Inpatient Psychiatric Rehabilitation:
An Alternative to Bringing Back the Asylum
Dawn L. Reinhardt‐Wood
Kenneth T. Kinter Rutgers University
Department of Psychiatric Rehabilitation and Counseling Professions, Rutgers University, Scotch Plains, NJ.
Reinhart-Wood DL & Kinter KT.(2016) Inpatient Psychiatric Rehabilitation: An Alternative to
Bringing Back the Asylum Dawn. International Journal of Psychosocial Rehabilitation. Vol 20 (2) 55-58
acknowledge the inspirational individuals who demonstrate that recovery
is possible despite the challenge of mental illness. We thank Thomas
Bartholomew, Joseph Birkmann, and Dr. Kenneth Gill, Department of
Psychiatric Rehabilitation and Counseling Professions, Rutgers
University, Scotch Plains, NJ for their feedback on early drafts.
L. Reinhardt-Wood, MA, CPRP, Department of Psychiatric Rehabilitation
and Counseling Professions, Rutgers University, 1776 Raritan Road,
Scotch Plains, NJ 07076 (email@example.com).
recommendations by medical ethicists advocate for the return of asylums
to improve long-term psychiatric care for individuals who have
treatment refractory psychiatric conditions. Long-term inpatient
psychiatric hospital environments are not conducive to learning tenancy
and recovery skills necessary for optimal community integration.
Psychiatric rehabilitation and alternative community interventions
provide greater opportunities for learning practical and
recovery-oriented skills. Increasing evidence-based psychiatric
rehabilitation interventions in the inpatient setting while adequately
funding community-based service options is a better alternative.
Returning to the asylum-model of long-term psychiatric treatment will
harm advances made in the field of psychiatric rehabilitation and the
reduction of stigma.
Keywords: Psychiatric rehabilitation, recovery, hospitals, severe and persistent mental illness, medical ethics
Segal, and Emanuel (2015) asserted that long-term institutionalization
is the “optimal” course of treatment for individuals diagnosed with
treatment refractory severe and persistent mental illness. Their
opinion was offered despite long-standing contradictory evidence. In a
32-year longitudinal study of long-stay patients, researchers found
that 50-75% of participants achieved considerable improvement or
recovery following discharge (Harding, Brooks, Ashikaga, Strauss, &
Breier, 1987). Rather than press for the return to newer versions of
the “asylums” of old, a more ethical approach would be to advocate for
the increase in funding and support for evidence-based practices
(EBPs), including psychiatric rehabilitation, in the least restrictive
community setting. In some cases, inpatient hospitalization may serve
as the least restrictive community setting for periods of time for
individuals with significant psychosocial impairment. Therefore, such
settings must increase their provision of interventions aimed at
restoring or improving upon previous skills individuals require to live
fully integrated lives in the community.
We agree with Sisti, et
al, (2015) on one point: inpatient institutional settings should be
safe and modern. They should also utilize scientifically proven
interventions to improve individualized outcomes. State psychiatric
hospitals are a vital component in the continuum of psychiatric
services. These hospitals serve individuals during periods when they
cannot otherwise remain in the community due to dangerousness to self
However, psychiatric inpatient facilities often do
not provide an environment in which individuals living with psychiatric
disorders can best learn and practice the skills necessary to improving
community integration. State psychiatric hospital services should be
further integrated within a continuum of community services in order
that persons can be served in the community wherever possible and
appropriate (National Association of Mental Health Program Directors,
2014). Integration begins by psychiatric rehabilitation practitioners
being increasingly included into the hospitals’ staffing, bringing with
them the ability to inspire the change from a culture of stabilization
and maintenance to one of action and improvement. For far too long,
psychiatric rehabilitation has been emphasized in the community-based
setting alone. Increasing psychiatric rehabilitative interventions in
the inpatient setting may contribute to the paradigm shift our aging
institutions urgently require.
Large psychiatric hospitals
frequently lack high-fidelity evidence based treatment interventions
and practices. These settings are large and change happens slowly. It
is imperative for any initiative to be championed by and monitored by
leadership. For EBPs to be effective, they must be delivered with
fidelity to intended clinical standards.
Without adequate clinical
supervision within institutions, it is difficult to achieve delivery of
high-fidelity EBPs. Until clinical service settings can administer EBPs
as they are developed and studied, the problem of the imperfect and
inadequate application of research to clinical practice will persist
(Dixon, L.B., Dickerson, F., Bellack, A.S., Bennett, M., Dickerson, D.,
Goldberg, R.W., Lehman, A., Tenhula, W.N., Calmes, C., Pasillas, R.M.,
Peer, J., & Kreyenbuhl, J., 2009). Hospital executive
administrators and senior state governmental leaders must be supportive
of the human and financial resources required to effectively implement
EBPs. It is our role as psychiatric rehabilitation practitioners to
advocate to these stakeholders. There are benefits for the service
participants and long-term cost-savings to communities when individuals
recover and require shorter and less frequent hospitalizations.
institution is not a home. In accordance with the Olmstead v. L.C.
United States Supreme Court decision, States are required to place
persons with mental disabilities in community settings rather than in
institutions when they have determined that community placement is
appropriate, the transfer from institutional care to a less restrictive
setting is not opposed by the affected individual, and the placement
can be reasonably accommodated, taking into account the resources
available to the State and the needs of others with mental disabilities
(Olmstead v. LC, 1999). Advocating for the long-term
institutionalization, without also emphasizing the need for efficacious
interventions, violates the spirit and intent of the Olmstead
legislation. Withholding an individual’s right to
take risks that may allow them to grow and flourish inside and outside
of the inpatient environment seems inconsistent with the traditional
medical model value to “do no harm.” Psychiatric recovery is not a
linear process and individuals may experience periods of sustained
wellness interrupted by instances of symptom relapse. The learning that
occurs along the way, during either period, is essential to one’s
personal recovery process. This learning can occur in the inpatient
setting if rehabilitative programs are implemented effectively and
receive ongoing administrative and organizational support.
factors other than symptoms severity contribute to an individual’s
successful community tenure. Factors regarded as important for recovery
include empowerment, hope, optimism, knowledge about illness and
services, life satisfaction, increased self-esteem, self-respect,
improved self-control over symptoms and stress, social connectedness,
social relationships, and social support (van Gestel-Timmermans,
Brouwers, Bongers, van Assen, & van Nieuwenhuizen, 2011).
Recovery is possible
despite the presence of manageable psychiatric
symptoms. The findings by van Gestel- Timmermans, et al. (2011),
indicate the need for increasing opportunities for individuals to
strengthen their occupational and tenancy skills while hospitalized.
Individuals may require acute intensive services when they experience a
recurrence of distressing symptoms, however, by aiding individuals in
building support networks and developing skills necessary to “life
after the hospital,” individuals can learn techniques to manage
symptoms distress and strengthen their roles as citizens in the
community of their choice.
Traditional long-term institutionalization should not be the only option.
hospitalization, when offering psychiatric rehabilitative services,
should be among the evidence-based offerings in a well-integrated
continuum of behavioral healthcare services available to service
participants. Pratt, Gill, Barrett, and Roberts (2014) present several
brief alternatives to long-term institutionalization for individuals
experiencing significant psychiatric symptoms. These approaches include
crisis residences, peer-delivered crisis services, partial and day
programs, in-home crisis services, and early intervention teams (Pratt,
et al.). At an intermediate level of care, short-term care units can
further stabilize individuals who are unable to be stabilized in a less
structured community or voluntary inpatient setting. This reduces the
need for admission to state psychiatric hospitals and provides local
communities with more intensive treatment alternatives. Short-term care
units are often accessed via a psychiatric screening commitment when an
individual has been deemed a danger to self or others.
keeps the individual in their community and does not disrupt connection
to local mental health providers, social services, and natural supports.
do not consider hospital confinement, as it exists today, the optimal
course of treatment for practically any other group of medical
conditions other than severe and persistent mental illnesses.
Individuals make decisions on a daily basis that may hasten negative
consequences of chronic illnesses such as diabetes, hypertension, and
hyperlipidemia. Are these individuals not contributing to a possible
early demise by being “non-compliant” with treatment recommendations?
They may even be contributing to increased healthcare costs for the
nation due to the secondary conditions brought on by poor management of
their primary health conditions. Couldn’t the poorly managed diet of
the individual with diabetes cause a fluctuation in blood sugar, loss
of consciousness, and a traffic accident (when that individual is
behind the wheel) jeopardizing the safety and welfare of the public? If
that sounds ridiculous, it is meant to be. Let’s remember that we are
not talking about persistently dangerous people. We are talking about a
minority of the individuals diagnosed with severe and persistent mental
illness who, episodically, exhibit behavior that is deemed unsafe. If
we say that we desire mental health care parity with traditional
primary health care, we must enforce parity on both sides. Equality for
individuals living with mental illness will only come when the
providers and leaders in this field walk their own talk. This change
will not occur without psychiatric rehabilitation practitioners
advocating for a change to inpatient settings.
President Kennedy promised people with severe and persistent mental
illness that they would be treated in the community and funds once used
for psychiatric incarceration would follow them into the community. We
find it unethical and counter- therapeutic to break that promise and
revert to a system that didn’t work the first time.
L.B., Dickerson, F., Bellack, A.S., Bennett, M., Dickerson, D.,
Goldberg, R.W., Lehman, A., Tenhula, W.N., Calmes, C., Pasillas, R.M.,
Peer, J., & Kreyenbuhl,
J. (2009). The 2009 Schizophrenia PORT
psychosocial treatment recommendations and summary statement.
Schizophrenia Bulletin, 36(1), 48-70.
Harding, C.M., Brooks,
G.W., Ashikaga, T., Strauss, J.S., & Breier, A. (1987). The Vermont
longitudinal study of persons with severe mental illness, I:
Methodology, study sample, and overall status 32 years later. American
Journal of Psychiatry, 144(6), 718-726.
Irmiter, C., McCarthy, J.F., Barry, K.L., Soliman, S., & Blow, F.C. (2007).
following psychiatric discharge among VA patients with serious mental
illness: A national longitudinal study. Psychiatric Quarterly, 78(4),
279-286. DOI: 10.1007/s11126-007-9046-y.
National Association of
Mental Health Program Directors. (2014). The vital role of state
psychiatric hospitals. Alexandria, VA: National Association of Mental
Health Program Directors.
Olmstead v. L.C. 527 U.S. 581. (1999). (Supreme Court)
C.W., Gill, K.J., Barrett, N.M., & Roberts, M.M. (2014).
Psychiatric Rehabilitation (3rd Edition). New York: Academic Press.
T., Dunn, C.L, & Sledge, W.H. (2010). Predicting time to
readmission in patients with recent histories of recurrent psychiatric
hospitalization: A matched- control survival analysis. Journal of
Nervous and Mental Disease, 198(12), 860- 863,.DOI:
Sisti, D.A., Segal, A.G, &
Emanuel, E.J. (2015). Improving long-term psychiatric care: Bring back
the asylum. Journal of the American Medical Association, 313(3),
243-244. DOI: 10.1001/jama.2014.16088.
J.A., Brouwers, E.P., Bongers, I.L., van Assen, M.A., & van
Nieuwenhuizen, C. (2011). Profiles of individually defined recovery of
people with major psychiatric problems. International Journal of Social
Psychiatry, 58(5), 521-531. DOI: 10.1177/0020764011412710.