Hospitals vs Community Care: Why Are They Seen As Enemies


Why are there limited choices when it comes to mental health reform?

Last week, I published excerpts from Rep. Tim Murphy’s recent hearing entitled:  “Where Have All the Patients Gone? Examining the Psychiatric Bed Shortage.”  Experts at that hearing explained how a lack of crisis care beds has frustrated mental health workers and contributed to  jails and prisons becoming our new mental asylums.

The last excerpts that I published Saturday came from Arthur C. Evans Jr., the director of mental health services in Philadelphia who acknowledged the bed shortage but added this caveat:

“It is counterintuitive that the solution to a perceived inpatient bed shortage is to build a strong community-based service system. But, experience consistently shows this to be the case. An over emphasis on inpatient beds can drain needed resources away from the very services that prevent people from needing crisis services.”

In a press release, one of the first issued since she became the new executive director of the National Alliance on Mental Illness, Mary Giliberti also commented on Rep. Murphy’s hearings, saying: “…there are not enough beds. Supply does not meet demand…”  But she quickly added:

“Hospitals are important downstream elements in the continuum of care, but upstream measures must not be neglected…Other mental health services are being starved. Community services that can provide cheaper, incremental alternatives and prevent acute crises and hospitalizations are under-funded or non-existent.”

Director Giliberti cited mental health screening, crisis response, discharge planning, outpatient services, peer support, assertive community treatment, supportive housing and jail diversion as vital community programs that are under-funded.

When I appeared on the Kojo Nnamdi show on NPR recently, the then- head of mental health services in Fairfax, County, Va., Mr. George Braunstein issued a similar warning.

 I agree, there needs to be more beds available. But I am also saying that there’s a number of people who are — have very acute symptoms whose needs can be met by some of these (community) alternatives as well…we also have to look at all the other alternatives and grow those as well. We have crisis stabilization services, we have partial hospital programs, we have mobile crisis teams. We train the police in crisis intervention training, which is very important. And there are other kinds of programs that could be available along that continuum that need to be in place as well because we have to be careful not to try to look at this over simplistically.

So here is my question. Why is this argument always framed in terms of choosing between hospital beds and community services?

Clearly, funding issues are at play. But I also suspect that much of this has to do with two other influences. The first is our past when underfunded state hospitals were seen as giant warehouses and horrific places. Mental hospitals have been forever frozen in the public’s mind as cruel institutions that by their very existance rob patients of hope and dignity. Consequently, anyone who dares to say that we need more hospital beds is cast in the role of being anti-consumer and an advocate for turning back the clock to the days of One Flew Over The Cuckoo’s Nest.

The second influence that I have noticed during my travels is the impact of the recovery movement. Because of our history, hospitals are not viewed as helping people recover, but rather as a sign of a failure in community services. This is what Mr. Evans was alluding too in his testimony. If you just had better community services, you wouldn’t need hospital beds.

I believe this sort of “either/or” thinking needs to be re-examined. Crisis care hospital beds should be viewed as a normal and important part of our mental health care recovery system for individuals who, for a variety of reasons, cannot have all of their needs met in the community.

Instead of being asked to choose between the two, why don’t we demand both: a decent crisis care hospital bed network and community based services? Are the two rivals or can they compliment each other?



About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.