What’s more, both sides broadly agree that mental institutions alone would not be the solution. “Bring back the asylums” sounds catchy, but here are some more useful slogans to help steer the conversation:
1. DEMAND SENSIBLE COMMITMENT STANDARDS Exact wording varies by state, but commitment standards in general dictate that people cannot be hospitalized against their will unless they pose a clear and significant danger to themselves or others. That sounds reasonable, but with so few inpatient facilities, mental health workers have a strong incentive to determine that even someone who needs to be committed — perhaps someone dangerously delusional — does not meet that standard.
2. CREATE A CONTINUUM OF CARE Deinstitutionalization was predicated on the 1963 Community Mental Health Act, which was supposed to create well-staffed, well-funded community mental health centers in about 1,500 catchment areas across the country. These centers were supposed to provide clinical care, housing and employment support, and community outreach. When President John F. Kennedy announced the legislation, he estimated that it would ultimately return about half of the 500,000 or so people then living in state psychiatric hospitals to be “treated in their own communities and returned to a useful place in society.”
If only the law had been given a chance to work. States failed to devote their savings from the closure of large institutions to community-based care, and few communities were willing to host the centers in their backyards. In the end, only about 750 centers were ever built, and zero were ever fully funded. Today, less than half of all adults suffering from mental health conditions receive help, and mental illness is the leading cause of lost workdays in the United States, costing about $193 million in lost earnings a year.
People who suffer from behavioral and psychiatric disorders need and deserve a wide range of care options: community mental health centers, short-term care facilities, and — yes — longer-term arrangements for the small portion of people who can’t live safely in the community. The pro-asylum camp is right that the number of people needing those longer-term placements is greater than zero. But the figure is also small enough to avoid the need for the thousand-plus-bed facilities that were once the sites of so much abuse.
3. STAND UP FOR INSURANCE PARITY This October marks 10 years since Congress passed the Mental Health Parity and Addiction Equity Act, which requires health insurers to provide the same level of benefits for mental health treatments and services as they provide for medical and surgical care. On paper at least, both the Affordable Care Act and the 21st Century Cures Act bolstered that 2008 statute by requiring plans on the health insurance exchange to cover a list of essential behavioral health benefits and by enacting greater enforcement of the parity rules.