Bring Back Asylums?


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. 

Abe Bergman
Abe Bergman
Abe Bergman is professor emeritus in pediatrics at the University of Washington


  1. Hi Abe!
    Thank you for sharing your very personal perspective on this issue. My org We Heart Seattle is Volunteer led providing debris / garbage clean ups primarily where homless live or lived + intervention forward outreach. Our number 1 goal is to connect people to treatment and reovery housing and convince council that treatment is housing and funds need to be directed towards the many halfway house projects that exist and to bolt of treatment services to existing transitional housing like tiny homes. I wanted to also call out an error in your article that We Deliver Care are volunteers. They are fully staffed and employed ; funded through the Mayor’s office as part of the 3rd Ave Project. They do good work for sure. Andrea

  2. Abe, I agree.
    I am so sorry about your son.
    Yes. “Persons impaired by addiction and mental illness who refuse asylum treatment should be compelled to do so.”
    Unfortunately, given the progressive legislature and current Governor there is virtually no chance of changing the involuntary commitment law.

    • Virtually no chance as the legislature now sits. But kudos to Doctor Bergman for having the guts to call for one. I hope that the legislature can be reminded how this same doctor, years ago, demanded changes in child cycling safety laws and motorcycle helmet laws, among others. I hope they’ll listen to someone who’s reporting from the frontier of mental health and child health with unquestionable integrity.

    • I think it’s not helpful to blame those you call ‘progressives’ for thinking there’s no chance for modification of the current involuntary commitment law. It became law prior to the situation we now face with people without homes and the easy availability of drugs such as fentanyl.

  3. Thanks so much for this heartfelt and thoughtful commentary — a rare, but much-needed combination. So long as we think in binaries, such as autonomy to make decisions versus mandatory ‘do this,’ we’ll be stuck in this situation of lack of choices. People will continue to suffer, unnecessarily much of the time, and people will continue to be dismayed at seeing people suffer, at seeing other human beings — whether they’re acknowledged as such — in too many places where there is no help forthcoming.

    Surely we can summon the courage to consider Dr. Bergman’s ideas. Dismissing them out of hand, or because they seem unworkable, or because they violate an existing law (or laws), or because we’ve tried ‘everything,’ or for any other reason or excuse should no longer suffice. I think it’s socially, politically and morally untenable to let current circumstances continue.

  4. Thank you, Doctor Bergman, for your principled and personal writing about the mental health crisis in Seattle — your proposal is a brave one, and I am sure there might be blowback from the community. But is there another alternative? Because I sure can’t think of one. I hope we won’t be stalemated for another decade, while people continue suffering, as we look for a perfect answer.

  5. As I recall the story, the case against large asylums was to return care to neighborhood-based, smaller-scale clinics. They were never funded, even though the big hospitals were closed. Another example of noble intent in the 1960s and feeble (perhaps intended) follow-through. It may be that community-based care is still a possibility, though more expensive and less professional.

  6. Thank you, Dr. Bergman. You’ve added to my hopes for WA.

    (And thank you, Andrea, and all the volunteers with We Heart Seattle!)

  7. Thank you Dr Bergman for your powerful article on addressing these vexing issues and for the heartfelt description of your son’s challenges. As you suggest, there must be a better solution for the care of unsheltered people with serious mental issues than ERs, jails, and city sidewalks, and more thought on various levels of care needed depending on individual needs while recognizing individual autonomy. It seems that the plight of the unhoused mentally should be treated as a public health emergency to assure health and safety of all citizens. Thanks also for noting the impressive work of We Deliver Care as that organization provides direct service to homeless people. Best wishes.


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