When I was growing up, I had never heard of “psychiatric hospitals.” But I had heard of “insane asylums”—there was one in a nearby town we drove by occasionally, in a big Victorian building, intimidating as I remember it. I didn’t know what “stigma” was either, nor did I know anyone who had been at the “asylum,” although my mother did. These souls unknown to me were stigmatized in some sense in my mind, in the sense of being alien. My mother also knew of The Menninger Clinic and revered it, having heard Karl Menninger speak in another nearby town. We never thought of The Menninger Clinic as an insane asylum.
…Asylum is something to be cultivated and treasured.
Now that I’ve spent over half my life working in a psychiatric hospital, I have a very different attitude toward “asylums.” I find it regrettable that, in the field of mental health, asylum has acquired such negative connotations. Many of the patients we see in the hospital have experienced a pileup of severe stress prior to admission that has left them feeling overwhelmed and ill—and often ashamed of their illness, hence feeling isolated and alienated. And their recent stress often comes on the heels of a lifetime of stress, beginning in childhood. They need asylum, in the sense of a refuge or safe haven, as defined in Webster’s dictionary: “any place of retreat and security.”
But, having cracked open Webster’s, I see that my childhood version has not gone out of date, as in another variant: “an institution for the protection or relief of unfortunate, afflicted, destitute, or defective persons; as an asylum for the poor, for the insane, for orphans, or for the aged.” This latter definition underscores how widespread is the need for asylum, and it doesn’t even include the pervasive need for political asylum. In my current mind, asylum is something to be cultivated and treasured.
Institutional asylum for persons with severe psychiatric disorders has been increasingly difficult to come by; over the past half century, state hospitals have been shut down and long-term private psychiatric hospitals have become virtually extinct. This trend is not entirely to be lamented: alternatives to long-term hospitalization are much desired, although the initial vision of the community mental health movement has hardly come to fruition. For countless mentally ill persons, the alternatives to institutional asylum include the jails and the streets.
Now virtually all psychiatric hospitalizations are brief—providing much-needed asylum for a matter of days. These brief hospital stays can be life saving for persons in the midst of acute crises such as suicidal states or psychotic episodes. Yet many crises are not quickly resolved, nor are the longer-term vulnerabilities that render persons susceptible to such crises quickly ameliorated.
At The Menninger Clinic, we have a unique opportunity to provide intensive inpatient treatment for an extended time period of several weeks. How do we think about this opportunity? In the past year, Ian Aitken, our president and CEO, and John Oldham, MD, our chief of staff, led a clinical workgroup devoted to rethinking our treatment delivery system at The Clinic. In the course of this group process and subsequent discussions, we articulated a four-tier foundation for treatment, each tier of which takes time—several weeks’ time.
The first tier, a precondition for all else, is a safe environment. This first tier captures the “hospital” aspect of treatment, and around-the-clock nursing care buttresses it. To a large extent the hospital protection patients need relates to their self-destructive urges, which include suicidality as well as non-suicidal self-injury. This hospital environment provides more than safety, namely, containment, structure and support for maintaining a daily routine. Many severely impaired psychiatric patients struggle with pervasive ill health, which includes disrupted patterns of eating, sleeping and activity. Reorganizing these behavioral patterns cannot be done in a matter of days but rather takes weeks. Moreover, restoring physical health requires the availability of general medical care, which may require consultations, evaluations and interventions over a considerable period of time.
The second tier is establishing effective psychopharmacological treatment, which often takes weeks for several reasons. First, it takes time to achieve diagnostic clarity in the midst of acute psychopathology and a multiplicity of symptoms and syndromes often intertwined with personality disturbance. Second, many patients are admitted with prescriptions for multiple interacting medications and must be gradually withdrawn from some or all of these medications while others might be started. Third, many patients are addicted to alcohol, illicit drugs and prescribed medications (commonly anti-anxiety agents and narcotics) that require a period of withdrawal as psychiatric medication regimens are adjusted.
The third tier is the therapeutic community, which encompasses all patients and staff members. For treatment to be effective, this community must embody a therapeutic ethos, which includes caring, acceptance, compassion, respect and hope—as well as challenging maladaptive patterns of thinking, feeling and behaving. We cannot underestimate the role of the patient community in this respect: abundant anecdotal evidence and results of surveys of patients’ perceptions of the quality of care indicate that patients regard their peer group as paramount in their healing. Development of these healing confiding relationships takes time, as it hinges on the emergence of trust and abatement of acute psychiatric symptoms. Accordingly, staff members not only intervene with respect to individuals’ problems but also strive to facilitate a stable community ethos conducive to healing and to intervene when conditions threaten this ethos (e.g., scapegoating, disregard for others’ welfare, active sabotaging of others’ treatment).
The fourth tier is psychotherapeutic work, that is, an effort to understand the basis of individuals’ psychological problems in the context of their relationships over the course of development and to do so in a way that promotes further development and growth. We employ the concept of “mentalizing”—mindful attentiveness to mental states such as thoughts and feelings in oneself and others—as the foundation for a broad range of psychotherapeutic treatments: individual and group psychotherapy from theoretical perspectives ranging from cognitive-behavioral to interpersonal and psychodynamic. A cornerstone of this fourth tier of psychotherapeutic work is the clinical formulation, around which treatment revolves. A collaborative mentalizing process between patients and clinicians is the basis of this formulation and the treatment that stems from it.
Brief as it is, oriented to treating acute psychiatric problems, inpatient treatment throughout the nation is largely focused on the first tier, providing asylum in the sense of a safe and secure environment as well as very brief treatment. Given several weeks to work with patients intensively, we are able to do considerably more. We have an opportunity to understand not only the illness but also the person who is ill. We have an opportunity to assist patients in joining a community in which they can establish trust and support while overcoming alienation and shame.
Above all, we have an opportunity to engender hope, which the Menningers summed up as a motive force for a plan of action. As they heal, patients become energized and develop the motive force, which we dub “agency”: initiative, ownership of their illness and a sense of responsibility for their wellbeing. In addition, patients have the opportunity to develop a sound plan of action, which concretely takes the form of a wellness plan that includes post-hospital treatment. Hence one might say that, in combination, these four tiers provide a foundation for hope—the ideal outcome of intensive inpatient treatment.