When Asylums Are the Only Hammer, Everybody Looks Like a Nail

“If you’ve only got a hammer, everything looks like a nail.”

The Dix Visionaries, a group of CEOs, land developers, and community leaders, are determined to turn Dorothea Dix State Hospital’s grounds into a destination Central Park for Raleigh, NC. The Park, one visionary was heard to say, might have something like the Georgia Aquarium, the largest in the world, to draw tourists, restaurants and more hotels to NC’s capitol city. The contract between the state and the city for $10.5 million for 306 acres is awaiting the final stamp of approval by the Governor’s Council of State.  For the past two months, Dix has not been on their agenda. There is a good reason for this stall.

In the last week of January 2015, Raleigh psychiatric hospitals, both public and private, found themselves full. Patients trying to come in their doors were “diverted,” told to go to the emergency room at WakeMed. There the Emergency Department had 62 people waiting for a bed or other services. [Rose Hoban, “Wake Mental Health Patients Face Long Emergency Department Stays,” NC Health News, 2-11-2015]. Care coordinators from the Managed Care Organization didn’t arrive until Monday when WakeMed was also trying to “divert” patients — some back home where their crisis may have been triggered.  Many wandered back out onto the streets. Dave Richard, Assistant Secretary for the Department of Health and Human Services, found that most of the people weren’t brought in by law enforcement, but came voluntarily, (a fact that refutes E. Fuller Torrey’s claim that mental patients lack insight into their condition). North Carolina dropped from 1,461 public psychiatric beds in 2005 to 761 beds in 2010; that put North Carolina 44^th in the nation in beds per capita. It is estimated that more than 1,600 individuals in NC are housed in jail or prison where there may or may not be a mental health clinic.

Emergency Rooms have become the triaged door to mental health care. Even without so many walk-ins, doctors and health care workers agree that the ER may be good for heart attacks and gun shot wounds, but not for delusions, extreme agitation or despair. If anything the average 75-hour wait for an already distressed person, strapped to a gurney or a chair awaiting a bed, while being guarded by someone from the sheriff’s office, is inhumane. No other diagnosis has ever been treated so callously, not even tuberculosis or AIDS. The bed a hospital worker may find may be hours across the state or on a ward where the acuity is already too high. The patient who was suicidal is only likely to feel worse, to have “deteriorated.”

Those who come voluntarily, when a bed is found, are put on involuntary status. That means they can’t just walk out, or refuse the heavy medication forced on them that might not have been needed if other services had been available sooner. This also means they have to answer YES to the question on official paperwork about have you ever been committed against your will. Currently in many counties, especially rural counties, with shortages of personnel, the only way to get a return phone call or an appointment in shorter than 3 months away or attention in a hospital setting is to be in major crisis. Crisis becomes a learned behavior and mind set.

Wake Med shouldn’t have been caught by surprise by the number of patients appearing in late January-February. It is February when people’s experiences of family Christmas get-togethers — to which they weren’t invited, the presents and Christmas cards they couldn’t afford, the presence of alcohol at holiday parties, the Goodwill jacket and wallet lost on the train, or the anniversary of their grandmother’s death — all disturb the mind after the fact because they have had no one to listen. Service providers only want to know: “Are you taking your pills? Are you sleeping? Are you suicidal? On a scale of 1 to 5, how happy are you overall with your treatment?”

When the news of overcrowding at WakeMed hit the Raleigh News & Observer, the cry from the public was to re-open the old Dix Hospital. One letter suggested that at least six to eight acres on the Dix property could be a new hospital, which would clearly be a blight on Raleigh’s Central Park environment due to public perception of those “dangerous people.”

There are many alternatives to crisis and hospitalization that consumer activists know about from attending conferences and networking with mental wellness advocates across the country. Unfortunately, all the presentations by current and former recipients of mental health services about alternatives to hospitalization have been made to employees of the Department of Health and Human Services, or at recovery conferences, to other recipients of services. But, the decisions are made by tax payers and legislators. Citizens and politicians are only familiar with treatments at the turn of the century.

If all you have is an Asylum Fix, then every worried or grieving or traumatized or elated individual looks like he or she needs long-term care.  It would make sense try something different—some tools that promise to promote wellness and recovery. North Carolina used to have many exemplary club houses, but for financial reasons, and job shortages for ex-patients only a few are left. The state is 15 years behind the rest of the country in developing drop-in centers and recovery and wellness educational program; the existing ones struggle for ongoing funding.

Here are 10 alternatives to crisis and misery:

1. Respite Houses. Second Story in CA is for people before they are in crisis to take responsibility to prevent spiraling out of control. Staying up to 14 days in a house mostly staffed by peers, the guests are surprised to find that staff doesn’t want to “fix” them but to “be with them” This respite houses follows the philosophy of Intentional Peer Support developed by Shery Mead and recognized as a “promising evidence based practice.”
   [www.madinamerica/author/yjacobs/]
2. Daily peer support by those who have “been there” with services up to two years, not for four weeks with a “fading plan” as Utilization Management of a Managed Care Organization often approves. Certified peer supporters above all listen and may also mentor, tutor, enable their assigned peer to keep schedules, get along with landlords, set goals, and be assertive with their physician and family about their needs and what is working and what is not helpful.
3. Emotional CPR where a layperson, not necessarily a clinician, listens to what’s happening as opposed to observing symptoms and making a diagnosis. It is an education program that teaches Connecting, emPowering, and Re-vitalizing. [[email protected]]
4. Mobile Crisis Teams staffed with peer support, a nurse, and a clinician. This service is especially suited to urban, but not rural, areas. Mobile Crisis goes to the client or a neutral place for an evaluation and seeks to stabilize the individual and make future appointments and sometimes even arrange transportation.
5. Walk-In 24 hour crisis centers which may include a doctor and medication check, a nurse, peer support, de-tox time, with safe rest in a big lounge chair for three to 14 days for up to 16 people. Estimated annual cost is $900,000 to operate this residential program.
6. A WRAP crisis plan with designated roles for chosen family members, friends, clergy, and occasionally a therapist and plans for rest, food, writing, favorite music, walking, sun light– whatever the person has found from experience to be restorative.  Best of all the Wellness Recovery Action Plan, designed by Mary Ellen Copeland, contains a list of signs that things aren’t going well and actions to take before a crisis. WRAP is a best practice and internationally used.
7. Alternative Modalities such as meditation, deep breathing, acupuncture guided imagery, dance, art, music, journaling, and life coaching have been mentioned in personal stories as being “life savers.”  What is tragic is that all these supports recommended in Oprah and other self-help magazine are largely unavailable to the poor due to lack of training or access.
8. Spiritual counseling, because for many individuals questions about sin, forgiveness, mercy, unanswered prayer, the existence of evil in the world, and transcendence occupy their minds. If conducted in a non-judgmental way, this counseling uses spiritual resources and personal faith to address the loss of hope.
9. UNC’s Outreach and Support Intervention Services (OASIS) is for young adults experiencing the onset of psychoses [ Taylor Sisk, A Person-Centered Approach to Recovery,” The Carrboro Citizen and North Carolina Health News, 1/16/2013]. This daily, then weekly, support and education program has from 100-130 clients. About a quarter of clients are uninsured and Medicaid covers only certain services like medication management. 60-65% of participants return to school or work. OASIS addresses the fear that one is “losing his mind” and hopeless, only exacerbated by a trip to an Emergency Room.
10. Healing Communities such as CooperRiis farm in Mill Spring, NC. 110 residents work with 150 staff on nutrition, exercise, work, modern psychiatry, psychology, substance abuse counseling, complementary modalities and a work and service program. The typical stay is six to nine months for those diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, major depression or anxiety disorders, and borderline personality disorder. The fee is $15,500 per month with scholarships available after the second month. CooperRiis program “affirms strengths and rekindles possibility.” [[email protected].]

Deinstitutionalization was supposed to redirect money back into the community. That’s what activists said. But politicians wanted the land back and savings from operating expenses.  The mental health budget in NC is trimmed every year. The savings of closing down NC hospital beds (51 million) that were to go into the community were placed in a trust fund, only to be raided by former Gov. Easley for the general fund. The 51 million was never replaced. Alternative recovery programs are either pilots or dependent on time-limited grants from endowments and foundations and block grants.

People say we can’t have different programs because we can’t afford them. Can the state afford alternatives with better outcomes than the Asylum? Jail costs $95,000 a year and may not have a mental health clinic. State hospitals cost $1,667 per day and $1,440 in for profit hospitals. This works out to $608,455 a year. For this reason the state tries to keep the average stay at 3 days. Recidivism is high. Nonprofits point out that they could operate exemplary programs for a year on the savings from jail or emergency rooms but the pockets of money are in different budget categories that can’t be mixed. Patients have often laughed and proposed that they could stay in a five-star hotel with meals, privacy, TV, a visiting nurse, peer support and a chance to sleep in a safe uninterrupted environment.

The Raleigh asylum on a hill was lobbied for by Dorothea Dix just before the Civil War in reaction to patients being housed in jails and poor houses in squalid conditions. Patients at Dix Hospital lived in small enclaves on a farm where every person had a job vital to the community. Dorothea Dix believed that patients needed respect and compassion for what they had been through. She fully expected them to recover. When there is a shortage of psychiatric beds, let’s not call for the return of Asylums, but for programs in the community based on genuine caring and hope.