicles with few distractions outside of television and asking for a tranquilizer from a medical nurse on the floor. This has become a crisis in some states. In Washington, a judge recently ruled that this is no longer legal and that mental health patients are required to be given a psychiatric bed, or be discharged.

We are also seeing a wholesale shift towards prison management of people with mental health concerns. In Canada, 60% of female inmates are now treated with psych drugs. The New York Times recently outlined the horrific abuses taking place within prison settings to “manage” people labeled with a mental illness. From the Times article, Winerip and Schwirtz write

”The growing numbers of mentally unstable inmates, with issues like depression, schizophrenia and bipolar disorder, are a major factor in the violence. Rikers now has about as many people with mental illnesses — roughly 4,000 of the 11,000 inmates — as all 24 psychiatric hospitals in New York State combined. They make up nearly 40 percent of the jail population, up from about 20 percent eight years ago.”

Knowing all that, should we take Torrey and Jaffe’s advice to dramatically ramp up the amount of hospital beds nationwide? On a basic level this question is a non-starter because it won’t happen even if there was a desire for this. There is simply not enough money to pay for this very expensive form of care. Most of the hospitals in Portland, where I live, lose money in their psychiatric units. In most cases, they retain these units as a way of diverting the “mentally ill” population out of their emergency departments to make way for better paying patients with physical health problems.

Even if there were a new pot of money to pay for a gigantic increase in beds, I would argue that this is a very poor way of managing crisis. Right now, hospital units are run primarily by highly paid psychiatrists and nurses. The main overwhelming focus is on medication “stabilization.” This is an extremely costly system. Instead I would support shifting monies to creating crisis care centers that are run almost entirely by peers and therapists with a small group of doctors and nurses as adjuncts. This would not only create a much cheaper model of care, it would also emphasize what is truly needed, humane care directed towards listening, attending to needs, comfort measures, and receiving a space to experience deep distress and extreme states that is safe and caring. Peer respite centers such as Second Story are already on the front lines of providing this type of care.

So yes, I would agree with Torrey and Jaffe that we need more crisis care beds. But what kind of beds are we talking about? The kind where someone is simply started on powerful psychotropics and then sent out the door? Or one that truly addresses the needs of an individual, one based on human contact and not one solely based on “medication management” and “rapid stabilization.”

Until we move away from a primarily psychiatric model of attending to those in crisis, we will be forever caught in an extremely costly and at times harmful way of helping people in distress. Do we need more beds? Sure, but not the kind that the Treatment Advocacy Center wants.

51 COMMENTS

  1. Make more hospital beds, take more from peoples lives, make more profits from drugging. Why not give people free housing instead so they can have their own roof over their heads and find new places to live easily and be more independent without need for a hospital bed. And give em outpatient stuff on their terms.

    Warning: people seek profit by mandating psychiatric care. What a shocker that the industry pushes for and conducts these studies to make it happen and information against them such as alternatives is always ignored.

    http://www.obamasweapon.com

  2. Another reason the big hospitals closed was that people were outraged by the horrible conditions in them. Someone who writes here (Mark Ragins?) commented that nobody cares about the horrible conditions in prisons. The money to fund an improvement in conditions is absolutely there, it’s just being sucked up and wasted by a for profit system.

  3. I beg to disagree with both you and E. Fuller Torrey, D. J. Jaffee, et al. What we don’t need are more beds! What we need is more tolerance.

    As someone I met once said, “If you give them more beds, they will fill them.”

    Over and over again, if that bears repeating, let me repeat it. “If you give them more beds they will fill them.”

    By the end of the 19th century, national systems of regulated asylums for the mentally ill had been established in most industrialized countries. At the turn of the century, England and France combined had only a few hundred individuals in asylums, but by the end of the century this number had risen to the hundreds of thousands….

    http://en.wikipedia.org/wiki/History_of_psychiatric_institutions

    That was the 19 th century, and there’s a lesson to be learned in this that we still aren’t learning.

    You don’t need to double the number of patients you have because the population doubled. In fact, you don’t need to double the number of patients you have because the population didn’t double. You don’t need to double, triple, qua-triple, etc., the number of patients you’ve got.

    I used to live in Virginia. They are adding beds in Virginia. They are building “crisis stabilization units”. The same things is happening in California. The patients in these facilities are in all likelihood heavily drugged. They are not ex-patient/patient run, and they are not going to be. Yes, we could use “crisis respite centers”, and “crisis respite centers” that are ex-patient/patient run, but on any large scale that is still potential rather than reality. The reality is these “crisis stabilization units”. What we don’t need is more beds because that’s where they’d be going in the main.

    If the criminal justice system is using petty offenses and frivolous laws to lock up people with problems, that’s another issue altogether. It’s a problem that shouldn’t be. People go to jail and prison because they break the law, people don’t go to jail and prison because they are “sick”. I’m not saying we couldn’t use a little jail diversion for some folks. I am saying that jail and prison are not the primary problem here, and walking into a trap set by the Treatment Advocacy Center is not a great thing to do either.

    We still need less beds. What we don’t need is more beds. Reinstitutionalization, and outpatient commitment may be the TAC’s thing. Don’t let it be your’s.

    • “If you give them more beds, they will fill them.” This is, in fact, true. A doctor I had the misfortune of being shipped to, Dr. V R Kuchipudi, has now been arrested by the FBI for having many, many well insured patients medically unnecessarily shipped to him from all over the Chicagoland area, “snowing,” patients, then performing unneeded tracheotomies on them – all just for profit.

      http://chicagoist.com/2013/04/16/chicago_hospital_owner_doctors_arre.php

      What we need is for the psychiatric industry to stop creating “life long, incurable, genetic mental illnesses,” with their drugs, not more hospital beds.

    • “That was the 19 th century, and there’s a lesson to be learned in this that we still aren’t learning. ”
      Interesting that it correlated with industrialisation and horrific social condition for workers and disappearance of natural family and community relationships. Much like in the neoliberal era we live now.

  4. I strongly agree with most of what you say, Jon. That your background has included working in an inpatient psychiatric setting gives you more credence in my eyes. Some people’s comments, whether in favor of increased or decreased psychiatric hospital beds, seem naive and make me wonder whether they’ve ever really experienced or witnessed the extreme mental states that lead to civil commitments. Don’t get me wrong, I’m not justifying such commitments, and especially not the ill-conceived “treatments” forced on people in such extreme states. But I’m convinced that any really effective alternative (such as the “Open Dialogue” treatment model in the Lapland province of Finland) has to be very well thought out, carefully staffed and implemented.

    I’m totally on board with your vision of a very different type of crisis care, staffed primarily by peers and therapists; a place that would provide as you say “a space to experience deep distress and extreme states that is safe and caring”. And I further agree that increasing existing hospital beds is both untenable in terms of cost and ultimately leads to great harm to those it purports to help.

    However, I have to ask you to be very real and honest about this: Based on your experience, both in the inpatient psychiatric unit and in your current practice at “Hearthside Healing”, do you believe the primarily peer-staffed facilities you’re aware of would really be equipped to appropriately help people in the most distressing mental states (e.g., psychotic mania)? What about the issue of locked wards? Do you think this is ever warranted, and if not, what is the alternative? How would you address safety for residents and staff? You probably know that people in the “Torrey/Jaffe” camp have plenty of concerns and “scare stories” from people who disparage alternative programs as grossly inadequate (of course, we’re well aware of the very real “scare stories” that abound in the current “gulag psychepelago” system!)

    Part of the maddening dilemma, as i see it, is fueled by the pernicious circular reasoning of conventional psychiatry. Since the existing “standard of care” dictates that these extreme states be “treated” aggressively with medication, there is no allowance for non-drug interventions. Therefore, aside from the few drug naive distressed people who might find their way to such a progressive, primarily peer-staffed facility, many of those who come in will be in the throes of prescription drug withdrawal (perhaps mixed with effects of street drugs), or will need to have careful adjustment (hopefully tapering and eventual discontinuance) of the drugs they’ve been put on. And, of course, there’s the issue of very little funding and public support of such alternatives.

    Oi vay! But I like your spirit and ideas, and we have to keep plugging away!

  5. More beds?

    Quick, someone book that nice hotel in the Bahamas for a week, we will need to have a conference to discuss what color sheets we are going to buy.

    And all that added responsibility, 15% pay rises all round. Bring my copy of Wheels magazine, i’m in the market for a new car.

    So for 5 million a politician gets to open the new dvd player for the ward.

  6. This is the very same E. Fuller Torrey who has declared that schizophrenia is most probably caused by a virus picked up from cats!! The problem is not a shortage of hospital beds, and it is not a problem of “mentally unstable” persons alone. What we are seeing is yet one more effect of the mass destruction caused by neoliberal economic policies that have only served to further the gulf between the haves and the have-nots, that have further dismantled the social contract while blaming the victims of this vicious system, thus leaving large swaths of the populace impoverished, ignored, without protection and without hope. This is NOT a medical problem to be solved by pouring more money into psychiatry and will certainly not be solved by the likes of Fuller Torrey. It is a social problem and will only be solved by rethinking the question of how we wish to live together on this planet.

    • There seems to be quite a bit of evidence that the toxoplasmosis virus, which is carried by cats, can infect people’s brains. It is a known to cause mental retardation in fetuses, why could it not possibly be a cause of schizophrenia? Unless you know for sure what causes schizophrenia, please do not be so dismissive of the research looking for the cause of this devastating disease. The only way we will ever find a cure is if the public supports research into the cause or causes of this terrible disease. I have watched someone I love come done with this disease. It really is a disease and not just a “social problem”.

      • “T. gondii infections occur throughout the world, although infection rates differ significantly by country.[56] For women of childbearing age, a survey of 99 studies within 44 countries found the areas of highest prevalence are within Latin America (about 50–80%), parts of Eastern and Central Europe (about 20–60%), the Middle East (about 30-50%), parts of Southeast Asia (about 20–60%), and parts of Africa (about 20–55%).”
        From Wikipedia. Quite a lot of underdiagnosed schizophrenics out there… Btw, some viruses do cause psychosis (HIV being the most prominent) but then the treatment is to suppress the virus and not pump someone full of psych drugs.

    • I am sorry about your loved one, madincanada. But I’m pretty sure that the majority of the increase in the number of “bipolar” patients, from approximately .05% of the population historically, to 7% of children and 4.4% of American adults is a massive misdiagnosis problem, and a societal injustice problem. I agree with you, Eugene.

      And I suppose it’s possible my black cat at home caused the brief “schizoaffective symptoms” I suffered from right after being drugged with 17 different drugs, in willy nilly drug combinations of at least seven drugs at a time, over a ten day period. But I’m pretty certain it was the “snowing” that caused the “schizoaffective symptoms,” not the black cat.

      My daughter just convinced me to get an orange cat, he’s much nicer than our black cat. And my medical records now list most the drugs (my current doctor got too embarrassed to finish the list on my first appointment with him) that made me “bipolar” with “schizoaffective symptoms” listed as drugs I have bad reactions to. Plus, I took my name off the organ donor list. So hopefully I won’t run into that problem again.

      I’d like to live in a society where it’s considered of paramount importance all people show mutual respect towards all others, and profiting off making people “mentally ill” for life, completely with drugs, is no longer considered “appropriate medical care.”

  7. We would not need more hospital beds if we did this:

    “The main difference is that a holistic therapist spends quite a bit of time focused on health and well being. That means looking at diet, lifestyle habits, herbal and vitamin supplements, sleep, rest and exercise patterns as cornerstones of good mental health. At the core of the practice Jon emphasizes nourishment. A well nourished body helps regulate emotions, diminishes anxiety and depression, strengthens cognitive function and improves an overall state of well being.”

    Well Said.
    Well lived.
    Off to make some good cheap food and sleep.
    After a few golden hours spent weeding my garden and enjoying sunlight.

    Health isn’t that complicated.
    Thank you for being here.
    I’ll be returning to cleaning houses soon.
    You don’t need much money to live simply.
    Even the most broken of us can do that.
    If given half a chance.

  8. I think the question is answered by reading the article in the “In The News” section of MIA today, showing that there is a dose-dependent relationship between increasing psychiatric care and increasing suicide rates. Sounds like the only reason to pay for more psychiatric beds is if we want more people to kill themselves!

    —- Steve

  9. I agree with just about everything the author of this article says. I think almost all the readers of MIA would also agree.

    I know I have said this a lot lately, but I think we need to figure out a way to reach the public and create the political will to do away with all the damaging psychiatric interventions and replace them with helpful practices like Soteria Houses, Open Dialogue, etc.

    We know now what needs to be done, now we have to figure out how to get it done. More activism is badly needed.

  10. Five-year Study Re-affirms that Housing Stabilizes People
    June 28, 2014

    A five-year study involving 497 homeless people with mental health or addictions problems in Vancouver found that, when provided free apartments, most people “stabilized their lives and coexisted peacefully with their neighbours,”

    Read more https://www.madinamerica.com/2014/06/five-year-study-re-affirms-housing-stabilizes-people/

    “Zoning laws throughout this country are designed to keep out poor people and homeless people by making it illegal to build small, affordable, eco-friendly houses.”

    LAKEWOOD, NJ — An impoverished man learned the true nature of government as he watched tearfully as bureaucrats demolished his home in the woods. He was bothering no one except the government.

    This was the reality that was presented to “Sam,” a 70-year-old homeless man living in the forest in Lakewood Township, New Jersey. Sam was a part of “Tent City,” a homeless encampment where between 80-120 individuals have stayed at any given time over the past decade, on so-called public land in Lakewood. These individuals were making the best of their situation by erecting tents and shelters in the woods instead of sleeping on park benches and relying on welfare housing and government subsidies.

    Read more http://www.policestateusa.com/2014/tent-city-nj/

  11. Jonathan:

    I think we need more beds, period. Yesterday, I left my office because of a grinding headache and vertigo. Since our office does not have a cot to lie down on, I took two ibuprofen and went outside to lie down in my friend’s car, parked outside in the an inner city parking lot. I slept and several hours went by yet I was still weak with debilitating pain and vertigo. the sun started to bake me inside this tin can and my muscles became cramped from the small space afforded by the front driver’s seat. I twisted and turned and became more miserable with each passing minute but I was not well enough to look for my elevator key and stagger up to my third floor office, plus there was no where to lie down in my office anyway.

    Still weak and dizzy, I staggered around, oblivious to how I must have appeared, a middle aged disheveled, odd looking woman; onlookers may have thought I was drunk or stoned. I desperately looked for a patch of grass outside to spread out my body and lie down. Each step was like climbing the last Hillary Steps of Mt. Everest. My mind could still think clearly and one of my thoughts was this is what the homeless experience when they are sick. For the first time, I really was walking in the shoes of someone who is ill from iatrogenic harm with a history of institutionalization, someone whose family members have mandated, ‘our way or the highway. Take your meds, or you can’t live here anymore! If you are in this predicament, here are no legal places to lie down!

    I work in a concrete jungle with very few parks. What parks exist are highly regulated. It has become illegal for the homeless to lie down in parks and stretch out on park benches!

    We live in an era not unlike the time that the parable of the Good Samaritan was told by Jesus. We walk right by people who are sick every day and do nothing. We talk about creating sanctuaries but we aren’t organizing to overcome the zoning restrictions, and the bureaucratic and funding barriers.

    Imagine coming off a toxic cocktail of neuroleptic medications and being homeless with nowhere to go. Imagine experiencing brain zaps, confusion, delerium, sore muscles, nausea, weakness, thirst, hunger, akathesia, terror that someone will see you or report you and hurt you by having you arrested or forcing you to return to the hospital where you have been forcibly restrained, medicated with Haldol, Thorazine, etc.

    I called a good friend who used her GPS to tell me where the nearest park was located. I was too weak to walk the eight blocks so she came and picked me up and took me to a clinic where I was examined for stroke, heart attack, etc because this was so unprecedented for me. They then released me with a bill and a diagnosis ‘migraine’ after which my friend took me to her house, put me in bed and fed me soup and medicine. The next morning, I felt much better and went to work.
    I am very grateful to be plugged into a caring loving network of friends and peers, people with lived experience or whose children have been harmed by psychiatry. I am fortunate. What about those who aren’t yet plugged into our community?

    At this writing, I am still weak from this mysterious episode. I am still perplexed by it and somewhat embarrassed. But I am grateful for the reminder that, as a part of our demands as a movement, we must fight for the right of homeless people to simply lie down, even in public places. It’s absolutely inhospitable and cruel to think that people who are ill should only be allowed to lie down in institutions and jails. People need safe places to lie down outdoors without having to submit themselves to zillions of regulations, and an intake interview at a day shelter, homeless shelter, hospital clinic, etc. I would suggest that we start creating small ‘oasis’ (plural?) throughout cities–small landscaped areas with shade from the sun and rain, well lit and landscaped, not big parks, just strips of grass, designated for use by anyone who needs to lie down temporarily to take a nap. They don’t need to be much larger than a bus stop and we could designate the upkeep, graffiti, landscaping, etc. to churches and civic organizations. We could pass out flyers to homeless people about the location of each oasis.

    So while we are talking about hospital beds, let’s not forget, that sometimes people end up in jail for simply wanting to lie down. How about asking for more beds, period?

    • Madmom

      Your symptoms remind me of when I had Lyme disease several years ago, and it was not a fun experience; a bad headache is just one of the symptoms. I live in New England (Ma.) and we have a lot of ticks that carry this disease. Untreated Lyme disease can become a long term problem if not treated with antibiotics when the symptoms first appear. If you had a Lyme titer blood test today it might come back negative because not enough antibodies would have been mobilized yet to show up in the test. In a few weeks this test would be more accurate. Just a thought that you might consider on the medical side of things.

  12. The longer answer:
    “We are also seeing a wholesale shift towards prison management of people with mental health concerns. In Canada, 60% of female inmates are now treated with psych drugs.”
    Well, the number of people on psych drugs is not a way to measure how many of them have a “mental illness” (even if you agree with the term in general). People are being drugged for a simple reason – it allows the staff to tranquilise them and makes the whole thing run smoothly. The whole mess is a combination of ridiculous policies of war on drugs, cut backs in social services, cutting taxes for the rich creating massive social problems, overmedicalisation of pretty much everyone (which then also leads to illicit drug addiction) etc. etc. Changing one type of prison into another is not an answer. There are too many people in prisons who should never be there and there are too many people locked up involuntarily in psych wards and there should be none.