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.