Joel T. Braslow

Experiencing community: perspectives of individuals diagnosed as having serious mental illness.

OBJECTIVE Community integration is recognized as a crucial component of recovery from serious mental illness. Although the construct of community integration can be measured with structured instruments, little is known about the subjective and experiential meaning of community and community involvement for persons with serious mental illness. METHODS In 2010, 30 individuals with serious mental illness treated in two public mental health clinics completed semistructured interviews that elicited the places and people that they associate with the experience of community and the larger meaning of community in their lives. RESULTS Participants described four experiences as integral to their concepts of community: receiving help, minimizing risk, avoiding stigma, and giving back. Participants looked for communities that provide reliable support, and they described the need to manage community contact in order to protect themselves and others from their symptoms and from discrimination. Most participants experienced communities centered on mental health treatment or mentally ill peers as providing opportunities for positive engagement. CONCLUSIONS The experience of having a serious mental illness shapes preferences for and perceptions of community in pervasive ways. Participants described community involvement not as a means to move away from illness experiences and identities but as a process that is substantially influenced by them. Mental health communities may help individuals with serious mental illness to both manage their illness and recognize and enjoy a sense of community. The findings indicate the need for further research on the relationship between community integration and outcome in serious mental illness.

History and Evidence-Based Medicine: Lessons from the History of Somatic Treatments from the 1900s to the 1950s

This paper examines the early history of biological treatments for severe mental illness. Focusing on the period of the 1900s to the 1950s, I assess the everyday use of somatic therapies and the science that justified these practices. My assessment is based upon patient records from state hospitals and the contemporaneous scientific literature. I analyze the following somatic interventions: hydrotherapy, sterilization, malaria fever therapy, shock therapies, and lobotomy. Though these treatments were introduced before the method of randomized controlled trials, they were based upon legitimate contemporary science (two were Nobel Prize-winning interventions). Furthermore, the physicians who used these interventions believed that they effectively treated their psychiatric patients. This history illustrates that what determines acceptable science and clinical practice was and, most likely will, continue to be dependent upon time and place. I conclude with how this history sheds light on present-day, evidence-based medicine.

Relationship of community integration of persons with severe mental illness and mental health service intensity.

OBJECTIVE Community integration is integral to recovery for individuals with severe mental illness. This study explored the integration of individuals with severe mental illness into mental health and non-mental health communities and associations with mental health service intensity. METHODS Thirty-three ethnically diverse participants with severe mental illness were categorized in high-intensity (N=18) or low-intensity (N=15) mental health service groups. Community integration was assessed with measures of involvement in community activities, social capital resources, social support, social network maps, and subjective integration. RESULTS Although participants rated themselves as being more integrated into the mental health community, their social networks and social capital were primarily derived from the non-mental health community. The high-intensity group had a higher proportion of members from the mental health community in their networks and had less overall social capital resources than the low-intensity group. CONCLUSIONS The findings suggest opportunities and possible incongruities in the experience of community integration.

The making of contemporary American psychiatry, part 1: patients, treatments, and therapeutic rationales before and after World War II.

This article, the 1st in a 2-part series, uses patient records from Californias Stockton State Hospital to unearth the midcentury roots of contemporary American psychiatry. These patient records allow the authors to examine 2 transformations: the post-World War II expansion of psychiatry to include the diagnosis and treatment not only of psychotic patients but also of nonpsychotic patients suffering from problems of everyday living, and the 1950s introduction of the first psychotropic drugs, which cemented the medical status of these new disorders, thus linking a new therapeutic rationale to biological understandings of disease. These transformations laid the groundwork for a contemporary psychiatry characterized by voluntary outpatient care, pharmacological treatment of a wide range of behaviors and distress, and a doctor-patient relationship and cultural acceptance of disease that allow psychiatric patients to identify themselves as consumers.

The making of contemporary American psychiatry, Part 2: therapeutics and gender before and after World War II.

In this article, the 2nd in a 2-part series, the authors use patient records from Californias Stockton State Hospital to explore the changing role of gender norms and other cultural values in the care of psychiatric patients. The authors show that cultural values are always imbedded in psychiatric practice and that their role in that practice depends on the patients, treatments, and therapeutic rationales present in a given therapeutic encounter. Because the decade following World War II witnessed dramatic changes in psychiatrys patients, therapeutics, and rationales, Stockton State Hospitals patient records from this time period allow the authors to show not only the extent to which gender norms shape psychiatric practice but also how psychiatrys expansion into the problems of everyday life has led to psychiatry taking a more subtle and yet more active role in enforcing societal norms.

From cultural to structural competency-training psychiatry residents to act on social determinants of health and institutional racism

Reckoning With Social Threats to Mental Health Psychiatrists in training launch their careers in a time of inequalities and structural barriers to their patients’ health. Many believe that the uncertain funding and regulation of the US health care system and a frayed social safety net have led to a crisis in mental health care. The United States has fewer mental hospital beds per capita than almost all peer countries, while US suicide rates are at a historic high.1 Prisons and jails have become the largest provider of “care” of those with severe mental illness. Systemic violence and discrimination based on race, ethnicity, religion, sex, and sexual orientation have increased.2 These broader forces not only likely contribute to psychiatric disorders but also make living with these disorders significantly more difficult.3 Over the last 50 years, psychiatric training and education have incorporated the revolution in the neurosciences. At the same time, psychiatric education has paid little attention to the powerful social determinants of mental health, which call on us to rigorously train our residents to understand and work at systems levels to eliminate the structural causes of illness. While cultural competency initiatives train residents in beliefs and behaviors of patient groups that experience health inequalities, cultural competency often falls short of systemic intervention. As a result, psychiatrists may not have the tools to improve their patients’ outcomes, which may lead to professional burnout, departure from clinical practice, and severe shortages of psychiatrists in the public sector.4 As psychiatrists also trained in the social sciences, we have adopted what we call a structural competency approach5 in training residents in US programs to address the social determinants of mental illness. The approach builds on a rich tradition of social and community psychiatry in the United States by specifying competencies for clinical training based on the following 3 fundamental principles: (1) understanding patients’ experiences of illness in the context of structural factors (eg, unstable housing and violent neighborhoods leading to anxiety and trauma-related disorders), (2) intervening to address structural factors at institutional levels (eg, to work with community groups to promote recovery, to collaborate with schools and law enforcement to divert symptomatic people from arrest to clinical care, or to testify to city and state legislatures on the association between housing availability and mental health), and (3) developing community connectivity and structural humility, a posture of collaboration with community leaders and with other disciplines and of patience with the slow pace of structural change. These competencies are critically important for improving mental health outcomes for patients who are socially marginalized by virtue of their race, ethnicity, sexual identity, socioeconomic status, and where they live and work. Structural factors, such as inequalities in law enforcement, housing, education, access to health care, and other resources, ultimately shape the ways in which individuals experience and recover from illness. The term structural brings into focus institutions and policies that can be altered to promote health equity, while competency signals that there are tangible skills clinicians should acquire to address the social structure factors that act as barriers to improved mental health outcomes. Because physicians learn through practice, this shift in focus from individuals to institutions requires bridging the gap between the literature documenting social determinants of health and clinical strategies to rectify them.

Using Electronic Health Records to Enhance a Peer Health Navigator Intervention: A Randomized Pilot Test for Individuals with Serious Mental Illness and Housing Instability

Individuals with serious mental illnesses have high rates of comorbid physical health issues and have numerous barriers to addressing their health and health care needs. The present pilot study tested the feasibility of a modified form of the “Bridge” peer-health navigator intervention delivered in a usual care setting by agency personnel. The modifications concerned the use of an electronic personal health record with individuals experiencing with housing instability. Twenty participants were randomized to receive the intervention immediately or after 6 months. Health navigator contacts and use of personal health records were associated with improvements in health care and self-management. This pilot study demonstrated promising evidence for the feasibility of adding personal health record use to a peer-led intervention.

How Health Reform is Recasting Public Psychiatry

This article reviews the fiscal, programmatic, clinical, and cultural forces of health care reform that are transforming the work of public psychiatrists. Areas of rapid change and issues of concern are discussed. A proposed health care reform agenda for public psychiatric leadership emphasizes (1) access to quality mental health care, (2) promotion of recovery practices in primary care, (3) promotion of public psychiatry values within general psychiatry, (4) engagement in national policy formulation and implementation, and (5) further development of psychiatric leadership focused on public and community mental health.