A prison, an asylum, or both?

Why are there so many homeless people in the US, so often suffering from mental illness? Because we closed the asylums, of course! That Q&A has become canon. But what would happen if we opened large psychiatric institutions again?

Fort Lyon. Photo (c) The Pueblo Chieftan

NPR has a piece on such a proposal: Colorado Weighs Reopening Psychiatric Hospitals for Homeless (including a short audio segment from All Things Considered). Though much of the impetus seemed to come from creating jobs and reusing an existing campus — Fort Lyon, which was once a veterans’ psychiatric hospital and then a prison — the plan would bus up to 300 of Colorado’s homeless people to the Fort, which would serve as a rehabilitation and transitional housing facility. At the end of the week, the bill to make this happen was shot down, but it will be added as an amendment to another bill.

Improving the plight of mentally ill homeless people should just be a matter of balancing cost/benefit of allowing things to continue as they are or bringing back the institutions, right?  The solution is not a simple binary (and neither was the problem, I’d argue, though that has become the prevalent discourse). Even if we imagine a Utopian care and rehabilitation facility and not a dumping ground like Vita, is the best option to remove homeless people from the community, sweep them out of sight, and hope that budget priorities don’t empty them onto the streets en masse again?

Sam Tsemberis of Pathways to Housing is quoted in the NPR piece. “Having someone in transitional housing teaches people how to manage living in transitional housing.”  I’ve heard a bit about the Pathways to Housing model in the past: it provides housing first — immediately taking homelessness out of the situation — and then adds needed counseling and treatment. (The website is very broken in Chrome; I didn’t check other browsers.) PBS NOW did a half-hour piece about the success of this approach, despite the obvious concerns it raises. [Watch video.]

The head of Colorado’s Coalition for the Homeless, John Parvensky, sees a need for both approaches to reach the range of people who find themselves long-term homeless.

“It’s not really a question of either-or: Should the state support community-based options or should they support Fort Lyon?” says Parvensky. “They really should be doing both, but historically they’ve been doing neither.”

Reading a number of Colorado news articles, it quickly became clear that what’s being debated is not the question of what’s best for homeless people. It’s about budget and jobs and veterans (an earlier proposal had Fort Lyon as transitional housing explicitly for homeless veterans). It’s about the corollary to the American Dream that says that everyone should pull himself up by his bootstraps and take personal responsibility for improving his life.

I’m not convinced that large inpatient institutions are the solution — my personal opinion is that they cause new problems without solving anything but how to hide inconvenient people — but it’s hard to argue that ignoring the problem is better for anyone involved. On my future reading pile: a list of psychology/psychiatry and social work studies on the Housing First approach (anyone have a good anthropological study to recommend on this?) The claimed cost savings of it soothe my fiscal conservative side, while a humanistic method that treats those on the streets as people first — not as junkies or crazies — appeals to my inner anthropologist. The phenomenological experience of being treated worthy of shelter must be so different than that of trying to get clean, find work, or stay on a psychiatric regimen while homeless in order to be considered for a housing program.

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Patient dumping: from Greyhound buses to private planes

Last night’s Colbert Report did a “The Word” segment about “medical leave”. No, not when you take time off from work for illness, but what people are calling medical repatriation. I’d only known that phrase as part of the travel insurance I buy when heading out of the country, to get me home in case I fall ill or am injured. Colbert’s segment is talking about something else, less euphemistically known as patient dumping. [Watch the video.]

The first example in the video is that of two undocumented workers in Iowa who were comatose after an automobile accident. They had insurance (which is rather remarkable and kudos to the unnamed agricultural firm that employed them), but it wasn’t clear to the hospital if long-term care would be covered. So, after less than two weeks, the hospital flew the unconscious men to Mexico and put them into a hospital in Veracruz.  There’s a more complete summary from the Des Moines Register.

Fiscal responsibility is certainly important for hospitals, but patient care is supposed to be their raison d’etre.  Medical repatriation is just one example of where those two purposes conflict. Writing in The American Journal of Bioethics last year*, Mark Kuczewski proposed that medical repatriation could be ethical (legality is a separate issue) if particular conditions are met:

(1) Transfer must be able to be seen by a reasonable person as being in the patient’s best interests aside from the issue of reimbursement. (2) The hospital must exercise due diligence regarding the medical support available at the patient’s destination. (3) The patient or appropriate surrogate must give fully informed consent to being returned to another country. (Kuczewski 2012:1)

There are some excellent peer commentary essays that critique his approach as well as a response from Kuczewski. Even if we accept his initial three requirements, it seems that the Iowa case falls far short. And, that was just one case.  A recent report states that there have been more than 800 cases of attempted or successful medical repatriation from the US in the past six years.

The second example in Colbert’s piece is about a Las Vegas hospital accused of putting psychiatric patients onto Greyhound buses and sending them to other states without a support system in place at the destination. This practice came to light through a March story and a follow-up investigative report in April by The Sacramento Bee. The Nevada Department of Health and Human Services investigated and found that of 1,500 patients discharged from Rawson-Neal Psychiatric Hospital since 2008, ten had been bused off into the abyss without any support.

During the five-year period reviewed, Rawson-Neal maintained an aggressive practice of discharging patients to the Greyhound terminal in Las Vegas, sending them off, unaccompanied, with Ensure nutritional supplements and a limited supply of medications.

The second Sacramento Bee article notes that funding for mental health care in Nevada has been slashed in recent years, and that from 2009 to 2012, the number of discharged patients bused out of state from southern Nevada increased 66%. Or as Colbert puts it, “In America, we don’t turn a blind eye to the needs of our fellow man. So we need to send them someplace we can’t see them at all.”

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* Kuczewski, Mark. 2012. “Can Medical Repatriation be Ethical? Establishing Best Practices”. The American Journal of Bioethics 12(9): 1-5.

A room designed by prisoners

Gizmodo has an article this week about a room prototype built by inmates in Spoleto, Italy, who attended design workshops. It’s not intended to be a cell though it has the same dimensions; it is built with the lived experience of people who spend each day in a 96 square foot room. While the Freedom Room lacks the style of a tiny space by IKEA, the inmates designed it to have storage and useful surfaces.  Does this remind anyone else of Sam’s “2010 Center” ideal prison in Dreaming of Psychiatric Citizenship: A Case Study of Supermax Confinement by Lorna Rhodes?

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The former director of the prison had a thought-provoking reaction: 

“The heavy, mortifying restrictions placed on furnishings and accessories… tend to sharpen the wits of the detainees, who will try to make every possible use of the objects they are allowed to keep…. I sincerely hope that Prison Administrations will consider and adopt this project to promote a ‘culture’ of prison life which, for the first time, may be determined to a certain extent by the inmates themselves.”

I find myself cringing at the idea of an inmate-determined culture, but that’s because my notions of incarceration are (thankfully) shaped more by HBO’s Oz than by personal experience.  However, I think it makes a lot of sense to consult current or former inmates when designing prisons — not to make them cozy or vulnerable, but to see what basic human needs could be addressed without loss of security.  As I write this, there are 52 comments on the Gizmodo piece. Some understand the Freedom Room as a design project, but there is also a lively debate about what living conditions for inmates should be. Some examples:

“I don’t get this. They are in prison. There should be 4 bare walls and a toilet. Why should they live in nicer housing than I do? This is insane.”

“…That being said, whether you had an accidental life altering decision or your just a person who is inclined to do bad things, you need to be punished with discomfort. This is how society is enforced and why most of 360 million people in America are not in prison.”

“Holy Hell, let’s just put everybody in a box for years and see if they come out the other side sane and happy for work and living in the real world. If you place these people in an environment that promotes penance, education and learning, this- to me- seems the better nature for how to deal with those whose lives have been so damaged by their circumstances.”

Should we rage against the dying of the light?

The reading assigned for today by Mary Jo DelVecchio Good looks at the political economy and culture of hope that serve as a legitimizing ground for what she terms the “biotechnical embrace”.  She notes that even as the medical system promotes and naturalizes experimental treatments that have very low success rates, the same medical personnel that maintain public optimism are privately critiquing the practice.  Here’s an excerpt from a resident:

“Being given high doses of chemotherapy and a bone-marrow transplant is not a natural event.  Sometimes oncology in general kind of bugs me, in that it seems – especially for bone-marrow-transplant patients … I was feeling, Why are we doing this?

A recent article in the LA Times asks the same question.  Even as the rates of Medicare patients who are choosing to spend their final days at home or in hospice are going up, an increasing percentage of these patients are spending all but their final weeks undergoing invasive, expensive and painful treatments.  With the encouragement of both doctors and support groups, and an individualist and even moral discourse of “winning battles” and “never giving up”, Americans tend not to go gentle into that good night.  And yet 9 out of 10 Americans say that when the end comes, they would rather die at home, with treatments focused on comfort rather than extending their lives.

There is one group that does not seem to buy into the ideology of hope for their own terminal care: doctors.  A recent Radiolab episode explores the disparity between what we want doctors to do for us, and what they want done for themselves- see doctor’s responses below when asked what treatments they would want given a scenario of irreversible brain injury without terminal illness:

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From the New York TimesFighting a Drawn-Out Battle Against Solitary Confinement

Micah drew attention to this quote from the article about the politics of a bare life/homo sacer existence, “You take a person and you just peel back the skin and make him just some raw flesh in a tomb.”