📷 David Geffen School of Medicine
Journalist: Luke Peterson
Luke: Welcome to SciSection! My name is Luke Peterson, and I am a journalist for the SciSection Radio Show broadcasted on the CFMU 93.3 FM radio station, and we are here today with Doctor Marica Meldrm. Thanks for taking the time to meet with me Dr. Meldrm.
Meldrum: Thank you for asking me.
Luke: Can you begin by telling our audience about what you do at UCLA and what your roles consist of?
Meldrum: I work as a teacher and a professor but also as a researcher at UCLA. I’ve been working for the last 10 years for the Center for Social Medicine and the Humanities which is very interested in the problems of mental illness and care for the mentally ill, particularly in Los Angeles County, and as part of that I’ve done extensive research into policies that have been developed and programs for the mentally ill in Los Angeles County, and I’ve conducted interviews with care-providers, policy-makers, clients and family members of clients. When I say clients I mean people of mental illness who are part of the mental healthcare system.
Luke: So would you mind describing any observations that you’ve made about that mental health system. Are we talking about LA Country in particular?
Meldrum: Some of what I’m going to say is reflected in other urban mental healthcare centers across the country. However, LA County is the largest mental health system in the country. I won’t say it’s the most diverse, but it’s certainly one of the most diverse; it’s certainly at the very top. In many ways, it’s characterized by a series of initiatives which started and continued but without necessarily being integrated over time. The department of mental health originally believed it was going to act in an advisory capacity to clinical programs around the county, but later found itself, because there was no other care provider, it found itself becoming a major provider of care. And since 2004 or 2005, with the funds available through the mental health services act, it has been able to expand those initiatives and initiate recovery-oriented programs in many parts of the county for individuals with mental illness, and many of these programs are really excellent and many people with severe mental illness have been helped by such programs have been able to get into housing, to get into at least some form of employment and find some kind of normalcy in their lives. At the same time this was developing, however, the psychiatric hospitals in California had been closing rapidly since the late 1960s, and under the assumption that community mental health centers would be able to take care of the clients, this was a false assumption; a fallacy. The community health system was not in any way able to take care of the clients that were released into the general population. And the psychiatric hospitals that were in the county at the present time, although many of them were excellent, they were not set up to provide for the population many of them; the size of the mental health population. And most hospitals in the county operate on what’s called the 51/50-Hold, which is if the client is picked up in the street or at their home behaving in a way which is disruptive indicating that they have mental illness, that they can be picked up by emergency services or by the police, they may be taken to the hospital under the 50/51-Hold, which is 72 hours/3 days. And the hospital would then stabilize them on medication and the hospital is not equipped nor do the staff wish to hold the individual for longer than that. Within 72 hours, possibly sooner, they’re going to release this individual again, maybe with medication, quite often without follow-up so that the person then gets continuing care. As a result, many individuals with mental illness go in and out of hospitals without receiving long-term care that they need. There are a number of programs that are within the country that are set to provide for people with drug abuse issues and various types of mental health issues, most of them however are not really equipped to deal with the severely mentally-ill. They are therefore generally living in a kind of revolving-door system, and they go in and out of the hospital and some different times they may be picked up and sent to jail, out of necessity the LA County criminal justice system has developed its own mental health unit which is one of the largest mental health hospital in the country. There again, even though there are a number of dedicated people there with a number of good programs, they’re not equipped to deal with all the people who are hospitalized who have mental health problems, many of whom should be in a hospital or should at least not be in jail for a long period of time while the staff and the criminal justice system try to figure out exactly what to do with them. It’s not a good system.
Luke: You mentioned earlier that as of 2004 or 2005, the Mental Health Services Act that long-term care moved to a recovery-based system, but that doesn’t seem very similar to the situation that you just described, so maybe you can address that? Also, before that, when deinstitutionalization was occurring from the 1960s onward, would you say that that wasn’t recovery-based explicitly?
Meldrum: Both of those actually have related answers. The idea behind deinstitutionalization was that people were just staying in the hospitals for long periods of time and they were not getting any better. In 1952-54, the first set of psychoactive drugs were developed: Thorazine and its sister drugs. We now have a whole armament of medications available. The incentive behind deinstitutionalization was that people could be maintained in the outpatient system simply if they took their medication. This is true: if people take their medication, they often can achieve behavioral normalcy and they can in a sense recover; it’s probably better to say they can manage their mental illness so they can live a normal life. But the problem is is that the medications have their own side-effects, and many of the mentally ill don’t want to take them for the long-term. There are a number of books that have been written by people who have gone through mental illness eventually stabilized on medication that nearly all say they didn’t want to take it in the first place. It was only after a long period of struggle that they realized they had to take their medication. When a person comes to that realization and puts themselves on that medication, then that’s really recovery in a sense, where they’ve really come to a point where they can manage it on their own, but many people never come to that point. And certainly just sending people out into the community system to promote people to take their medication and to ensure that they did so was not a really good plan. As people became lost in the system, and were often ending up in jail or homeless on the streets, the recovery movement developed as a more positive way of approaching this problem, and there are a number of excellent psychiatrists and ideas behind the recovery program and examples of states that tried it with great success. The basic principle behind the Recovery program is that you meet the patient where they are, figure out what they need and try to address those needs whether they need housing or useful work or simply the encouragement to participate in social activities, or whatever it is they need. And certainly prescribed medications would try to work medications into a larger problem which over time moved them towards being able to self-manage meant their own medication and over time to recovery which is defined basically as being able to live independently in the community. Recovery is an excellent idea, but it’s not simply - there are programs in LA County where it works really well. But it’s not something which works easily for the people with severe mental illness. It can be very hard to get them to serve and accept the ideas of recovery and get them to move towards progressing this goal. Many of them simply need more long-term support than the recovery movement envisioned them needing. And therefore instead of recovering, they go off their meds or they stop taking their prescribed medications and take illicit drugs instead which truly aggravates the whole situation. They’re offered housing; the housing is often - many of the housing situations seem like living in a college dorm living with a roommate you don’t like very much. They leave; they don’t want to stay there, why should they? They were in many ways not as comfortable but in many says happier in the streets. So medication is not enough. It’s not enough; it promotes recovery, but if there’s one additional thing which is needed, it’s relationships. A long-term and trusting relationship with a caregiver hopefully augmented by a caring relationship with friends or family. Those are essential I think for most people to make the journey from mental illness to something close to recovery.
Luke: So would you think that the Recovery should enlist holistic methods, so you mentioned relationships and how those help. Are there any other methods that you think can help?
Meldrum: In its concept it is very holistic. Once to offer the individual social activities, opportunities for meaningful work of some kind, drug counseling if they need it, housing if they need it, making sure they have the benefits they can get. As well as some level of talk-therapy and psychological counseling; there are different key therapies that they identify; motivational intermingling; psycho-education, which is explaining to the individual why the way they’re thinking about medication or something is incorrect and helping them understand the correct way of thinking. So a certain amount of talk therapy; all of these are necessary, and the Recovery movement postulates that in the initial stage the individual will receive all of these servies in a very intensive level, but it also assumes that in a period of time that they will be able yo move to a place where they won’t need such intense services. The problem for many people is that the period of intensive service needs to last longer than that.
Luke: So how much of a correlation do you think there is between the problems you outlined with the mental health system in LA County and the issue of homelessness in that county.
Meldrum: I want to say first that probably the main issue is that there isn’t enough affordable housing. Certainly there’s a correlation. One of the major factors contributing to homelessness is not being able to pay rent or maintain a home on one’s own, and the loss of family ties which might help you have a home of your own. And then the individual winds up on the street and becomes homeless and over the long-term, homelessness often exacerbates-living on the streets under the severity of those conditions, often not having enough food and depending and often getting street drugs as a way to relieve life, to get through the day, but relying on street drugs often suffering different kinds of physical ailments for which the person doesn’t get medications- all of these things are going to exacerbate mental illness. Many individuals who initially become illness because of financial probably over time fall into very; become seriously depressed or possibly develop some form of mental illness because as a result of being homeless. They might not have done so if they had been able to maintain stable housing. So yes, mental illness severely exacerbates the problem of homelessness. That’s by no means to say that all of the people who are living without homes in LA County are mentally ill; many of them are not.
Luke: So do you think that the primary approach that one could take to try to begin solving the problem would be to address housing first?
Meldrum: There’s a whole movement about that. Housing both for people who just need housing and housing for the mentally ill which is problematic because often they find that hard times to adjust to housing in a building which expects a normal level of behavior. But all these things can be done, but they require a lot of public will, and they require a certain amount of funding. I know that LA County has been trying on this level, and I’m not really able to say too why they’re not succeeding or to what level they are succeeding, but certainly they aren’t succeeding fully. And part of the issue is that the funding required is large, but also many people are generally in favor of getting the homeless into housing as long as it isn’t in their neighborhood. The homeless have to go somewhere. Housing has to be found for them and it needs to be found within neighborhoods where they can live like other people, or it’s really meaningless. This will be an ongoing problem for I think years until we pull together and figure out what to do with that.
Luke: Are there any other recommendations that you’d like to make or is there anything else that you’d like to say? Or emphasize?
Meldrum: I would like to emphasize this: I think that one of the things that people find is problematic for dealing with the mentally ill is that many people are afraid of them. Their behavior is often unpredictable. In some cases this is merited; people with mental illness can sometimes be violent, but the percentage of violent acts committed by mentally ill people is much lower than that committed by perfectly ordinary non-mentally ill people. Most of the mentally ill are afraid than anything else. They respond to people who reach out to them and talk to them and treat them like human beings, just like any of us do. I think that that too is something people- at one point we seemed to be making some strides towards reducing the stigma of mental illness; we still are, but it’s still harder for people to accept the idea that someone with mental illness might be living in their neighborhood. And yet, really, there is nothing in most cases to fear from such individuals. They need help, and they need friendship just like all of us do.
Luke: Is there anything else you want to say?
Meldrum: No, I think that’s it.
Luke: Ok, thank you for talking with me today. That’s it for this week of SciSection! Make sure to check out our podcast available on global platforms for our latest interviews, and I’ll talk to you later!