Resistance to alternatives to hospitalization

Hospitalization has endured as the predominant form of psychiatric treatment for serious mental illness, despite accumulated evidence that outpatient treatment, ranging from halfway houses to day programs to traditional clinics, is equal or superior to inpatient treatment. Reasons for the apparent reluctance to use alternatives to the hospital include social prejudice against community treatment, economic disincentives, administrative chaos, training, professional sociology, and the countertransference meanings of hospitalization. The foregoing is not an argument against hospitalization, but rather an argument for being very clear about policy objectives and treatment goals. If these objectives and goals are made explicit, proposals can be evaluated for their efficacy. If community tenure, the assumption of responsibility for him or herself, and relinquishment of the patient role are goals, then hospitalization must be examined more skeptically. For society, this means the assumption of more responsibility for the establishment of a system of mental health care, for enunciating national policy goals and implementing them consistently, and for committing the necessary funds and manpower to this endeavor. For the clinician, it means examining the clinical efficacy of his or her treatment recommendations and distinguishing between responsibility for the patient's treatment and responsibility for the patient's life. The abdication of social responsibility for the patient and the assumption of omnipotent clinical responsibility for him or her lead inexorably to more institutional and more restrictive treatment, even in the absence of evidence that such measures are therapeutically effective.