‘We’re at a point of historic reckoning’ on standards for behavioral health care

    Dominic Sisti (Paige Pfleger/WHYY)

    Dominic Sisti (Paige Pfleger/WHYY)

    We’ve come a long way from the days when mental hospitals, like England’s notorious “Bedlam”, doubled as carnival sideshows, where the public paid good money to gawk at the antics of the patients chained to their walls.

    But even in the U.S., Pennsylvania Hospital, a main place for treating people with mental illnesses through the 1840s, attracted similar attention. While psychiatry pioneers like Dr. Benjamin Rush looked to new kinds of therapy, focusing on daily routines and excercise, to ‘cure’ those with mental illnesses, onlookers had different intentions, often provoking and disrupting daily activities.   

    In the view of bioethicist Dominic Sisti, even today, our society could do better when it comes to granting the mentally ill the dignity and care they deserve. Sisti, bioethicist at the University of Pennsylvania and director of the Scattergood Program for Applied Ethics of Behavioral Health Care, spoke with the Pulse’s Elana Gordon about the evolution of places where we treat those with serious mental illness and some of the shortcomings of even our more enlightened age.

    EG: What do you make of the moat story?

    DS: It’s a fascinating story that speaks to the revolutionary thinking of some scientists and physicians in Philadelphia, and that revolution was to begin to think about individuals with mental health conditions as sick and not morally depraved or possessed by demons.

    EG: What do you make of the spectacle aspect, and of people coming to gawk at those with mental illnesses? Is that so different today?

    DS: I think it does reflect a certain curiosity that we continue to have. One need only look up at the Pennhurst Asylum, which is a modern day attraction now, that was a former psychiatric hospital for individuals with intellectual disabilities and mental illness, and they turned it into a Halloween attraction. There are no patients there–it’s not like people are wandering through and gawking at real people–but the memories of individuals who were there, and who suffered there often times, have been turned into a spectacle. To me, it’s unseemly. It’d be like if an old oncology ward were to be turned into a spectacle for people to wander through and laugh about cancer. One would never think that that’s acceptable. But for some reason the Pennhurst Asylum is acceptable. So I think this idea that individuals with mental illness are to be objectified for entertainment for individuals who are not mentally ill I think is still with us, and it’s a commentary on our society.

    EG: And what about when you think about the spaces for mental health treatment?  We hear about, in the early days, cells, and the creation of the psychiatric hospital, these kind of isolated spaces for treatment. And, there’s this focus on isolating patients as a way to get well, or as a way to treat, and I wonder if that has changed a lot today.

    DS: So, there aren’t many spaces any more for individuals with serious mental illness. The number of hospital beds has declined in the past seven years by about 95 percent. But to your point, I think, yes, there is still this notion of therapeutic isolation for a time for some individuals. However, a lot of new models emphasize the important features of community, and milieu therapy was, I think, the beginning of that, where individuals become ensconced in a small therapeutic community, perhaps at a recovery center. And they learn and they become rehabilitated in the ways of the community, so that they can return to the community.

    EG: What’s different today?

    DS: Today, we have modern pharmacotherapy that really does, I think, stabilize patients in a way that purging and bloodletting did not. We have electroconvulsive therapy for patients with severe mental illness that sometimes helps them overcome major depressive disorder, for example. So we have therapeutic interventions that obviously they didn’t have then. And I think the notion that an individual can actually heal and recover is, itself, revolutionary still, to this day.

    EG: What do you think are some of the things that, in 100 years, people might be looking back on today and thinking, “oh wow, they did that?”

    DS: I think we’re at a point of historic reckoning again in behavioral health care, and I say that because many of the individuals who are seriously mentally ill, who have not been able to access or succeed with community based treatment, now find themselves entangled in the criminal justice system. So we’ve sort of gone back to the pre-moral-treatment days where we’re incarcerating and putting in chains individuals with serious mental illness. And I think 100 years from now people are going to look back and think, ‘wow, they were really immoral, unethical,’ and the social expectations I hope will be much higher for the way we treat some of these most vulnerable people.

    Listen to the interview with Dominic Sisti above.

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