Dilemmas of Managing Sexual Activity Among Psychiatric Patients
State mental hospitals have undergone dramatic changes in the past 10 years (Bachrach, 1996; Hogan, 1996). The closing of institutions, the coalescing of services and the (by and large) greater continuity of care between inpatient and community providers have dominated public psychiatry and have resulted in improved standards of care within most state facilities. Allied to these developments have been the prodigious advances in the pharmacological treatment of psychosis, which have vastly improved the quality of life and expectations for sustained community tenure among those patients who hithertofore would have resided indefinitely in long-term facilities (Buckley, 1998). The public mental health system has also been responsive to broader developments in health care that presage the arrival of managed care approaches, an open-market, competitive philosophy and consumer choice. These competitive forces require that state facilities at a minimum provide active treatment (as opposed to the historical and often too true stereotype of custodial care) and that they focus on objective patient outcomes (Imbornoni et al., 1997). Changes in the patterns of care are results of interrelated trends: improved treatments, expanded community care, and expanded financial support for inpatient care in other settings such as general hospitals. These changes are also linked to changing attitudes about
mental illness (e.g., support for mental health's inclusion in health reform as reported by the Judge David I. Bazelon Center for Mental Health Law, 1995) and changing paradigms of illness such as the" recovery paradigm" (Anthony, 1993). These changes have reduced the capacity of state hospitals. But these facilities still serve a crucial role and treat many vulnerable patients. Bachrach has suggested that amidst such change, state facilities have the opportunity to redefine and assert their role as a resource and also their expertise in the management (both clinical and policy making) of patients with serious mental illness (Bachrach, 1996). Viewed in this context, endeavors to promote thoughtful and sensible deliberation on inpatient sexuality are both timely and necessary.