Changing attitudes in medicine have meant that more people with severe psychiatric illnesses are denied admission to hospitals than in decades past. This may lead to their landing back on the streets, and perhaps even in jail. Joel T. Braslow, MD, PhD, is working to fix what he sees as a broken system.
For much of his 27 years at UCLA, Joel T. Braslow, MD, PhD, Frances M. O’Malley Endowed Chair in Neuroscience History and professor of psychiatry and biobehavioral sciences, has studied and taught the history of medicine. A key focus of his research has been on medicine’s shifting attitudes toward relevant issues, such as the nature of mental illness, and, in particular, how the medicalization — viewing problems that previously were considered to be nonmedical as medical in nature — and demedicalization of psychiatric illnesses have played against one another over time.
Exploring this interplay, Dr. Braslow coauthored the first in a recently launched series by The New England Journal of Medicine that explores how social forces and beliefs shape clinical care. In the piece, he writes about the impact of demedicalization of mental illnesses on people like Mr. N, a homeless man diagnosed with schizophrenia 30 years earlier. Psychotic, unable to house himself and hungry, Mr. N arrived at UCLA’s emergency room for care but was not admitted and was released. “A resident recommended that he be admitted; the attending physician that he be discharged,” Dr. Braslow says. Back on the streets, Mr. N landed in jail a few months later. The example of Mr. N shines a spotlight on a nationwide problem: the difficulties faced by ERs when presented with cases like Mr. N and how people in need too often slip through the cracks. “Demedicalization — seeing mental illness as a social problem and fundamentally outside of medicine’s purview — has sent a lot of people back to the streets, and that’s not always in their best interest,” Dr. Braslow says.
Dr. Braslow spoke with U Magazine contributing writer Alice G. Walton about the factors that have led to demedicalization, its consequences and the steps that are necessary to address the issues it presents.
How did you become interested in the issue of demedicalization?
Dr. Joel T. Braslow: I am the director of the Social Sciences Track of the UCLA-Caltech Medical Scientist Training Program. Funded by the National Institutes of Health, the program supports students to get an MD and a PhD in the social sciences or humanities. I’m also a psychiatry attending physician supervising residents in the UCLA Psychosis Clinic, and, when I am on call, I supervise residents who see patients in the Emergency Department of Ronald Reagan UCLA Medical Center. I spend the balance of my time doing research on the care and treatment of individuals with serious mental illness. My research looks at the ways in which sociocultural forces shape public mental health policy, conceptions of mental illness and everyday clinical practices.
When I started my psychiatry residency, in the late 1980s, psychoanalysis recently had been dethroned by biological psychiatry and an increasing reliance on psychotropic drugs. I found this transformation fascinating, in part because it illustrated that social and cultural forces were at play in the ways in which we draw the boundaries between the normal and the pathological. I also found that looking historically at psychiatry could help tease out some of those forces. The history of psychiatry over the last 50 years illustrates significant changes in the care and treatment of people with serious mental illness. With the emptying, and later the closing, of most state hospitals in the late 1960s and 1970s and a growing reliance on drugs, psychiatrists’ vision of what they can and cannot treat underwent a dramatic narrowing. For a psychiatrist of the 1950s, it would have been unthinkable not to intervene when an individual’s psychosis led him or her to homelessness.
Today, psychiatrists see homelessness in their seriously mentally ill patients somewhat differently than did their predecessors in the 1950s. Because of the major sociocultural and economic changes, of which deinstitutionalization was a part, we now no longer see homelessness as an acute psychiatric emergency in need of immediate intervention.
How does this shift in attitude affect you as a psychiatrist?
Dr. Braslow: Los Angeles has the largest homeless population in the country. For those of us living in Los Angeles, we are reminded of this every day. The streets of Westwood, where I work, are home to numerous unhoused people, many of whom suffer from psychotic illnesses. I cannot help but feel a sense of sadness and guilt that I and my colleagues have been rendered incapable of caring for many of those who most desperately need our help.
When a patient comes into the ER, psychotic and unable to find housing because of his or her psychosis, my colleagues and I often are unable to provide the kind of care that a previous generation of psychiatrists would have considered a critical ingredient of psychiatric treatment. I think we have transformed homelessness from a medical symptom in need of medical intervention — it is itself an indication that these people are unable to function in the world, which definitionally is an element of psychosis — into a societal issue that is outside of our medical purview. With any other serious medical concern, we would feel that we need to address it. But in ERs throughout the country, we no longer consider someone who is homeless to be gravely disabled, even though it is their disorder that is driving their inability to find shelter and to function in general.
How did the medicalization of mental illness give way to its demedicalization in the latter half of the 20th century?
Dr. Braslow: Before the 17th and 18th centuries, psychosis, or madness, was interpreted in a variety of ways — religious, willful, moral and so on. Most people lived in agrarian, often tight-knit, communities where individuals afflicted with mental illness were cared for by their families, and the community.
With the rise of industrialization and capitalism in the 18th and 19th centuries, communities became increasingly fragmented, families shrunk and, to survive in the changing economy, many people moved to cities. The shift from an agrarian-based economy to one dependent upon industrial production led to rapid urbanization and a dependency on wage labor. Taken together, all of these factors made it increasingly difficult for families to care for their mentally ill loved ones. Quite similar to the circumstance we find ourselves in today, growing numbers of individuals with serious mental illness found themselves jailed, homeless or living in a variety of inhumane conditions.
In the first half of the 19th century, a growing chorus of reformers called for funding of public asylums. An important aspect of this moment in the history of psychiatry was the “medicalization” of psychiatric illnesses. That is, madness no longer was viewed through a moral or religious lens. As such, the creation of the vast network of asylums created by states rested upon the newly minted belief that madness was a medical illness and that one could cure it by creating specialized institutions called asylums, which were renamed “state hospitals” in the early 20th century.
Despite popular conceptions, my research suggests that state hospitals and their staffs, though often flawed, attempted, and often succeeded, to provide humane care. Patients easily came and went. Wards often were unlocked. In California, state hospitals provided care for all who needed it regardless of ability to pay. These institutions provided a vital refuge, even if imperfect, for those who were unable to function in a rapidly industrializing America. State hospitals instituted a wide variety of therapeutic activities, ranging from occupational and industrial therapy to beauty shop therapy and bibliotherapy.
What began to change?
Dr. Braslow: The state hospital system began to falter in the 1960s. Though conditions had improved substantially after World War II, this came at substantial cost. Some states spent upwards of 25 percent of their budget on their state hospital system. With a brewing economic crisis over the course of the 1960s, states increasingly questioned the cost of mental health care. The passage of Medicaid and Medicare in 1966 gave states the ability to shift the burden of care onto the federal government. Largely an unintended consequence, the passage of Medicaid and Medicare legislation led to a dramatic decline in state hospital populations. Much like the process in which the medicalization of psychosis helped to rationalize the asylum movement of the 19th century, the belief that community care was better than state hospital care helped to rationalize the massive decline in state hospital populations from a peak of 550,000 to about 40,000 patients today.
The problems that the mentally ill face in Los Angeles painfully illustrate the failure of public policy. This is especially obvious in our massive homeless population, many of whom are homeless by virtue of their mental illness. More hidden, but perhaps even more tragic, is the number of mentally ill people who are incarcerated in the Los Angeles County Jail. In fact, with nearly 5,000 inmates on any given day, the Twin Towers Correctional Facility in downtown Los Angeles is de facto the largest psychiatric institution in the country.
What is being done at UCLA to address this issue?
Dr. Braslow: Our psychiatry residents have been remarkable in waking up the faculty to our responsibility toward those with serious mental illness. Along with junior faculty members, they have been instrumental in creating the UCLA Community and Global Psychiatry Program. What ties them together is a deep concern for the mentally ill and the ways in which social inequality and injustice contribute to the suffering of their patients. The residents helped to establish a clinical rotation at Twin Towers, they advocate for better care of indigent psychiatric patients and they actively challenge the attitudes of their attending physicians. They have, over the past few years, become increasingly concerned about this problem, and they now are more interested in public psychiatry. It is quite remarkable, I think, how much this attitude has changed over the past five-to-10 years. In fact, our residents have been instrumental in creating more classes in public psychiatry; we now have 20, up from six. And we have a new concentration in community psychiatry. They have made me feel enormously hopeful for the future of psychiatry.
What needs to happen politically and within the larger medical community?
Dr. Braslow: Psychiatrists have a moral responsibility to alleviate all aspects of psychiatric suffering, regardless of the often arbitrary distinctions between the social, psychological and medical causes. The medical community needs to think more broadly about the fundamental nature of psychiatric illness and to treat it appropriately. We need to acknowledge that psychiatric disease is reflected as much in an individual’s social and psychological worlds as it is in disordered neurotransmitters. If we accept the reality that mental illness is a disease that ignores the distinctions we arbitrarily make between psychological and social well-being, then I think we will be less willing to withhold care from our most vulnerable and sickest patients and allow them to languish either in jails or on the streets.
“Medicalization and Demedicalization — A Gravely Disabled Homeless Man with Psychiatric Illness,” New England Journal of Medicine, November 15, 2018