In response to:

Under Lock & Key: How Long? from the December 17, 2015 issue


To the Editors:

The past horrors of some shuttered institutions are undeniable, but we must also recognize the disturbing realities of the present. There are over one million individuals who have serious mental illness warehoused in our nation’s jails and prisons—many committed nonviolent crimes. A quarter-million more are homeless. Some of these individuals—and others—cannot care for themselves, they deny or are unaware of the severity of their illness, or they present a danger to themselves and others. In the Journal of the American Medical Association, we argued that for some of these seriously ill patients psychiatric asylum is warranted.

In their essay “Under Lock and Key: How Long?” [NYR, December 17, 2015], Aryeh Neier and David J. Rothman distort our position, claiming that we endorse custodial and abusive “closed institutions” of the past, and imply that we want unjust institutionalization of mentally ill persons in perpetuity. Importantly, Neier and Rothman offer little in the way of new solutions to a deepening mental health crisis.

We used the word “asylum” to refer to its etymologically correct meaning as a place of sanctuary for vulnerable persons. We do not, as Neier and Rothman assert, “give asylums priority over community settings.” We urged a full spectrum of mental health services. Indeed, we specifically argued that “asylums are a necessary but not sufficient component of a reformed spectrum of psychiatric services.”

Like any medical condition, for mental illness there is a spectrum of severity that demands a congruent and gapless range of clinical approaches and settings. The majority of persons with serious mental illness should be treated in their community. In fact, one of us (Emanuel) has stated that individuals with chronic mental health conditions should receive the equivalent of VIP care. This hardly sounds like an idea Neier and Rothman would attribute to us.

When Neier and Rothman quote the Supreme Court’s Olmstead decision, they do so very selectively. Justice Ruth Bader Ginsberg wrote, “Nothing in the ADA [Americans with Disabilities Act] or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings.” Justice Anthony Kennedy warned of the potential “tragedy” in driving “those in need of medical care and treatment out of appropriate care and into settings with too little assistance and supervision.” Advocates like Neier and Rothman conveniently ignore these admonitions.

In these very pages, Oliver Sacks also endorsed the asylum—in exactly the same sense we used the word. He described the promise of recovery from serious mental illness for people who live, for a time, in therapeutic communities. Unfortunately, at around $20,000 a month, such high-quality care is often available only to the one percent. These models should be brought to scale through public and private partnerships for anyone who needs them.

Finally, we agree with Neier and Rothman that the Affordable Care Act marks an important step forward. But without significant reform that encourages integration, behavioral health care will remain separate and unequal in our modern clinics.

Dominic Sisti, Ph.D.
University of Pennsylvania
Philadelphia, Pennsylvania

Ezekiel Emanuel, MD, Ph.D.
University of Pennsylvania
Philadelphia, Pennsylvania

Aryeh Neier and David J. Rothman reply:

We are pleased that Sisti and Emanuel’s letter states what the original article did not: the “past horrors” of mental hospitals. They equivocate by using the term “shuttered institutions” and seem to believe that defining an asylum as a “sanctuary” sidesteps the grim history. It helps them avoid confronting the implications of compulsory commitment, hardly the way people usually enter a sanctuary. These language ambiguities deserve emphasis because nowhere do they offer recommendations to prevent modern-day asylums from sooner or later resembling their predecessors. Confining disabled people to sealed-off spaces is almost certain to be accompanied by inadequate funding and weak monitoring. Call them what you will, but as we wrote, out of sight is out of mind.

In their letter, they say there are a million persons with serious mental illness in jails and prisons and imply that they advocate confinement of these persons in asylums. In their article, they included those with “substance abuse disorder,” which accounts for a lot of prisoners. Also in their article, they referred to about ten million “seriously mentally ill” persons in the United States. They were not clear whether all these are their candidates for confinement in asylums. For any significant portion, the expenses would be staggering.

They cite three psychiatric institutions favorably where the average cost per inmate exceeds $250,000 a year. Apparently recognizing that such costs are insupportable on a large scale, they advocate instead asylums that would be “safe, modern, and humane.” This omits treatment to help inmates leave and live freely, suggesting long-term—perhaps lifelong—custodial institutions, like the asylums of the past.

Sisti and Emanuel recognize the need to provide outpatient services and say they do not advocate “dismantling of community mental health services.” Far from “dismantling” those services, there is a need for many more. Do they imagine that funds will be available both to build and operate new asylums and to provide extensive community health services? We advocate focusing resources on outpatient services, not reinventing the asylum.

They quarrel with our citation of the Supreme Court’s Olmstead decision. We pointed out that Justice Ginsburg’s opinion for the Court “was hardly a radical holding. It did not require that people be released from institutions over the objections of treatment professionals or patients; also such release was made contingent on the resources available to the state.”

They do not mention our assertion that deinstitutionalization of the developmentally disabled has been more successful than of the mentally ill. We attribute this to greater provision of community services to the developmentally disabled. This suggests the value of focusing on such services.

If Sisti and Emanuel are committed to community services, why didn’t they include a discussion of the Affordable Care Act in their article? Indeed, why not use the influence of the Journal of the American Medical Association to promote outpatient care instead of the chimera of bringing back the asylum?