The decline in the use of psychiatric hospital beds, since the 1950s, has provided the opportunity for the creation of a number of alternatives to the hospital for acute treatment. Small, open-door, non-coercive, domestic settings providing similar services to those in a psychiatric hospital unit have been operating for decades in many places around the world including Boulder, Colorado; Vancouver, British Columbia; Trieste, Italy; and cities in the Netherlands. These alternative settings are in the same tradition as the York Retreat – small, normalizing facilities that are un-locked and genuinely in the community, allowing the resident to stay in touch with his or her relatives, friends, work and social life. They are more flexible and non-coercive than hospital wards and more likely to be based on peer relationships than on hierarchical power structures. They offer opportunities to residents to be involved in the operation of the living and treatment environment. Since the cost is lower than hospital care, the pace of treatment in the alternative setting need not be as rapid, making it possible to offer a more quiet form of genuine asylum.
The recent growth in the use of alternative settings of this type in Britain is a trend which has been stimulated by the closure of psychiatric hospitals and encouraged by the emergence of the recovery model which emphasizes the importance of patient empowerment and interpersonal support. In line with this focus, alternatives to the hospital offer a treatment approach in which coercion and paternalism are reduced and peer support is fostered. They offer a treatment atmosphere with more autonomy for residents and staff. Important benefits include their cost-effectiveness, greater emphasis on human interaction rather than medication, and improved user-satisfaction.
We should be aware, however, that in the U.S. there is often a drive to increase the size of such residential facilities, lock the doors, and introduce the use of seclusion and restraints –a reflection of the tension between the drive to security and cost-efficiency, on the one hand, and human-scale, personalized care on the other.
As in moral management, treating people with respect in normalizing, domestic settings leads them to exercise greater “moral restraint” or self-control over their impulses. When you are in someone’s home, you feel obliged to treat your hosts and their property with consideration, but in an institution, anything goes. This helps us understand why it is possible to care for patients in involuntary treatment in open-door, domestic settings. If the alternative setting is more attractive to the person than a hospital, then he or she will call upon reserves of self-control in order to be allowed stay there rather than in hospital.
Cedar House (now renamed Warner House), a 16-bed hospital alternative that has been in operation for over 30 years in the public mental health system of Boulder County, Colorado, has found that the facility can accommodate at least half of the catchment-area patients in need of acute inpatient care at any point in time, including many patients requiring compulsory treatment.
Balsam House, the residential treatment facility of Colorado Recovery, can also accept patients in involuntary treatment, when necessary.
Recently developed British hospital alternatives are similar to Cedar House and Balsam House in that they are small (average capacity 8 beds), provide a fairly extended period of care (over a month on average), have staff awake at night and accept compulsory admissions. A substantial proportion of patients are compulsorily admitted and most suffer from psychosis.
Crisis homes – private family homes that accommodate people with acute psychiatric problems while they receive treatment from the mental health system – are another domestic-style acute treatment approach that reinforces the concept of “moral restraint.” (See moral management.) Care systems have been established in Wisconsin and Colorado in the USA, in Sydney, Australia, and elsewhere. Psychiatrists, nurses and other staff from the mental health service work with the family in providing care and treatment. These foster families are selected for their warmth and acceptance but are not expected to offer counseling. The job of the family is to provide a home-like environment and tell staff what they observe while the client receives professional treatment. Each client is provided his or her own room and treated like a guest. Some of these programs have operated for decades; the average length of stay in the home is around ten days. They have shown themselves to be valuable for the acute care for people with psychosis and for the crisis care of clients with borderline personality disorder.