Bring back asylums?

By Abe Bergman – professor emeritus of pediatrics at the University of Washington

Media attention about the unsheltered homeless is unabating, especially in Seattle. But the stories remain identical: pathetic victims, angry neighbors, and paralyzed public officials. Nothing has been accomplished in the last seven years to alleviate the problem. Yet there is one action that could have an immediate effect — bringing back asylums.

I do not mean the large institutions of the past  The literal definition of asylums is: “places of refuge and comfort.” Which can be interpreted as small supported living units that offer drug treatment, case management, and lockable doors. Now comes the hard part: Persons impaired by addiction and mental illness who refuse asylum treatment should be compelled to do so. 

The number and degree of impairment of the unsheltered homeless continues to surge because of fentanyl. The victims look haggard, smell bad, shout the “f-word,” and evoke fear in those who pass by. They are a difficult group to assist, often resisting measures like drug treatment, that would help them “get better.”

Sadly, my young-adult son is one of them. Like most of the others, he wants to stop taking drugs. He also wants to receive Supplemental Security Income for which he is eligible, and replace the food assistance card that he keeps losing, The drug habit assures that he cannot carry out these ordinary tasks without help.

It helps to take a look at asylum history. A series of changes in American society in the 1960s led to the virtual emptying-out of public asylums. Attitudes about mental illness were affected by the civil rights movement. For example, there was a strong feeling among some reformers that persons with mental illness, however impaired, should make decisions for themselves, honoring their autonomy.

The consequence was an emptying of state institutions, shifting to their families the responsibility of caring for individuals with disabling mental illness or developmental disability. These overwhelming care burdens have led to the creation of the home care industry, with chronically underpaid workers. 

New asylum homes would emphasize drug treatment with well-defined goals, case management, security, long-term follow-up, and jobs. The opportunity for productive work probably surpasses the value of any other form of therapy. An example is the Seattle Parks Conservation Corps, which has provided outdoors work for the homeless since 1986.

My son made many stops in his journey through the mental illness and criminal justice systems. They included county jails, group homes, and treatment centers  In terms of benefiting his behavior, the highest quality care was provided at Western State Hospital. where he stayed for a year.

My son refused to talk to psychiatrists, psychologists, or social workers. He did talk with nurses, but his closest attachments were with custody staff members. They did not ask questions about his past and played basketball with him. Most effective was the system of rewards and restrictions. My son knew that fighting meant he could not go to the gym or library. He stopped fighting and attended group meetings. 

Political support for the impaired homeless does not exist. But a great deal of “sweat equity” is provided by idealistic souls working on their behalf. In particular, the temporary shelter groups like the Downtown Emergency Service Center, Reach Out operated by Evergreen Service Center, and faith-based organizations like Union Gospel Mission. Especially impressive is We Deliver Care, volunteers who walk Third Avenue handing out water, snacks, and socks. It is these people who have earned a measure of trust who should be involved in the planning and operations of prospective asylums.

Washington law limits involuntary commitment to situations “when there is a danger of substantial harm to oneself or others.” The admittedly controversial proposal offered here is broadening that definition of harm to include “individuals unable to meet their basic living needs.” Strong resistance will come from those passionate about civil liberties, disability rights, and public defender rights.

But the fundamental conflict between the responsibilities of public health and safety, versus the rights of individuals to maintain responsibility for their own health and safety, has gone on for generations. This conflict has also played out with devastating effect among Covid vaccine refusers.

Given this unresolved conflict, drug treatment asylums are unlikely to appear anytime soon. But at some point, public disgust with bodies on sidewalks and fentanyl deaths might induce some action. At the very least, mandatory asylum commitment should be an issue that is openly discussed.