The following is an excerpt from the March-April 2020 Pacific Palisades Task Force on Homelessness Newsletter. To read this newsletter in full, please click here.
The Demedicalization of Mental Illness
(L-R) Dr. Joel Braslow, Dr. Enrico Castillo
At the PPTFH January 27 community meeting, we learned about how the changing definition of mental illness has resulted in thousands of mentally ill individuals living in homelessness on our streets. Dr. Joel Braslow (UCLA Professor, Department of Psychiatry and Biobehavioral Sciences) shared his historical research which shows that up to the 1950’s “insanity” was viewed as a medical problem that could be helped by hospitalization. Institutionalizing someone with an inability to survive in the world because of mental illness was considered the humane course, reflecting a social sense of responsibility. No one was allowed to fall into homelessness because of their mental state. Thus, the number of mental institutions grew through the 1950’s, but some of those institutions were better than others.
In the 1960’s, the growing use of psychotropic drugs allowed more mentally ill people to return to their communities. The advent of Medicaid and Medicare supported this trend, thus redirecting resources and funding formerly used for mental health to other needs. Social attitudes changed. Society grew to view institutionalization as something a civilized society should not do. Psychiatrists’ vision of what they could and could not treat underwent a dramatic narrowing of scope. This was the beginning of our current failure to provide for those with mental illness.
Dr. Braslow was joined by Dr. Enrico Castillo in expressing the current need to redefine and re-expand what we consider as our responsibilities to the mentally ill populations living on our streets. They explained that we no longer see homelessness as a psychiatric emergency in need of immediate intervention. We no longer consider someone who is mentally ill and homeless to be “gravely disabled” (part of a definition we use to diagnose someone as mentally ill). A major complicating factor is the availability of resources. With limited funding resulting in a shrinking number of acute care beds (by more than 50%), society has rationalized narrowing the definition of who is gravely disabled, who will be hospitalized and ultimately who will receive the care they need. We have rationalized allowing mentally ill people to live and die on the street.
There is some indication of the beginnings of change. Dr. Castillo reported that as clinicians, more home visits are occurring and there is now a clinical rotation at Twin Towers (LA County jail) which is considered the largest mental institution in the world. We are now asking the question “When do we stop rationalizing because of funding and decide that we should go back to providing care in an institution that is designed with and for 21st century knowledge and needs?”
In addition, we learned the following:
The language of 5150 holds (the California law code for temporary involuntary psychiatric commitment) was changed two years ago so that the threat to self or others must no longer be limited to imminent.
A first responder (such as a police officer) no longer must view the threat but can take the word of other involved persons when putting someone on a 5150 hold.
The State is currently conducting an audit of 5150s, looking at practices and interpretations for additional possible changes to strengthen the practice.
A bill in the Assembly (AB1938), if passed, will change the way financial allocations are made and will broaden the interpretation of 5150.
Another bill in the Senate (SB854), if passed, will require private insurance companies to offer substance abuse medication.
Audience discussion led to conclusions for action:
Watch for a forthcoming audit of 5150 practices that may suggest allowing treatment for a mentally ill individual who cannot care for their physical ills, even if they refuse treatment. Express your opinion in the public-comment phase.
Express support for state bill AB1928, which will allow Prop. 65 funds to be used for inpatient and involuntary treatment.
Advocate removing the MediCal exception in state bill SB854, so that MediCal recipients (as well as persons with other insurance) can receive paid medication for substance abuse.
In the words of Dr. Braslow, “We should be less willing to withhold care from our most vulnerable and sickest patients and [less willing to] allow them to languish either in jails or on the streets.”
Editor’s note: A recent LA Times opinion piece, “My Daughter’s Preventable Murder,” provides an example of the consequences of current laws restricting treatment of the mentally ill.