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Author: Sigrid Bathen (Page 1 of 4)

Mental health courts cut costs, inmates, but lack oversight, data

Sacramento County Superior Court Judge Lawrence Brown. (Photo: Steinberg Institute)

San Francisco attorney Jennifer Johnson views her life and legal trajectory as “life before and life after” a devastating 2016 homicide case that forever changed her view of how the courts treat defendants who are mentally ill.

The case in San Francisco Superior Court involved an 85-year-old defendant, Don Rebello, who suffered from severe dementia.  Suddenly and for no apparent reason, he stabbed and killed his beloved friend and longtime roommate, Erik Kleins, 83 – two of three elderly men who had long shared a San Francisco home.

While dementia is a neurological condition, it is technically not categorized as a mental illness, although symptoms and behaviors are often strikingly similar.

Fredderic “Freddie” Crawford, a retired physical therapist who was the eldest of the three at 87, witnessed the horrifying and abrupt attack, losing his two best friends, his family really, in one terrible tragedy. Crawford and Kleins, who had managed several San Francisco movie theaters, were trying to care for Rebello, a retired law librarian, at home as his condition rapidly deteriorated. They had been looking for a care facility for Rebello when the attack occurred.

Traumatized, grieving and physically very frail, Crawford dutifully came to court as a witness, and at one point collapsed during the lengthy proceedings.

“He came for the arraignment and was there to support the partner who had killed his other partner,” Johnson recalled. “When they brought [Rebello] out, Freddie collapsed, overcome with grief.”

Johnson had long represented mentally ill defendants, though few of the cases were homicides – the one category of crime that was not allowed to be transferred to the Behavioral Health Court she helped to create and where she usually worked. Occasionally, she would be assigned to represent defendants in homicide cases in which “mental health was an issue.”

While dementia is a neurological condition, it is technically not categorized as a mental illness, although symptoms and behaviors are often strikingly similar. Dementia and mental illness rarely “fit” into neat legal categories, in which “competence” to understand court procedures is evaluated.

In such cases, defendants may be legally deemed as “restored to competency” and able to understand the proceedings – or not.

“One of the huge gaps in the criminal justice system is the aging population of people with dementia,” Johnson said. “Obviously, he (Rebello) could never be ‘restored’ [to mental competence]. He was never going to get better.”

Johnson retired last year, after two decades in the San Francisco Public Defender’s office, where she co-founded the Behavioral Health court in 2003 to help get mentally ill defendants into treatment and out of a punitive criminal justice system ill-equipped to help them.  She had dealt with difficult cases before, but nothing like the Rebello case.

“I was probably too attached. It was the one case where I sort of lost my objectivity.” — Jennifer Johnson

The defendant’s severe dementia meant that he had no concept — nor memory — of what he had done, was unable to communicate and never recognized Johnson as his lawyer. But under California law, he was charged with murder and jailed, while the wheels of justice ground mostly to a halt.

“It was the most frustrating case, and it changed my life forever,” said Johnson, who now works as an attorney in the San Francisco Sheriff’s Office and as a consultant on mental-health and criminal justice issues for government agencies and nonprofits. She also co-teaches a course in Mental Health and the Law (with neuropsychiatrist Dr. George Woods) at UC-Berkeley School of Law.

She is writing a memoir about the Rebello case and her journey through a court system which struggles with how to manage – much less help –the increasing numbers of mentally ill offenders filling California prisons and jails. Using pseudonyms for the victim and defendant, she spoke at length about the case last year in a San Francisco presentation and podcast about mental health and the criminal justice system, co-sponsored by the UC-San Francisco Citywide Case Management Program, which provides intensive mental-health treatment services.

Jennifer Johnson

“I was probably too attached,” she said. “It was the one case where I sort of lost my objectivity. I felt strongly about Freddie, who had lost both life partners and had to endure the long delays” in adjudicating the difficult case.

The case dragged through the courts for two years, as the uncomprehending, frail and elderly Rebello was shuttled between the San Francisco jail and Napa State Hospital, where he was finally deemed legally “incompetent” to stand trial – a fraught and glacial process that can take months, often years, while the accused stays in jail.

“I’ve been fighting the criminal justice system for mentally ill people for so long, and it was a breaking point for me,” says Johnson.“What I had to drag the last living victim (Crawford) through, all the waiting, it was agonizing. I’d never had a case that had been that tragic and that heartbreaking, and highlighted how much change our system needs.”

Johnson’s hard-fought defense included evaluations of Rebello by three physicians “who all said he would never get better.” Nonetheless, a traumatic transfer to Napa State Hospital was ordered for Rebello to undergo further evaluation. At Napa, she said, “they quickly decided he could never be ‘restored’.” Ultimately, Rebello was placed in a public conservatorship, and sent to live out his days in an Oroville care facility where he died in July. Crawford died in June.

“It was a wildly expensive process that doesn’t have good outcomes,” Johnson said.

‘The law doesn’t fit the reality’
While considerable progress has been made in establishing mental health courts around the state, extricating significant numbers of mentally ill offenders from the criminal-justice system, Johnson said, “the law doesn’t fit the reality, and it has not evolved with our understanding of the brain.”

“But decades of bad public policy have left a legacy – people traumatized by incarceration, lack of mental health care.” — Jennifer Johnson

A nationally recognized legal authority on mental health law, Johnson was the resident public defender on a team of legal and behavioral health experts who helped mentally ill defendants in San Francisco’s Behavioral Health Court to get treatment and services which would keep them out of jail and prison – in some cases reducing their sentences or even dismissing the charges against them.

Like others involved in mental health courts throughout the country, Johnson says a collaborative, team approach is essential for the courts to work. “Mental health, prosecution, probation, defense – all are needed at the table to make these programs operate properly,” she said in several interviews with Capitol Weekly. “And that’s not an easy thing to do in an adversarial system.”

Many mental-health advocacy groups press for more prevention and education as the best means to keep the mentally ill out of the criminal-justice system. “I’m all for prevention,” says Johnson. “But decades of bad public policy have left a legacy – people traumatized by incarceration, lack of mental health care. We need both prevention and reversing the damage of our own bad policies.”

In a 2016 commentary in the San Francisco Chronicle, she urged policy-makers to “unravel decades of damage” by recognizing “the crucial role that the mental health system plays in ensuring public safety, and prioritize its resources accordingly,” with legislation, policies and funding that ensure treatment, not incarceration.

“For 40 years, we have swept homeless, vulnerable, poor, addicted, black and brown people into our jails and prisons,” she wrote. “Nearly half of those people have a mental illness. . . Instead of receiving treatment, they languish behind bars, waiting for a treatment bed. Or they are released to the community without any treatment plan at all and fall through the gaping holes in our social safety net.”

State legislation was approved in 2018 to create “diversion” programs in California courts for defendants with mental illness, drug addiction and other specific issues underlying their crimes. It has removed many defendants from the court system and somewhat reduced the number appearing in mental health courts, although Johnson said in San Francisco that it means “we get the more serious cases.”

And, in an odd quirk of the 2018 law, diversion programs (in which a defendant’s charges are withdrawn if they comply with the program), will not accept individuals with certain mental-health diagnoses, Johnson said. Those include Borderline Personality Disorder, a serious but common diagnosis often confused with Bipolar Disorder.

“We should be looking at their functioning in the community, not their disorder,” says Johnson, who like many criminal-justice and mental-health experts is critical of the 2018 law, which critics say was amended late in the legislative process and rushed through with limited discussion.

“Our service providers are heroes.” — Lawrence Brown.

While San Francisco’s Behavioral Health Court accepts serious cases, other local mental health courts may accept only misdemeanors. There is no statewide legislative or legal standard for mental health courts to follow in California, only guidelines and wild variations in funding. There is no state oversight and no comprehensive statewide data collection.

“If you’ve seen one mental health court,” says Johnson, “you’ve seen one mental health court. There are no statutory requirements. And, frankly, they should be different, because each county is different.”

Mental health courts expand in Sacramento
In Sacramento, Superior Court Judge Lawrence Brown is in his eighth year presiding over two mental health courts – a period when he says “our numbers have grown exponentially.” Brown also helped design a re-entry court for state prison parolees with mental-health issues, easing their adjustment to life on the outside with intensive counseling and treatment.

Since the mental health court was created in 2007, with 16 offenders in the program, it has grown to two courts currently serving nearly 300 participants, according to detailed statistics kept by the court. An estimated two-thirds are under 40 and nearly 30 percent are 19 to 28 years old. In the most recent quarter of 2020, ending Sept. 30, some 72.5 percent were “successful graduates,” while 27.5 percent were discharged for “non-compliance” with the intensive programs overseen by the court, including counseling, medication and regular court sessions.

“Our service providers are heroes,” Brown said in an interview with Capitol Weekly. “Everyone is talking the same language. Probation, the lawyers (prosecutors and defense attorneys), and treatment providers all have a shared objective of treatment. There is an understanding that we have these tools to deploy to keep a person in the community, and treated.

“It takes a village, and it’s not foolproof. . .But it is some of the most gratifying work I’ve ever done.”

Placement of a defendant in mental health court requires a commitment from participants to follow their judicial and treatment plan.

“Each of the participants knows that the court cares, and that they are going to be held accountable,” says Brown. “That’s why we bring them back in front of the court on a regular basis for updates, to see their accomplishments – and to sanction if we have to.”

“I discovered how cathartic it was for me to take over the court and to know that my lived experience was some benefit to participants.” — Lawrence Brown

“We may have to put them back in jail to stabilize,” he adds. “It’s not punishment, it’s with an eye to stabilizing.” He emphasizes the importance of a stable medication regimen —  and often shares with participants and family members how medication has helped his schizophrenic sister.

Brown cites “serendipity” for his decision to take on the mental health courts, which was originally a routine rotation, but one he ultimately asked to be permanent – an unlikely choice for a former state and federal prosecutor who was the director of the California District Attorneys Association before he was appointed to the bench by then-Gov. Arnold Schwarzenegger.

“Quite frankly, I had some trepidation” about the original assignment, he said. “I would love to claim I sought it out because my sister has a mental illness, but I had never really come to terms with losing my sister to serious mental illness and was quite content to leave the burden to my mother.”

Presiding over mental health court changed his perception of his now 60-year-old sister’s schizophrenia. He frequently mentions her struggles during discussions in his courtroom – and the impact of her illness on his family, particularly his mother. He is regularly involved in his sister’s care, frequently taking their 90-year-old mother to visit her in a Santa Rosa care facility.

“I discovered how cathartic it was for me to take over the court,” he says, “and to know that my lived experience was some benefit to participants. I would share with parents in my courtroom that we were in the same situation. I had never talked about my sister, and there I was, opening up on the bench. I’m much closer to my sister now and very involved in her life.

“I now get it.”

Like other mental health courts in California and around the country, the atmosphere in Brown’s courtroom is a far cry from the often rigid, ritualized routine of traditional courtrooms, as the judge banters with attorneys and defendants, remembering key personal details about each defendant, offering encouragement, praising their accomplishments.

Multiple agencies are involved in the mental health courts in California, and funding comes from a variety of criminal-justice and mental-health sources…

He holds regular graduations for those who successfully complete the court’s requirements, and even provides gift cards to defendants who stick with their prescribed medication regimens. It’s unconventional, and widely proven to save public funds by successfully keeping mentally ill offenders out of jails, prisons and hospitals, and off the streets.

“You see these miracles appearing before you, of people who were disconnected, not taking their medications,” Brown says, “and then they appear before you as totally different people. We celebrate that, and they know it, and feel it.”

In a profile of Brown last year in the legal newspaper, the Daily Journal, he was praised equally by prosecutors and defense attorneys, and in 2018 received the Judge of the Year award from the Indigent Defense Panel in Sacramento.

“He has such a deft way of helping the most vulnerable in our community,” Sacramento defense attorney Kelly Babineau told the Journal. “The whole defense bar felt he really deserved recognition for that.”

Funding a constant source of angst
Multiple agencies are involved in the mental health courts in California, and funding comes from a variety of criminal-justice and mental-health sources, including the state Mental Health Services Act (MHSA), the 1 percent “millionaire’s tax” on all incomes over $1 million that was passed by voters as Proposition 63 in 2004.

Funding is a constant source of angst for the courts, and relying solely on state court funding is unpredictable at best. The courts can tap into mental-health funding from other sources, such as the MHSA, and the various support services also have other funding sources, including Medi-Cal and Medicare. The alternative courts clearly save money, and judicial administrators are keenly aware of that. But without comprehensive statewide data collection on successes and cost savings – and more community treatment facilities — expansion of the courts statewide is difficult.

It became clear that “the mental health problem [in the criminal justice system] was more complex and deeper than we realized.” — Lloyd Connelly

Sacramento Superior Court Judge Lloyd Connelly, a former state legislator, Sacramento City Councilman and legal services lawyer, has long experience with the impact of mental illness on the criminal justice system. Technically retired, he continues to serve as the Sacramento court’s Chief Executive Officer, and mental health issues are high on his agenda.

“From my perspective,there is no question that it saves money,” he said in an interview with Capitol Weekly. “But funding is a part of it, and the truth is that there are not now or ever will be in the foreseeable future adequate [treatment] facilities. Over the last couple of years, there are more options for outpatient facilities, and that’s a big tool for Judge Brown. But it’s not enough. We have a spectrum of  [facilities], but we need more. And that’s always a struggle.”

Connelly is a longtime supporter of collaborative courts – such as mental health, drugs, veterans and parolees. “All of those demonstrate better success rates [than traditional courts], just by the nature of providing services, a judge assuming stewardship,” he said.

Lloyd Connelly

Over the years, he added, it became clear that “the mental health problem [in the criminal justice system] was more complex and deeper than we realized.”

Public attitudes toward mental health and the stigma attached to mental illness are often barriers to successful programs and adequate funding.

“There is a sense that, oh, if you just reach across and give them a shove,” Connelly says. “There is no comprehension that there is a fundamental chemical change that has occurred in the brain, that this is a diagnosable, measurable condition. This is not some person with an attitude, this person is really sick.”

Connelly has served as a mental-health court judge and presided over hearings in psychiatric facilities on involuntary civil commitments. Before he became a judge, he represented disabled and mentally ill clients as a legal aid attorney. As a former legislator, he is deeply familiar with the checkered legislative history of mental health law in California.

“Now here we are, years later in my life, and I can walk down the streets and see people that are exactly like the folks I saw in those illustrations from many years ago.” — Lloyd Connelly

He recalls as a student in high school and college reading about the barbaric treatment of the mentally ill, locked in asylums or left to wander and often die in the streets. “I remember these drawings about the treatment of mentally ill folks in the 18th century — horrific drawings of starving people, obviously physically and mentally ill.”

Although asylum warehousing of the mentally ill and developmentally disabled continued well into the 20th century in the U.S., closures of the state mental hospitals essentially dumped thousands of mentally ill Californians into communities completely unprepared to house or treat them. Many ended up in jails and prisons, and on the streets.

“Now here we are, years later in my life,” Connelly muses, “and I can walk down the streets and see people that are exactly like the folks I saw in those illustrations from many years ago, here outside my own office. We’re no different. The society is more complex, but we have not joined this issue like we should.”

The reluctant bureaucracy
Nevada County Superior Court Judge Tom Anderson, a former public defender in Nevada and Lassen counties, has seen the cost – both human and financial – of mental illness in the criminal and civil justice systems from multiple perspectives.

When he was a public defender, he defended clients whose severe mental illness, frequently combined with addiction issues, was at the root of their crimes, starting in their teens or early 20s, when mental illness is often first diagnosed.

“No business would continue to exist if it had an 80 percent failure rate.” — Tom Anderson

He pioneered Assisted Outpatient Treatment (AOT, “Laura’s Law” in California) in Nevada County as a public defender, after representing Scott Thorpe, who pleaded not guilty by reason of insanity to killing 19-year-old Laura Wilcox and two others in 2001, and who will likely spend his life in Napa State Hospital.

Nevada County Judge Tom Anderson

If  Laura’s Law had been in effect in the period before Laura’s murder — when Thorpe was unraveling and his family repeatedly tried to warn local mental health authorities, who ignored them – he likely would have qualified for the intensive treatment the law requires, one of the few legal avenues available to family members trying to get mentally ill relatives into treatment.

Anderson helped to create AOT programs in Nevada County and throughout the state and presided over the civil court that administers them. He was instrumental in getting the county to start specialized alternative criminal courts for the mentally ill, and those addicted to drugs and alcohol, to get them into treatment and keep them out of jail.

After decades of pushing an often reluctant bureaucracy to adopt programs widely proven to save money by diverting – and treating – offenders who would otherwise be clogging expensive hospital E.R.’s, jails and prisons, or homeless in the streets, Anderson remains mystified by  the glacial nature of the process.

“It’s always surprising to me how slowly it goes,” he told Capitol Weekly, “when there is all this information on [the successes of] mental health court, drug court, AOT: fewer days in jail, the ER, fewer people sitting on the streets, and what it means to families.

“All of those things save money.They’re also solutions to our incarceration system, and [its] presumed focus on punishment, its astronomical recidivism rates for decades.

“No business would continue to exist if it had an 80 percent failure rate.”

Like other judges presiding over mental health courts who were interviewed for this article, Anderson decries the lack of community treatment facilities, and the entrenched failure early-on to address the causes of severe mental illness in children and teens. “There just aren’t enough services in the communities to deal with serious mental illness,” he said.

Few California counties have juvenile mental health courts, which would provide a more coordinated response to help young people…

Anderson has recently been presiding over a Nevada County branch court in Truckee two days each week, and was troubled by a difficult case before him, a teenager with nowhere to go.

“It’s dangerous for him to go back to either parent,” Anderson said, and placements are limited for a troubled boy whose life has been blighted by family chaos, drug use and physical abuse, with all of the mental-health consequences that entails.

At 16, he ended up in court for “juvenile stuff, fighting, not serious,” Anderson said, and may be involved in a gang. Not an easy foster care placement, for all the obvious reasons.

From years of experience with difficult cases, Anderson knows the boy is at the point where the right intervention, support, counseling, treatment, can help prevent a further downward spiral. But the lack of community treatment facilities means the boy will likely be sent to a juvenile facility, where he’ll be housed with more serious offenders – or he might be returned to his father.

“That is what is pending as one of the likely alternatives,” Anderson said. “Neither is a good outcome, but it is a typical scenario.”

Few California counties have juvenile mental health courts, which would provide a more coordinated response to help young people who become ensnared in the criminal justice system, where it is estimated that about three-fourths of kids in the system have mental-health issues.

“It starts with juveniles and foster care,” says Anderson, “with not enough mental health care and early identification. Many come from families with significant mental-health issues, who are resistant to treatment, which perpetuates until it gets serious.”

Santa Clara judge creates ‘gold standard’ for mental health courts

Judge Stephen V. Manley listens to a defendant during veteran’s court in his courtroom at the Santa Clara County Superior Courthouse in San Jose, California, Wednesday, January 25, 2012.

Santa Clara County Superior Court Judge Stephen Manley refers to defendants in his courtroom as “clients” – an indication of the unusually informal and conversational tenor of the Behavioral Health Court he created more than two decades ago.

“It tends to break through a barrier,” Manley said in a recent interview with Capitol Weekly. “Defendant is the word of the court. Client or patient is the word of treatment. Stigma is still a major issue. . .They all know they’re defendants. If we act like they’re ‘bad’ or charged with a serious crime, the focus is only on the negative. Obviously, there are consequences, but I try to get them to focus not solely on their criminal charge, but on treatment and changing behavior. ”

In practice, he added, “I generally use their first names.”

Established in 1998, four years after he created a similar drug treatment court, Manley’s behavioral health court was the first such court in California, one of the first in the country, widely described as the “gold standard” for mental health courts nationally. His unusual – and highly successful – approach to keeping mentally ill defendants out of the criminal justice system has been adopted throughout California and in other states. Manley has received widespread news coverage and multiple local, state and national awards from criminal-justice and mental-health groups.

Designed to break the tragic pattern for people whose mental illness underlies their crimes — too often landing them, repeatedly, in jails and prisons ill-equipped to help them – Manley’s courts now serve 1,500-2,000 mentally ill offenders annually. Nearly 70 percent of them successfully completed their requirements and many charges were dismissed, according to Manley’s recent report to the Santa Clara County Board of Supervisors..

“Judge Manley was the pioneer, the dean of judges in this area (mental health courts),” says Randall Hagar, legislative advocate for the California Psychiatric Association. “He has more people go through his court than any other mental health court.”

“He was the trailblazer for collaborative mental health courts,” says Mark Gale, a well-known mental-health activist who is the Criminal Justice chair for the Los Angeles County Council of the influential National Association on Mental Illness (NAMI), and has long worked to make the courts a reality in more California counties — including his own, the massive Los Angeles County court system, which now has a variety of alternative courts and diversion programs.

“This is a team effort. We are the court, and the judge is joining with behavioral health, custody, probation. We’re all partners.” — Stephen Manley

Manley’s courts are often used as the template for successful mental health courts, and his tenacity overcame concerns from prosecutors suspicious of non-traditional courts and mental-health clinicians who questioned how additional treatment would be funded.

Manley credits support from other judges and the board of supervisors for the success of the courts. He emphasizes a coordinated approach involving multiple local agencies, from prosecutors and probation officers to public defenders and clinicians, to successfully divert cases – and people – from a costly, overwhelmed and overcrowded criminal justice system.

“This is a team effort,” Manley said. “We are the court, and the judge is joining with behavioral health, custody, probation. We’re all partners.”

Many California counties have some form of mental health courts, according to statisticscompiled by the state’s Judicial Council.

But few have attained the broad success of the Santa Clara courts, which now include two judges and two psychiatrists, as well as  prosecutors, public defenders, behavioral health specialists, probation officers, Veterans Administration staff and a host of programs to provide intensive treatment and specific services.

It’s a proven and cost-effective way to keep mentally ill offenders out of jail – and save public funds spent on the huge costs of incarceration, hospitalization, homelessness.

When a new county Family Justice Center Courthouse was opened in San Jose in 2016, space was set aside for a full range of services to keep people in treatment, with resources available for on-site treatment, from psychiatric consultations to help with medications, housing assistance, even a clothes closet.

Coordinated efforts are key to effectiveness in mental health courts, Manley said, and recent remote hearings via Zoom during the COVID-19 pandemic have been surprisingly effective.

“When they’re in the streets, they’re going to the ER or to jail.” — Stephen Manley

“It’s a very interesting and new way to work with people,” he said. “You have the DA and the public defender and the treatment team, perhaps 12 people involved on the same Zoom call. But it’s basically the judge talking directly to the client.”

Immediate intervention is essential to resolving the frequent crises bedeviling mentally ill offenders, often landing them in jail.

“The important thing is that you intervene as quickly as possible,” Manley said, to resolve an immediate barrier to recovery, like housing or accessing a program that provides free phones. In a traditional court system, the pace is often glacial at best, while quick resolution of major and minor issues requires a radical new approach in mental health court, to keep participants housed and in treatment.

“When they’re in the streets,” says Manley, “they’re going to the ER or to jail.”

Shortly before the first of two Capitol Weekly phone interviews — which Manley apologetically asked to reschedule for later in the day, because he was hearing cases, working through lunch – he had just conducted a Zoom session with a man calling in from a bus stop, where he was headed to a meeting with a caseworker. “If you have the case manager with the defendant,” Manley marvels, “you can do all kinds of things, like finding housing.”

“So often in the courts, we hear very formal testimony, and we get reports in writing,” he adds. “The pandemic has put the courts in the position of doing things differently. In the remote hearing I did this afternoon, the client was in the [treatment] program, meeting with his caseworker. Before, they’d say, ‘come and see our program,’ well, I couldn’t. Now, remotely, I can.”

‘Chaotic, noisy’ – and it works
Manley’s mental health courtroom is often described as “chaotic” or “noisy” in the many articles about him over the years, with a variety of legal and behavioral-health experts consulting in the courtroom – the revolutionary “team approach” that characterizes his court.

Insurers have historically refused to recognize dual-diagnosis, and often would not cover mental-health treatment if that individual also abused drugs

“There are [clients] who will scream, yell, sometimes spit,” says Manley, who cuts an imposing figure with his shock of white hair and a black eye patch over his left eye, the result of a long-ago accident. “We have plexiglass. . .

“Then, I see them 10 days later, after they’ve started their medication, and they’re doing much better. I understand stubbornness. Judges can be very stubborn. But if you can get out of that and move an inch forward, that’s incredible. Once you get past the first hurdle, the next one is easier.”

Manley was also an early adopter of “dual-diagnosis” mental health treatment – recognition, only recently widely accepted, that substance abuse and mental illness are closely related, and cannot be successfully treated separately.  Insurers have historically refused to recognize dual-diagnosis, and often would not cover mental-health treatment if that individual also abused drugs. Yet people with mental illness frequently turn to street drugs because they aren’t getting the prescription medications they need, or experience difficult side effects and are “self-medicating” with dangerous street drugs.

Recent state legislation requires that insurers approve both mental health and addiction treatment.

“Most people don’t understand that 80 percent [of mentally ill offenders] use drugs or alcohol,” says Manley, “because those are  ‘solutions’ to their problems when they’re feeling depressed or manic, when they’re hospitalized or homeless in the streets, which is traumatic. Going to court is traumatic, being in jail is traumatic. So they turn to street drugs.”

“There’s a stigma with the mentally ill that they are more dangerous, which is not true.” — Stephen Manley

Often, that drug is methamphetamine, which is widely available on the streets, cheap – and particularly disastrous for the mentally ill. “There is so much meth-induced mental illness,” Manley said.“If you can get people to stop using meth and get help for their substance-abuse problems, their paranoia clears [as do] meth-induced schizoaffective disorders, bipolar disorders, whatever. You have to concentrate on both.

“If you can’t stay sober for a day, what are we going to do about your mental health? If you don’t take your medications, we can’t help you.”

Manley, who often sounds more like a mental-health clinician than a judge, earned a Bachelor’s degree in behavioral health at UC Berkeley before getting a law degree from Stanford.

“I’ve worked with mental health clients for years, and I know our traditional method is to ignore them,” he said in a 2005 Q&A interview with the Center for Court Innovation, a public/private partnership originating in the New York courts that studies and proposes innovative programs in state courts.

“We either cycle them through quickly or we give them long sentences,” Manley said. “There’s a stigma with the mentally ill that they are more dangerous, which is not true. Some are, some are not. They are, however, far more difficult to work with. It makes absolutely no sense in my view to warehouse someone who is mentally ill and release them into the community with no services, when we know they will be rearrested again and go right back into jail.”

While he now has the full support of his colleagues and other county officials, Manley said in that interview it was an uphill battle to start the courts: “So I went to war with — or had discussions with — mental health [officials], and we changed things.”

“Serious mental illness has become so prevalent in the U.S. corrections system that jails and prisons are commonly called ‘the new asylums’.” — Treatment Advocacy Center, 2016 report

Not all judges are suited for mental-health court, he said: “A judge has to be committed, very patient, and willing to accept criticism from clients. Mentally ill people are very honest. They will tell you what is and isn’t working—if you ever bother to listen to them. Trying to meet the needs of these clients is an incredible challenge. There is no court that requires a more sophisticated and committed team than mental health.”

“Success,” he added, “is small things: Clients who are able to function, who learn how to take the bus, who learn to find a place to live that is somewhat permanent, who are able to get social security or their disability reinstated.

“I have different expectations and goals for every client.”

‘The new asylums’
Official estimates of the number of mentally ill inmates in jails and prisons differ widely – and are often outdated — but mental-health and criminal-justice experts consistently say the numbers are rapidly increasing, as are suicides in adult correctional and juvenile detention facilities.

A 2016 report based on 2014 numbers by the highly regarded mental-health policy nonprofit, the Washington-D.C.-based Treatment Advocacy Center (TAC), said “serious mental illness has become so prevalent in the U.S. corrections system that jails and prisons are commonly called ‘the new asylums’.”

The report estimated one-fifth of local jail inmates and one-fourth of state prisoners are seriously mentally ill.

“Based on the total inmate population,” the report continued, “this means approximately 383,000 individuals with severe psychiatric disease were behind bars in the United States in 2014, or nearly 20 times the number of patients remaining in the nation’s state [mental] hospitals.”

Estimates are based on state and local figures that are notoriously unreliable for myriad reasons. Many mentally ill inmates are never diagnosed, much less treated. Some refuse to participate in studies or don’t believe they are mentally ill. And the numbers may not include those with less severe mental illness, which can worsen without diagnosis or treatment, particularly while incarcerated.

A lengthy 2014 survey of state prisons and jails by TAC and the National Sheriff’s Association, found wide variation in state statistics. And the statistics are tied closely to the dearth of mental-health services in the community.

Among California’s 58 counties, the study noted, 26 have “no psychiatric inpatient beds whatsoever, public or private,” to treat mentally ill people in the community, and the remaining state mental hospitals – which were mostly closed in the 1960s and 1970s — house primarily those deemed criminally insane by the courts.

The Los Angeles County Jail has long been described as one of the largest mental-health facilities in the country…

“The consequences are as predictable as they are tragic,” the 2014 survey concluded, with jail suicides increasingly common, as well as attacks by other inmates, too often resulting in deaths. In line with national data, the California Department of Corrections and Rehabilitation estimated in the TAC/Sheriffs’ survey that one-fourth of inmates were mentally ill in 2012, a 6 percent increase over 2009, with 11,000 (9 percent) in solitary confinement, a common practice known to severely worsen mental illness.

As California prisons have been ordered to reduce population — as a result of court orders, legislation and more recently because of COVID — more inmates have been transferred to local jails, or released, too often ending up on the streets.

The Los Angeles County Jail has long been described as one of the largest mental-health facilities in the country, along with other, aging correctional horror chambers in Chicago (Cook County Jail) and New York (Riker’s Island).

Incarceration is expensive, but locking up mentally ill prisoners is exorbitant, with additional staff and prescription costs — assuming the prisoners are treated at all. In addition, there frequently are costly lawsuits stemming from injuries and deaths in custody and the vulnerability of mentally ill inmates to jailhouse brawls and attacks.

According to figures from the federal Bureau of Justice Statistics, a 2006 study that is available on the California Judicial Council website found a whopping 56 percent of state prisoners, 45 percent of federal prisoners and 64 percent of jail inmates had a mental health diagnosis or symptoms of mental health problems in the year before the study.

In addition to being more vulnerable to suicide and assaults, mentally ill prisoners are more likely to receive longer sentences.

For juveniles, the numbers were even worse – an estimated 65 to 75 percent of juveniles had a “diagnosable” mental health disorder in the 2006 study.

A 2016 report, “Justice that Heals,” by a panel of San Francisco Bay Area mental-health and criminal-justice experts, also concluded that, based on local and national studies, nearly two-thirds of  jail inmates across the country have mental-health problems. And the incidence of mental illness in jail and prison populations is worsening, with a patchwork of local, state and federal programs too often working at cross-purposes.

They recommended creation of a Behavioral Health Justice Center in San Francisco, which has long had active behavioral health treatment and diversion programs in the jails and courts. But budgetary and political barriers reportedly intervened, and then the COVID-19 pandemic, and the proposed center was never realized.

‘Restoration of competency’ – or not
In addition to being more vulnerable to suicide and assaults, mentally ill prisoners are more likely to receive longer sentences.  They are twice as likely to be charged with rule violations, according to the 2016 TAC report. They also experience longer pretrial detentions, particularly if they require psychiatric evaluation or “restoration of competency” to stand trial, causing growing waitlists for evaluations in the remaining state mental hospitals.

“Mentally ill inmates in some states are reported to spend more time waiting for competency restoration so they can be tried than they would spend behind bars convicted of the offense for which they have been charged,” the report concluded. Some are never declared “competent” and are consigned more or less permanently to state mental hospitals for the criminally insane.

“Many individuals were subjected to repeated instances of involuntary treatment without being connected to ongoing care that could help them live safely…” — State Auditor Elaine Howle

Often using the model developed in Santa Clara County, increasing numbers of California courts are creating similar mental health and other so-called “collaborative” courts (DUI, drugs, veterans, and others aimed at diverting specific cases), with widely varying methods and limited statewide requirements or data collection. A major criticism in a recent California Auditor’s report on mental-health care, was the lack of statewide data and follow-up care, particularly after incarceration or hospitalization.

“Perhaps most troubling, many individuals were subjected to repeated instances of involuntary treatment without being connected to ongoing care that could help them live safely in their communities,” state Auditor Elaine Howle  wrote in a cover letter  to the governor and legislative leaders.

In Los Angeles County alone, she said, “almost 7,400 people experienced five or more short-term involuntary holds from fiscal years 2015–16 through 2017–18, but only 9 percent were enrolled in the most intensive and comprehensive community-based services available in fiscal year 2018–19.”

At the local level, many mental health courts report considerable success in reducing incarceration and hospitalization by requiring intensive mental-health treatment and follow-up by caseworkers and the courts, although the number of participants in such courts remains small in many counties.

According to a 2015 report by a state task force, 30 California counties then had adult mental health courts, and some counties (a mere seven in the 2015 report) had juvenile mental health courts as well. That number has since increased to 36 counties with 50 adult mental health courts and 11 courts for juveniles. The task force of judges and court administrators was convened by state Supreme Court Justice Tani G. Cantil-Sakauye and the state Judicial Council to establish procedures for local courts to follow in establishing mental health courts.

Blaine Corren, a spokesman for the Judicial Council in San Francisco, said the Council has an active Collaborative Justice Courts Advisory Committee co-chaired by two Superior Court judges with long experience in mental health and other collaborative courts, Richard Vlavianos in San Joaquin County and Lawrence Brown in Sacramento.

The mental-health crisis in California’s criminal justice system – and on the streets – has a long, tortuous history.

He said the committee – which includes a mental health subcommittee chaired by Judge Manley – is expected to present a report to the Judicial Council’s annual meeting in January that will discuss “progress on the (2015) mental health task force recommendations,” as well as  current issues and concerns “related to the intersection of criminal justice and mental health.”

In addition, Corren said, the Judicial Council “partners with the Council of Criminal Justice and Behavioral Health, the Council of State Governments, and the County Behavioral Health Directors Association to do four regional trainings related to mental health diversion courts,” although training has had to be moved online during the COVID pandemic.

The Judicial Council’s Center for Families, Children and the Courts  also recently completed studies on the need for more juvenile mental health courts.

Many mental health and criminal justice experts say state legislation – and funding — is necessary to expand mental health courts and collect more comprehensive statewide data on the courts. Yet funding remains a perennial challenge, and proposals to expand the courts and provide more funding were stymied this year by pandemic-imposed state budget restrictions.

The mental-health crisis in California’s criminal justice system – and on the streets – has a long, tortuous history.  Closures of the state mental hospitals more than a half-century ago and the passage of laws to correct the horrific human-rights abuses of the hospitals, have resulted in a nightmare of equally epic proportions, playing out in plain sight in homeless encampments throughout California, in hospital ER’s, courtrooms, jails and prisons – at huge public expense and untold human suffering.

Clearly, new methods must be developed to evaluate and treat the growing numbers of mentally ill people who regularly, repeatedly tangle with a criminal justice system they often don’t understand and is ill-equipped to help them. And little real progress can be made, experts say, without more – and earlier – intervention and treatment programs in communities, to diagnose and treat people before they commit crimes.

“I go back again and again to the lack of capacity” in community mental-health care, says Manley. “There should be much more effort with young children and their families. We should be working with 2- and 3-year-olds. “We need to do far more work on the front end,” to create more local programs to help traumatized kids deal with dysfunctional families, poverty, violence.

“To be really successful, diversion shouldn’t be in the courts.”

Q&A: Darrell Steinberg’s longtime focus on mental health

 

 

 

 

Published on 9/16/20

When Darrell Steinberg first ran for the state Assembly in 1998, he made mental health the bedrock of his legislative agenda. Shortly after he took office, the former Sacramento city councilman introduced AB 34, which initially provided $10 million to fund pilot projects for community mental-health programs.

The bill marked the first significant state investment in an increasingly troubled mental health system in decades, resulting in what Steinberg called “the beginnings of real success, with decreased hospitalizations and reduced homelessness.”

More legislation would follow to expand on the success of the pilot programs, culminating in 2004 with the landmark Mental Health Services Act (MHSA), passed by voters as Proposition 63. The so-called millionaires’ tax – a 1 percent surcharge on taxable income over $1 million – has since raised billions for community mental-health care in California.

 

By then, Steinberg was termed-out in the Assembly and running for the state Senate, which he later headed as Senate President from 2008 to 2014. A lawyer, he worked in private practice, and founded the Sacramento-based nonprofit Steinberg Institute in 2015 to “dramatically raise the profile and increase the effectiveness of mental health policy-making in California.” He returned to local government when he was elected mayor of Sacramento in 2016.

As Sacramento faces an increasingly serious crisis in homelessness and mental illness, with thousands of citizens wandering the streets, many pitching tents in front of City Hall, Steinberg has continued to press for major local and state mental-health reforms. The COVID pandemic has further decimated government resources, and massive national outrage over police misconduct has sparked continuing protests, mostly peaceful but sometimes erupting in violence.

Steinberg, 60, has also advocated redirecting – not de-funding – police budgets to better respond to mental-health crises, pairing clinicians and social workers with officers to help de-escalate potentially volatile 911 mental-health calls.

In a Sept. 3 interview with Capitol Weekly, Steinberg responded to a wide range of questions about his decades of mental-health advocacy, past and current state legislation, local programs and future plans. This interview was edited for length and clarity:

CW: The recently concluded legislative session saw passage of several important mental-health bills, which have been described as “historic.” The principal bill in the Steinberg Institute package was a long-awaited “parity” bill. While parity laws have been part of state and federal law for years, critics say health insurers have found ways to deny care for mental health and substance abuse. SB 855 aims to change that, and improve enforcement. What does that mean for the estimated 13.4 million Californians who get insurance in the commercial market or from employers?

Steinberg: From my own personal perspective and history,  I’ve always strongly supported the parity bills, but most of my focus over decades  has been on the public side of the mental health system — MHSA, AB 34, SB 82 — all to strengthen services and to ensure that prevention and early intervention were hallmarks of our public system. It’s crystallized for me over the last couple of years, that the struggles we experience on the public side are in no small part due to the lack of parity. There is a discernible cost shift that goes on, where the health plans don’t cover the variety of innovative approaches that the public side covers. The end result is that the public side has much more demand than the resources available for those who need the help.

CW: And some families have even dropped private insurance in order to qualify for more comprehensive mental-health services under Medi-Cal? 

Yes, that’s exactly what I’m talking about. Of course, mental health has thankfully become a bipartisan issue. Regardless of how one approaches the discussion [and] the cost to taxpayers, the resources in the public system can never keep up with the need. In part, it’s due to the fact that we have all these other systems –commercial pay and medical managed care — where the rules are different, where parity is elusive in reality.

This bill is a fundamental shift in several ways. It increases the diagnoses that have to be covered under the parity law. I have a friend, a co-worker with a child whose real-life struggle illustrates what happens for thousands of families. This young girl has an eating disorder and qualifies for the highest levels of care. [Her family’s health plan] helps her to gain weight so that she physically gets out of the danger zone – temporarily — then they immediately step her down (reduce services). And she immediately loses weight again, because it’s a mental-health issue.

The health plans, I’m sorry, they do a lot of good work, and certainly keeping an eye on cost is important. I get that. There is not an infinite amount of money. But in mental health, people get pulled from pillar to post in times of great crisis. . .[Insurers] aren’t required to cover prevention, they don’t cover wraparound services, and they get to define medical necessity. This bill is a big deal. It has the potential to change the whole paradigm around getting care when you have insurance. If we can genuinely infuse parity in commercial pay and managed care, it will then allow the public system to care for those who don’t have insurance and need the public system. We’re really pleased that the bill passed with bipartisan support and hope the governor will sign it.

CW: Do you think the governor will sign it? 

Steinberg: I learned long ago not to predict those things, but I know he is a deep believer in improving mental health. He devoted all of his state-of-the-state address before the pandemic to mental health and homelessness.

CW: Are there ways the insurance companies can get around the parity law? Reportedly, some insurers can be very creative in that regard. But there will also be additional staff in the state Department of Managed Care, which will make enforcement more robust?

The willingness to enforce is as or more important than the words in the statute, for all the obvious reasons. Of course, there are ways clever folks can try to work around laws, but if there is a willingness to enforce the letter of the law, and the spirit behind it, and the message gets out there, that is so important. You can’t enforce  compliance for everyone. But if you have a willingness to enforce, it begins to change the lives of those who are trying to get help for their loved ones.

CW: Another bill, SB 803, would finally establish a peer-certification system in California, which is one of only a few states in the country without such laws. This has been one of your key legislative proposals for several years now, and previous bills have been passed but were vetoed. Are there any assurances that Gov. Newsom will sign the bill this year? And, if so, what will that do for mental-health care in local programs? Why is peer support so important? And why has it taken so long to pass a bill? 

Steinberg: It’s been so long that I don’t even remember whether I introduced it. . .When you look at the experiences of other states on peer services, the people in need get help.  They get help earlier. Peers know this, and people in the field know this — that there is no better way to heal than to have the help of someone who has suffered themselves.

And the other obvious point: We don’t have enough mental-health professionals. How can we deny the ready opportunity to increase access? This bill met the fiscal challenge directly (by having the counties) opt-in and decide whether to pay the federal (matching) funds.  The state cost is $1 million to set up the infrastructure statewide [using] MHSA administrative funds over two years. The opt-in was an amendment to get it through. Sometimes that works well, sometimes not.

There is a larger issue in play here. We have an opportunity to democratize mental health. I wrote about my late grandmother (in an op-ed for the LA Times). She was not trained or certified, but even as she was disabled, she was calling people who were lonely and shut in. We can all be a peer. We could use a different word, which is friend. To actually certify and train people with lived experience, not only helps them because they’re giving back, but it’s the most powerful thing for people who are hurting, [to know] that they are not alone and that other people have lived through it. . .It’s common sense here, but the system does not often enough acknowledge what is basic and what actually works and then build upon it. The peer movement is a very powerful one, and it’s largely volunteerism — as opposed to harnessing the power of people with lived experience to help others.

CW: Major police reform proposals largely failed this year, despite national protests of police misconduct.  While you don’t favor “de-funding” the police, you have said more needs to be done to improve law enforcement response to mental-health crises – which often end badly — utilizing mental-health professionals instead of police (or paired with officers) to respond to calls. The Sacramento Police Department last year hired a licensed clinical social worker, Bridgette Dean, to supervise the Mental Health Unit in the department, which provides training and assists officers in responding to police calls (Dean is now the interim director of the city’s new Office of Community Response).  I know you don’t run the Police Department, although you do consult regularly with Chief Daniel Hahn. What can the mayor do to improve police response in mental-health crises?.

Steinberg: To Chief Hahn’s credit, he’s ahead of his time in pairing police with social workers. My [police reform] initiative takes it to the next step. Most of the innovation is at the local level. It’s not an alternative to de-funding, but it’s systemic change over time that people are looking for. It redefines what we expect of police officers in our society. And it’s one area where we can find common ground among combatants on the issue. No matter what one thinks of the police, they are the first and last resort, the first responders, and they’d rather not be responding to all of these calls. They’re not trained to deal with homelessness or with a mental-health crisis.

For a person in a mental health crisis, seeing a person with a uniform and a gun can exacerbate the problem. The real answer, in my view, is not to defund, but to redefine what we expect of police officers. And to back it up with where the money goes, how we fund public safety in the broadest sense. We will actually shift resources to a new unit, the Office of Community Response, with non-law enforcement response to as many of these non-law enforcement calls that we can. The art is in how it is done. In some instances — domestic violence for example, that’s a crime — it’s important that officers accompany [clinicians] to a call. But then there is the handoff so that victims can get help, and perhaps we can prevent the second, third, fourth and 10th calls.

I’m very excited about this initiative. It’s different from saying we’re going to cut X percent of our police budget. We’re very serious about it, and the new interim director of the Office of Community Response, Bridgette Dean, is passionate and experienced in this area.

CW: Some of the protests recently have devolved into violent confrontations, destruction of property, looting, often by second waves of protestors, following peaceful protests and involving individuals described as anarchists or “outside agitators.” You’ve engaged directly in conversations with protestors, including a recent, intense discussion, filmed by TV news crews, when you were approached leaving a restaurant by protesters. 

Just another day as mayor. . .Some say it was a mistake to show up. I’m always going to show up. They have the right to say whatever they want. I continue to try to [show up]. As long as people are peaceful and nonviolent, they have the right to criticize me any way they want. I continue to try to elevate the discussion. . .

There are definitely people coming in from outside the community. I draw a very clear line. We uplift and uphold people who take to the streets to express their anger so long as they do so peacefully and nonviolently. But those who come in from outside or live here in the city, with bats and spray paint, it’s not acceptable. We have to differentiate between the two. It’s a dilemma for people in leadership, and we try to be thoughtful about it. I stick to that line. I think that is what most people believe.

CW: You recently wrote, with Dr. Jonathan Sherin, mental health director for LA County, an op-ed for the LA Times on the “antiquated” Lanterman-Petris-Short (LPS) law that has governed mental-health care in California for more than half a century. None of the mental-health bills that passed this session seriously addressed LPS, which has been called the “third rail” of mental-health policy in California. Why is it so difficult to make substantive changes in the law?

Steinberg: I’ve always believed that involuntary commitment and Laura’s Law (Assisted Outpatient Treatment in California) are a necessary part of the system at the very end of the continuum. Voluntary treatment and services are always a better way to start and to persist with. But there comes a point, and it is most clearly seen with people who are chronically homeless or they live for years in their parents’ back bedroom. Everyone suffers because they don’t seem to have any answers.

The LPS law ought to mean what it says, and it doesn’t. No one can argue with a straight face that someone who has been on the streets for years and living with severe mental illness, is not mentally disabled. It defies common sense. There is a lack of effective services, a lack of sufficient prevention and early intervention. And it’s all voluntary. We see the results.

CW: You and Dr. Sherin mentioned the “laudable” goals of LPS to “try to right the horrific injustices of prior decades”—the grotesque human rights abuses of the state mental hospitals, which have been mostly closed. But you also wrote that current conditions require updates to the 1967 law, particularly in the definition of “gravely disabled.” What changes do you recommend?

All sides of that debate are living with the trauma of a system (pre-LPS) that also did not work for people who deserved better. . . .That does not mean that what we have now is helping as many people as it must and it should.

Whether or not one believes in a right to shelter  — and an obligation for people to take shelter and housing if offered — the fact of the matter is we have a completely voluntary system on both sides. When something is optional or voluntary on either side, it doesn’t get the attention and the priority and focus that it needs and deserves. I’ve said this for a year and a half. . .Our legally enforceable mandate, AB 3269  by (Assemblyman David) Chiu (D-San Francisco), did not pass. But I’m coming right back with this idea, that some form of legal obligation from the government — and the consumer, if it’s offered with dignity — be part of this conversation. And LPS is part of that.

CW: As the author of the landmark 2004 Mental Health Services Act, Prop. 63, you’ve said some changes need to be made in MHSA. Explain.

Steinberg: This was one of the casualties of COVID. We were very focused on an MHSA refresh, and the administration was very focused, but it obviously got overwhelmed. We will go back next year to resume the work to refresh MHSA. So much about the MHSA is working well, but what we all want is a more outcome-based set of investments, where we can actually show how this money is being used, catalyzed with other public and private resources, and delivering results around the most serious consequences of mental illness. We don’t have to radically change it as much as we want to refresh it, to make sure that the county and the state are accountable for better results.

CW: The California State Auditor recently issued a scathing report on the state’s mental-health system, recommending major changes. While she did not recommend changing the basic structure of LPS, she did call for major improvements in delivering follow-up care to people who are released after LPS mental-health holds, often ending up on the streets, or in jails and prisons. You’ve said that the auditor’s report  addressed only a small portion of mentally ill people needing help – those who are detained in involuntary holds or find their way to a hospital ER. Could you elaborate?  

Steinberg: I actually thought there were parts of the audit that were really important and strong, and reinforced much of what we already know — that no matter what you do with the statute, if you don’t have a real system of care, services and treatment for people that is more easily accessible, then even an involuntary hold of some kind is just going to be a designation. [The audit] was very good and helpful, but it was incomplete. It only looked at the smaller cohort. It didn’t look at the definition of grave disability. It was a good piece of work, but there is more work to do.

Editor’s Note: Sigrid Bathen is a Sacramento journalist and former Sacramento Bee reporter who taught journalism at Sacramento State for 32 years. She has long covered mental-health issues, for several publications, and her writing has won numerous awards. She has covered health care, education and state government for Capitol Weekly since 2005. Her web site is www.sigridbathen.com. She can be reached at sigridbathen@gmail.com.

 

Lawmakers send historic mental-health bills to Newsom

 

 

 

Published September 3, 2020

Landmark legislation to improve California’s notoriously fractured mental-health system has been passed and sent to the governor in the waning days of a chaotic legislative session disrupted by the COVID pandemic.

“This package of legislation is a game-changer,” said Maggie Merritt, executive director of the Steinberg Institute,  a mental-health advocacy and policy nonprofit established in 2015 by Sacramento Mayor and former state Senate Leader Darrell Steinberg, a longtime advocate and author of major mental-health legislation spanning decades.

The fact that significant bills were passed in the middle of a pandemic – when the Legislature was  forced to curtail hearings and sharply limit the number of bills they could consider – “shows that our elected leaders understand how important mental-health services are at this vital moment,” Merritt added.

“It means that for the 13.4 million people who get insurance on the open market or from employers, the promise of parity will finally be true.”  — Julie Snyder

Steinberg said the legislative package “once again puts California at the forefront of mental health policy reform, requires more from the health insurance industry, and helps to address the mental health crisis that is taking such a devastating toll on our state and our country.”

Perhaps the most important measure,  passed after years of fierce opposition from health insurers, and many failed (or vetoed) bills, would require insurers to provide treatment for mental health and substance abuse based on the same standards as treatment for physical conditions.

So-called “parity” laws  have existed in both state and federal law for years, but insurers have used a complex determination of “medical necessity” to deny care for mental health and substance abuse — which is commonly a mental-health issue, a form of “self-medication.”

Senate Bill 855, by Sen. Scott Wiener, D-San Francisco, “is in itself historic,” said Julie Snyder, government affairs director for the Steinberg Institute. “It means that for the 13.4 million people who get insurance on the open market or from employers, the promise of parity will finally be true.” The bill also toughens enforcement by the state Insurance Department and the Department of Managed Care, which Snyder said will add 19 new positions provided in the governor’s budget.

“It’s an important change,” Randall Hagar, legislative advocate for the California Psychiatric Association, said of the new parity law. “It allows enforcement, clarity, and it’s going to make it harder for plans to deny care, which they’re really good at. . .The value of this bill is that it sets out criteria that plans have to use when making decisions. It levels the playing field.”

Strengthening ‘Laura’s Law’
Also approved was a bill to strengthen – and finally make permanent — California’s 18-year-old “Laura’s Law,” which gives family members legal recourse to get help for mentally ill relatives.   The original 2002 law is named after 19-year-old Laura Wilcox, who was killed in 2001, along with two others, when a deranged client of a Nevada County mental-health clinic, where she was working during her winter break from college, came for an appointment and opened fire. His family had for months warned clinic staff that his condition was seriously deteriorating, but they refused to listen, citing patient confidentiality.

The current bill, AB 1976 by Assemblywoman Susan Eggman, D-Stockton, would remove a “sunset” provision that required new hearings every five years, add judges to the list of family members and clinicians who can refer people for treatment, and require counties to hold public hearings when they decide not to adopt Laura’s Law.

One bill in the package supported by mental-health advocates would require the state to collect data on board-and-care homes.

Twenty of California’s 58 counties currently have Laura’s Law/Assisted Outpatient Treatment (AOT) programs — which have shown significant success in reducing homelessness, hospitalizations and incarceration — but other counties have quietly “opted-out” of Laura’s Law with little or no public discussion.

“This bill will finally require counties to make that decision in a public setting,” said Hagar, which will make it more difficult for counties to justify not adopting a program that has been shown to help families and save public funds. Counties opposed that provision of the Eggman bill, saying it amounts to a mandate.

One bill in the package supported by mental-health advocates would require the state to collect data on board-and-care homes, which have been closing in many cities because of high housing costs, and another would create a system of “peer certification” for people who have “lived experience,” but may not have clinical degrees, and often work in local programs.

Still others would expand the scope of practice for nurse-practitioners working without physician supervision and require insurers to cover consultations with psychiatric clinicians by physicians treating pregnant women and children. Two bills would create a Secretary of Homelessness in the Governor’s cabinet and an Office of Suicide Prevention in the state Department of Public Health.

None of the bills that passed  in this session, however, seriously addressed the “third rail” of mental-health care in California – the badly outdated 1967 Lanterman-Petris- Short Act (LPS)

While broad, substantive police reform legislation largely failed, one bill survived which would establish a pilot program to expand – and test – community-based responses to various crises, including those caused by mental illness. Law-enforcement response to mental-health calls, which often result in injury and death, have increasingly come under scrutiny as protests of police misconduct escalate around the country.

Widespread calls to “de-fund” the police have generally failed legislatively. But community programs have emerged that utilize mental-health experts rather than police (or paired with officers) in responding to and de-escalating potentially volatile crises.

The “third rail” in mental health law
None of the bills that passed  in this session, however, seriously addressed the “third rail” of mental-health care in California – the badly outdated 1967 Lanterman-Petris- Short Act(LPS), which has dictated state mental health policy for more than half a century.

Passed at a time when California’s archaic and often dangerous state mental hospitals were closing, the LPS law sought to prevent the grotesque human rights abuses of the hospitals, where mentally ill and developmentally disabled “residents” – many of them children – were locked up, often for years, with little recourse, hardly any treatment, and virtually no due process. Many were injured or died in the overcrowded, understaffed facilities.

One measure that failed would have made possible somewhat longer involuntary holds for severely mentally ill individuals who are detained, usually for a maximum 72 hours.

But the statewide system of “community care” that was to replace the hospitals never happened, leaving thousands of mentally ill people homeless and without treatment, wandering California streets and warehoused in jails and prisons ill-equipped to house, much less help them.

Several bills proposing minimal or technical changes to LPS were introduced this session, with little fanfare and varying results.

One measure that failed would have made possible somewhat longer involuntary holds for severely mentally ill individuals who are detained, usually for a maximum 72 hours, as a danger to themselves or others, under the so-called 5150 hold (named after the LPS section in state law that established a limited system of involuntary holds).

A less utilized section of the law, 5250, allows for 14-day holds under strict conditions. But most people are detained on the more common 5150 hold, ending up in overcrowded hospital ER’s, where they are often discharged well short of 72 hours, without the treatment they need or any follow-up care.

AB 2015, by Assemblywoman Eggman, was passed by the Assembly in June with a bipartisan vote of 76-0, but stalled in the Senate and was withdrawn by the author in mid-August. The bill would have allowed 14-day holds for individuals unable to care for themselves, whose physical deterioration results from their mental illness. A relatively minor technical change to LPS, which is vague on the definition of “grave disability” involving health conditions, the bill will likely be reintroduced next session.

A highly critical July 28 State Auditor’s report helped to revive legislation that would otherwise have been a casualty of cancelled or truncated legislative hearings during the pandemic.

Requiring consideration of physical as well as mental health in LPS holds would be a significant departure from LPS requirements that only mental health be considered in determining “grave disability.”  Advocates say the LPS law’s lack of clarity on the definition of “grave disability” has resulted in widely varying interpretations by hearing officers attempting to determine whether someone should be detained for care on an involuntary hold.

Another bill that easily passed, AB 3242 by Assemblywoman Jacqui Irwin, D-Thousand Oaks, would utilize telecommunications technology to assist health-care providers in determining whether someone should be admitted for treatment on an involuntary 5150 hold. Introduced in response to the pandemic and overcrowding in hospital emergency rooms, the bill was passed with strong bipartisan support.

“During the COVID 19 pandemic, many counties have turned to methods of telecommunications to conduct these [5150] assessments,” Irwin said in an Assembly bill analysis, “resulting in less egregious wait times for evaluation and less overcrowding in emergency departments.”

State Auditor helps to revive legislation
A highly critical July 28 state Auditor’s report helped to revive legislation that would otherwise have been a casualty of cancelled or truncated legislative hearings during the pandemic. The Eggman bill to strengthen Laura’s Law was essentially dead in the Senate, after passing 77-0 in the Assembly, until the auditor strongly recommended that California adopt AOT programs statewide.

Toward the end of the session, facing a statutory midnight deadline on Aug. 31, lawmakers struggled to prioritize and process hundreds of bills.

But the systematic overhaul recommended by the auditor is now left to future sessions, and advocates say the state has a long way to go in providing a coherent statewide system of mental-health care.

“It’s likely we will see much more on LPS, especially since the audit,” said Snyder, a veteran legislative staffer and advocate who recently joined the Steinberg Institute as government affairs director. “Most policy makers didn’t have time to address [the auditor’s report], but they’ll have an opportunity for a much more robust response in the coming session.”

She said “it just wasn’t the right year” for more comprehensive mental-health legislation, because of the pandemic. “It was very difficult to move legislation. Having been part of the legislative process for three decades, I’ve never seen anything like this.”

Toward the end of the session, facing a statutory midnight deadline on Aug. 31, lawmakers struggled to prioritize and process hundreds of bills. Members of the Senate Republican Caucus were largely forced to work remotely after one member tested positive, and tempers flared as the session sputtered to a chaotic end.

Nonetheless, the legislation that did pass makes significant, if incremental, changes, in how mental-health care is provided in California, at a time when voters are clamoring for solutions to a mental-health and homelessness crisis of epic proportions. Hagar, who follows as many as 100 bills for the California Psychiatric Association every year, said he is seeing “an increasingly larger portion” of bills in which mental health is either central or related.

“For the last three years, we have seen an increase in the number of bills that address both substance abuse and mental health,” he said. “Polls indicate that people want better health care, mental health care, solutions for homelessness.”

Hagar and other advocates are optimistic about even more substantive solutions in the next session. “A lot will depend on the shuffling of [committee] chairs,” he said. “As new legislators are elected and come into the process, we have an obligation to educate them and hope they will become advocates for sound mental health policy.”

Below are summaries of recently passed mental-health legislation, now awaiting action by the governor (Sources: Steinberg Institute, legislative records):

–SB 855 (Wiener, D-San Francisco), would expand the ability of Californians who buy insurance or get it from their employers to obtain treatment for w a wide array of mental health and substance use disorders. It would require commercial health insurers to pay for medically necessary treatment of any behavioral health or substance use disorder listed in the DSM-5, the American Psychiatric Association manual that defines mental health conditions. The bill is sponsored by the Steinberg Institute and The Kennedy Forum, a national mental health policy group founded by former Congressman Patrick Kennedy.

–SB 803 (Beall, D-San Jose), would require the state to establish statewide requirements for certifying peer support specialists –people who have personal experience with the mental health system who are trained to support and assist others who are going through mental health challenges. Counties that choose to do so would be responsible for implementing and managing the program and could access federal funds to partially cover the cost of employing peers, helping expand the workforce of people who can respond to the state’s mental health crisis.

–AB 1766 (Bloom, D-Santa Monica), would require the state Department of Social Services to annually report the number of board-and-care homes that serve low-income Californians living with a severe mental illness, track their closures, and notify county behavioral health departments within three days of receiving notice that an operator plans to close a home. Board-and-care homes are a crucial piece of the housing spectrum for people living with severe mental illness.  AB 1766 would provide policymakers statewide data to address the loss of these homes and help counties identify appropriate living options for people with severe mental illness.

–AB 890 (Wood, D-Santa Rosa), would allow nurse practitioners (NPs) to work to the full scope of their license by expanding their ability to treat patients, including those affected by mental health challenges, without a physician’s supervision. It would help address the large and growing workforce shortage of primary care physicians in California. The US Dept. of Veterans Affairs gives 6,000 NPs working in the VA system this authority, and the California Future Health Workforce Commission has urged California to do the same. California today is the only western state that restricts NPs from practicing without physician oversight.

–AB 1845 (Luz Rivas, D-Los Angeles), would create a Secretary of Homelessness in the Governor’s Cabinet to coordinate and consolidate multiple programs aimed at ending homelessness. The huge and growing number of Californians experiencing long-term homelessness includes a large number of people living with severe mental illness.

–AB 1976 (Eggman, D-Stockton), would amend the bill known as Laura’s Law, making it permanent and requiring all counties to implement the program, unless they formally opt out of doing so. The original 2002 law authorized counties to start programs to provide intensive assisted outpatient treatment (AOT) to people suffering from severe mental illness and enabled judges to order treatment for those who declined to accept offered services. (Editor’s Note: Most are voluntary)

–AB 2112 (Ramos, D-Highland), would create within the Department of Public Health an Office of Suicide Prevention to advise the state and regional partners on best practices for suicide prevention.

–AB 2054 (Kamlager, D-Los Angeles), would create a demonstration pilot grant program to expand and test community-based responses to all types of crises, including those caused by mental health challenges, for the state’s most vulnerable populations.

–AB 2360 (Maienschein, D-San Diego),  requires health insurers to develop telehealth networks for consultation with psychiatric clinicians by primary care physicians, pediatricians, and ob/gyns to support their provision of mental health treatment to children and pregnant women (up to one year postpartum).

Editor’s Note: Sigrid Bathen is a Sacramento journalist and former Sacramento Bee reporter who taught journalism at Sacramento State for 32 years. She has long covered mental-health issues, for several publications, and her writing has won numerous awards. She has covered health care, education and state government for Capitol Weekly since 2005. Her web site is www.sigridbathen.com. She can be reached at sigridbathen@gmail.com.

Auditor slams state mental-health system, revives Laura’s Law

 

 

 

Published August 8, 2020

A massive and highly critical state auditor’s report has given new life to legislation to deal with California’s notoriously troubled mental-health system. The shift comes as state lawmakers, convening amid the COVID-19 pandemic, face hundreds of bills in the closing days of the legislative session.

While a bill to strengthen and make permanent “Laura’s Law” in California sailed through the state Assembly in early June, it stalled in the state Senate, as legislative leaders clashed over how to manage the crush of bills awaiting action by the Aug. 31 deadline. 

But when state Auditor Elaine Howle unequivocally urged statewide adoption of Laura’s Law in California in her July 28 report – and after Assembly leadership complained that Assembly bills were not receiving fair hearings in the Senate – the measure was suddenly added to the agenda for a Senate Health Committee hearing on Saturday, Aug. 1.

The original 2002 law enables families with severely mentally ill relatives to access a program known as Assisted Outpatient Treatment  — AOT, or “Laura’s Law ” in California.

The bill, which gives family members legal recourse to get mentally ill relatives into treatment, easily passed 8-0.

“We were dead in the water,” said Randall Hagar, legislative advocate for the bill’s sponsor, the California Psychiatric Association, “and all of a sudden [the bill] was ‘pending’. It was the only bill added to the committee hearing.”

The Senate Health Committee’s required bill analysis was also expedited and it was joined with the Senate Judiciary Committee analysis.  The measure, AB 1976 by Assemblywoman Susan Talamantes Eggman (D-Stockton), now goes to the Senate Appropriations Committee and, if approved, to the Senate floor.

The original 2002 law enables families with severely mentally ill relatives to access a program known as Assisted Outpatient Treatment  — AOT, or “Laura’s Law ” in California. Experts say AOT has been successful in California and other states in reducing hospitalizations, incarceration and homelessness.

 

But California allows counties to decide whether they want to “opt-in” to the program of intensive treatment, and only 20 of California’s 58 counties have agreed to start Laura’s Law programs. 

Eggman’s bill would require counties to publicly state, in writing, why they choose to “opt out” of the program, would add judges to the list of those who can request treatment, and end a “sunset” provision which required renewal hearings every five years.

Many of Howle’s recommendations are not new. They have been addressed by legislation, reports and recommendations spanning decades.

Eggman agreed to extend the bill’s implementation for six months until July 2021 to give counties time to prepare.

Laura’s Law is named for Laura Wilcox, a 19-year-old college student who was working in a Nevada County mental-health clinic in 2001, when she and two others were shot and killed by a deranged clinic client whose family had repeatedly tried to get help for him, but were rebuffed by a clinic psychiatrist.

Laura Wilcox

“Laura Wilcox might be alive today if this program had existed then,” Eggman told the committee.

Laura’s parents, Nick and Amanda Wilcox, tirelessly lobbied state and local government for Laura’s Law and tougher gun legislation. Nick Wilcox testified at the Aug. 1 Health Committee hearing that the county programs have saved lives and reduced costly institutionalization.

“We’ve been approached many times by people who have told us that Laura’s Law saved the lives of their family members,” he said, by getting them into intensive treatment.

Most people voluntarily enter the program, but the law also provides for court oversight and intervention to ensure treatment.

Disability rights groups have long opposed the law, saying it infringes on civil rights, and county mental health directors – while supporting the concept of the law – dislike adopting it without more funding, and they say it places additional  burdens on already strapped local programs.

Decades of bills, reports, recommendations
Many of Howle’s recommendations are not new. They have been addressed by legislation, reports and recommendations spanning decades. But an increasing number of mentally ill Californians wander the streets, recycle through overwhelmed hospital emergency rooms, or end up in jails and prisons that have become de facto mental institutions ill-equipped to house, much less help them.

In the detailed, 120-page audit, in the works since last summer, Howle specifically addressed the 1967 Lanterman-Petris-Short (LPS) Act , the landmark law that has governed mental-health care in California with few changes for more than half a century.

The auditor did an in-depth analysis of involuntary mental health treatment procedures (LPS “holds” and conservatorships) in three California counties – Los Angeles, San Francisco and Shasta. Howle was particularly critical of state oversight of programs primarily run by California counties, which receive billions in federal and state funds for mental health, with little statewide coordination or comprehensive data collection.

Those detained on LPS “holds” frequently end up in overcrowded hospital emergency rooms, where they too often languish without substantive – or any – treatment.

Howle recommended no changes in the basic LPS criteria for involuntary treatment – originally designed to prevent the grotesque civil-rights abuses of mentally ill Californians who were confined, often for years and against their will, in aging state mental hospitals.

But her report slams the lack of follow-up care for those who are detained under LPS holds, usually no more than 72 hours. The auditor also studied people placed in conservatorships – the most restrictive and long-term commitment under LPS – and concluded they receive little or no community care after leaving conservatorships.

California’s mental hospitals, which also housed developmentally disabled residents, including children, often for decades, were largely closed in the 1960s and 1970s, with only a few facilities remaining, mainly for those judged criminally insane.

The Wilcox family, August 2000. (Courtesy, Wilcox family)

But the “community care” touted to replace them never materialized. Howle excoriated the state’s failure to provide adequate or even minimal follow-up care to those detained on LPS “holds,” who frequently end up in overcrowded hospital emergency rooms, where they too often languish without substantive – or any – treatment.

“Perhaps most troublingly, many individuals were subjected to repeated instances of involuntary treatment without being connected to ongoing care that could help them live safely in their communities,” Howle wrote in a cover letter to the governor and legislative leaders.

In Los Angeles County alone, she said, “almost 7,400 people experienced five or more short-term involuntary holds from fiscal years 2015–16 through 2017–18, but only 9 percent were enrolled in the most intensive and comprehensive community-based services available in fiscal year 2018–19.” 

Sacramento Mayor Darrell Steinberg described the auditor’s report as “compelling and spot-on.”

Mental-health professionals, advocates and families generally praised Howle’s report, while also recommending other changes in the law.

“It’s the first deep-dive that’s been done on LPS since it was passed,” said Hagar of  the California Psychiatric Association, which has sponsored much of the mental-health legislation that followed LPS. “It’s very impressive, and there is new life for mental-health legislation in part because of the audit.”

Sacramento Mayor Darrell Steinberg, as a state legislator  and Senate leader, authored significant legislation to improve mental-health care in California, including the 2004 Mental Health Services Act (MHSA), passed by voters as Proposition 63, the so-called “millionaire’s tax.”  He described the auditor’s report as “compelling and spot-on.”

“It’s a microcosm of what’s wrong with the entire system,” he added. “And an indictment of a system that, despite many gains and $2 billion-plus in [annual] MHSA funds, still has not become focused on outcomes, on prevention, early intervention and on integrating the multitude of funding streams that would help people get more timely help.”

But Steinberg, Hagar and others said the audit failed to recommend expanding the criteria for LPS holds and conservatorships to include physical health and deterioration caused by mental illness as part of the “gravely disabled” criteria under existing law.

Focused as it was on “those people who somehow make their way into the system,” albeit on involuntary holds, Steinberg said the report “did not address how we get more people into some care in the first place. At least they found their way into the system, flawed as it is, but what about all the people who don’t enter any kind of care?”

Redefining ‘grave disability’
While strongly supporting statewide adoption of Laura’s Law, Howle criticized the law’s requirement that it be used only for people in a current state of mental “deterioration,”  which the auditor said prevents the follow-up treatment necessary for individuals leaving involuntary holds and  conservatorships — who are deemed sufficiently “recovered” to live safely in the community.

But without continuing treatment, they often deteriorate rapidly. Hagar said he is drafting new legislation for the next  session to address that flaw in the law, noting that the auditor’s report “has given us the green light to do that.”

“It’s well-researched for those three counties, but we are a very big state.” — Sheree Lowe

Steinberg, Hagar and other mental-health advocates with long experience in legislative reform efforts, say the Legislature must address needed changes in the basic LPS criteria for involuntary holds, which they argue fail to protect people with severe mental illness whose physical health – and their ability to safely function in the community – are seriously impaired.

While the auditor concluded those criteria do not require change, critics say the report contained little analysis of how that conclusion was reached. “What is the basis for the conclusion?” Hagar asked.  “We didn’t find anything [in the report]. And that’s not enough.”

Some local mental health directors also disagreed with the auditor’s conclusion, pointing to individuals with severe mental illness whose physical health and safety are impacted. 

In Los Angeles County’s response to the auditor’s findings, the county Department of Mental Health said LPS criteria should be expanded to “redefine grave disability.” The county suggested legislation that “at a minimum. . .should address the capacity of an individual to make informed decisions and include criteria regarding the need for significant supervision and assistance, risk for substantial bodily injury, worsening physical health as well as significant psychiatric deterioration.” 

Sheree Lowe, vice-president of behavioral health for the California Hospital Association, praised the report, but said its scope was limited. “It’s well-researched for those three counties,” she said, “but we are a very big state. And one of the big problems with our county-based delivery systems is that the array and amount (of mental-health services) vary county by county and city by city, and there is little continuity.”

“Despite the billions of dollars the state invests in the county-based mental-health system each year, stakeholders do not have the information they need to assess the effectiveness of these funds on people’s lives.” — Elaine Howle

Nor did the report address the huge burden shouldered by hospital emergency rooms, Lowe said, which is where thousands of people experiencing mental-health crises, including 5150 holds (a reference to the law governing mental-health holds), end up, often brought there by a police officer.  And, as the auditor did note, data collection on the number of involuntary holds is limited and inconsistent, with no reliable statewide database.

While the state Department of Justice maintains confidential data on involuntary mental-health holds, the DOJ said in its written response to the auditor’s findings that its use of mental health records “is very limited to the purpose of determining someone’s eligibility to purchase or possess firearms and/or ammunition.”

Largely nonexistent statewide data collection on mental-health programs was a major criticism by the auditor.

“Despite the billions of dollars the state invests in the county-based mental-health system each year, stakeholders do not have the information they need to assess the effectiveness of these funds on people’s lives,” the auditor concluded. “Public reporting of dedicated funds [for mental-health programs] is disjointed and incomplete.”

The audit was originally requested in the summer of 2019 by the Steinberg Institute, founded by Mayor Steinberg to advocate for mental-health reform, and by legislators concerned about the lack of data on the state’s vast mental-health system, which is largely administered by the counties. And efforts to reform the aging LPS law were stymied by the lack of reliable statewide data.

The history of legislative efforts to address mental health in California is long and tortuous…

“What we found was that information being shared [about LPS reforms] was anecdotal,” said Maggie Merritt, the institute’s executive director. “There was no sound research or data. And there were legislators at the time who had bills on the LPS Act. We thought it was time for an audit to better inform the efforts that were in play.” She said the auditor’s report will help to inform future legislation.

Lack of treatment, ‘tragic deaths’
In a June 3, 2019, letter to the Joint Legislative Audits Committee requesting the audit, Sen. Henry Stern, D-Calabasas, and five other legislators said the audit was needed in order to support LPS reforms.

“The criteria for making a determination that a person is considered ‘gravely disabled’ [under LPS] has been subject to varying degrees of interpretations in jurisdictions across the state,” they wrote. “These subjective interpretations have created unequal application of the law from county to county,” resulting in lack of treatment and “tragic deaths.”

“By better understanding how and when the LPS Act is applied by the counties, we will come to understand how we might improve the LPS Act or other areas of the law to prevent these tragic deaths,” they concluded. The request was quickly approved, and the audit undertaken soon after.

The history of legislative efforts to address mental health in California is long and tortuous, and the LPS Act was a reaction – many critics have long said an over-reaction – to the blatant civil rights abuses of mentally ill and developmentally disabled Californians, who were often locked away in state mental hospitals, sometimes for decades, with limited treatment and little recourse.

The end result was no consistent community care and a patchwork of programs, with vast differences across the state, and thousands of mentally ill Californians recycling through hospital ER’s, wandering the streets or incarcerated.

The detailed 2012 task force report noted that inpatient psychiatric beds have been “substantially reduced” in California, and emergency rooms are overwhelmed by people in mental-health crises.

“Deinstitutionalization was the beginning of the difficult times,” Dr. Stephen Mayberg, former director of the state Department of Mental Health, which has since been absorbed into other departments in the constant bureaucratic juggling that characterizes the state mental-health system, told a California Journal  reporter in 1997.

“The state hospitals went from 35,000 to 5,000, and the community just was expected to deal with it, without the expertise or the resources.  It was a recipe for problems, and we’ve been digging ourselves out of that hole ever since.”

More than three decades after LPS was passed in 1967, the first of two community-based LPS Reform Task Forces was formed in 1998 to examine the law and recommend changes.

Comprised of prominent mental-health clinicians, judges, law enforcement, family members and advocacy groups (the California Psychiatric Association and the National Alliance on Mental Illness-California were major supporters), the task forces were not convened by any governmental agency. Both raised serious questions about the effectiveness of LPS and proposed some of the same legislative changes addressed in the state Auditor’s report.

The second task force report, in 2012, “Separate and Not Equal: The Case for Updating California’s Mental Health Treatment Law, has since served as a blueprint for legislative reform.

The detailed 2012 task force report noted that inpatient psychiatric beds have been “substantially reduced” in California, and emergency rooms are overwhelmed by people in mental-health crises. At the same time, state prison realignment policies dictate that more mentally ill parolees be treated in the community, with “little consideration…given to the failure of the mental health system to prevent their initial incarceration.”

At that time, the then 10-year-old Laura’s Law was operating in only two California counties.

“A person with severe mental illness is now four times more likely to be in jail than in a hospital bed,” the report concluded. “The LPS Act is 45 years old (in 2012), and it has not changed in response to an evolving mental health delivery system.”

“Mental illness is a disease of the brain” – Dr. Steve Seager

The first task force report, released in 1999, titled “A New Vision for Mental Health Treatment Laws,”  lambasted the failures of LPS, and made recommendations to change the law that are similar to the recent state Auditor’s scathing report.

Noting that LPS “was written 30 years ago, before scientific knowledge advanced, recognizing mental illness as a physical disorder of the brain,” the task force said flatly that the law’s purpose was primarily “to depopulate the state hospitals.” The “community care” that was to replace the hospitals was disjointed and inconsistent throughout the state, and the LPS Act was amended “piecemeal,” resulting in an involuntary treatment system that is “adversarial, costly and difficult to administer.” 

The report included summaries of testimony by families, clinicians and advocates at a remarkable 1998 Los Angeles hearing on mental health reform convened by L.A. County Supervisor Mike Antonovich and then-state Assemblywoman Helen Thomson, D-Davis, a former psychiatric nurse who authored major mental-health legislation, including the 2002 Laura’s Law.

The testimony reflected the makeup of the LPS Reform Task Force itself, and the accounts are instructive, thoughtful, wrenching – and more than three decades before widespread recognition of the need for substantive change.

Some of the dozens who testified are identified by name, mostly advocates and clinicians; others, mostly family members, are identified by initials. All called for change in the then 30-year-old LPS law, detailing horrific experiences in the state’s desperately broken “system” of community-based mental health care.

“Mental illness is a disease of the brain,” Dr. Steve Seager, a psychiatrist and author of several books on mental illness, testified at the LA hearing.

“It is not mystical, it is not demon possession, it is not punishment from God. It is a disease like heart disease, liver disease. . .The three most common admitting diagnoses from a study in San Francisco [of] homeless mentally ill were scabies and lice; starvation; and major trauma, either beatings, stab wounds or gunshots. . . The homeless mentally ill are murdered at ten times the rate that normal people are murdered. A third to one-half of homeless mentally ill women have been raped.

“The whole system is wrong.”

Editor’s Note: 
Sigrid Bathen is a Sacramento journalist and former Sacramento Bee reporter who taught journalism at Sacramento State for 32 years. She has long covered mental-health issues, for several publications, and her writing has won numerous awards. She has covered health care, education and state government for Capitol Weekly since 2005. Her web site is www.sigridbathen.com. She can be reached at sigridbathen@gmail.com.

Dangerous Mix: Law Enforcement and Mentally Ill Suspects

 

 

 

Published July 21, 2020 

(Second of two parts. Click here for Part I)
Calls to ‘defund’ police gain traction, as protesters — and public officials — contend that money would be better spent if clinicians and social workers responded to mental-health 911 calls. Police say many such programs already exist, and that they need more staff and funding.  

Police response to mental-health calls often ends – again and again – in chaotic, noisy hospital emergency rooms, where staff is stretched thin, and a heart attack is likely to take precedence over someone in the throes of a mental-health crisis.

“Traditionally, people would be dropped off at the ER, and the only option was to transfer them to a psychiatric facility,” says Dr. Scott Zeller, a nationally known emergency psychiatrist and former president of the American Association for Emergency Psychiatry.

“There is finally some recognition in the halls of government that there are solutions out there.” — Scott Zeller

Zeller is vice president of acute psychiatry at Vituity, a physician-led organization that provides staffing and consulting services to medical centers nationwide. Too often, he says, patients in psychiatric crises “would be stuck for days at a time in the ER, with very little treatment.”

The widely known author of articles in professional journals and the subject of news stories,  Zeller has long pioneered, with growing success, a different kind of ER for mental-health emergencies, called EmPATH units (emergency psychiatric assessment, treatment and healing unit). In that model, patients are diverted to a specialized psychiatric ER with supportive clinical staff who assess the patient’s needs – which often means simply listening, talking, adjusting medication – and frequently leads to faster recovery and fewer subsequent hospitalizations, at considerably less cost than in a traditional hospital ER.

“There is finally some recognition in the halls of government that there are solutions out there,” says Zeller. He developed the approach – now in use in dozens of hospitals around the country and in other countries  — as chief of psychiatric emergency services at John George Psychiatric Hospital in Alameda County, where he began treating patients in crisis in a separate, supportive, home-like setting, a far cry from the tumultuous environment of a hospital ER, particularly in the time of COVID.

Like other experienced clinicians, Zeller supports changes in how law enforcement handles mental-health calls.

Dispatchers take emergency calls. Photo: Gorodenkoff, Shutterstock

“We have to look at new ways of reducing police involvement,” he said, with more mobile crisis teams that utilize social workers and other clinicians as well as police officers trained in how to deal with mental-health calls. “The devil is always in the details.”

Even with additional training, police officers and 911 dispatchers must make difficult decisions in determining whether a mental-health call requires an armed police response or an unarmed social worker skilled in deescalating confrontational behavior. Often, it requires both.  “What happens if you get there, and the person is violent, threatening family, neighbors?” asks Zeller. “There has to be coordination. You’re not going to eliminate the police altogether [from mental-health calls]. . . But there are models, really good police squads, well-trained, paired with mobile crisis teams. De-escalation is always the preferred intervention.”

Like Zeller, Dr. Amy Barnhorst, a psychiatrist who is vice-chair for Community Mental Health at UCD Health and former medical director of Sacramento County’s crisis unit and inpatient psychiatric hospital, has long been on the front lines of California’s fractured emergency response to psychiatric crises. She applauds efforts to include more clinicians in police response to mental-health emergencies. But she also knows from vast experience that’s only part of the system that has failed the thousands of homeless mentally ill people wandering California streets.

“I’ve talked to a few families who say the best thing that has happened is when they got arrested.” — Amy Barnhorst

“A lot of the patients I work with don’t have homes,” she said, “and are not receiving treatment for their mental illness. Some have been arrested for vagrancy, public urination. A mom who takes her child to the park for a birthday party doesn’t want to see a transient urinating in public, but what can we do besides throwing him in jail, when it was really that he was just trying to survive?”

Homeless people struggling with untreated mental illness, which is often accompanied by substance abuse and “self-medication,” for decades have gone to the ER – or to jail – as a default response in a grotesque system with little coordination, inadequate resources and high cost.

“I’ve talked to a few families who say the best thing that has happened is when they got arrested,” says Barnhorst, because in jail they at least have shelter and a chance at treatment. “That shouldn’t be what it takes.”

“We need more services, more funding, better coordination,” she adds, “at all levels.” Like Zeller, she advocates more “respite care,” a place for people to go for short-term treatment, rest, a path to sobriety. “They may have a suicidal break, go back to using meth. They need to have  a few nights of a safe, sober place to sleep, get into a therapy program with a counselor, drug rehab. But all of these services are underfunded, underenrolled.”

Cops as first responders
Meanwhile, cops are more often than not the primary responders to mental-health crises. “Law enforcement has a lot of other things on their plate,” says Barnhorst, echoing the widely held view of both clinicians and officers. “It’s great to have trained mental health professionals involved in the response, but I’m not sure whether law enforcement should not be there. It’s not always clear whether it’s a mental-health emergency. They may get out there and find that it is, but that’s not always clear in the call.”

““This is an absolutely appropriate time to take a look at the links between the criminal justice and behavioral health systems.” — Stephanie Welch

Barnhorst, Zeller and others point to the success of mobile crisis and community support teams of social workers, clinicians and “peer support” workers – people who may not have clinical degrees but have “lived experience” — that now exist in many counties and accompany police officers on mental-health calls. “They understand the families,” says Barnhorst, “how to de-escalate, [while] police officers are trained to neutralize a threat.”

Capitol Weekly interviewed dozens of public officials, law enforcement officers and clinicians about how to improve police response to mental-health calls, and all emphasized that law enforcement is only one piece of the puzzle, that a coordinated, collaborative approach is essential, involving community members, families and allrelevant government agencies.

“The most important thing is not to look at just solving this aspect of it – police engagement and crisis response,” said Stephanie Welch, who has two decades’ experience in local and state mental-health programs and is executive officer of the Council on Criminal Justice and Behavioral Health in the state Department of Corrections and Rehabilitation, which works to prevent incarceration of people whose underlying mental illness is the root cause of their involvement with the criminal justice system.

“Otherwise, we’re missing an opportunity to take an overarching look at our overall system so that we don’t have so many people in crisis on the streets,” she said.

“This is an absolutely appropriate time to take a look at the links between the criminal justice and behavioral health systems,” Welch added. “And one thing in the COVID crisis is that we are not putting people in jail who need social services. To some extent there is an opportunity to do right by people.”

“Many  people ended up in prison because of, or largely a result of, their mental illness —  some very serious crimes, multiple murders, and others who just couldn’t function on the outside.” — Steve White

The concept of social workers and other clinicians working in law enforcement agencies is not new, but never has the public sentiment been so strong to make major changes in the way police respond to mental-health and other emergencies.

Sacramento Superior Court Judge Steve White was Sacramento’s elected district attorney in 1989 when he made the then-controversial decision to hire social workers in the DA’s office, in part to help deal with cases that involved untreated mental illness – and to support victim-witnesses in domestic violence cases who were often afraid to testify against their abusers.

White had made prosecution of domestic-violence cases a high priority at the outset, significantly increasing both staffing and prosecutions, going before the county Board of Supervisors to get additional funding for the two social workers, which at that time was highly unusual in a local prosecutor’s office. The volume of successfully prosecuted domestic-violence cases increased significantly.

As Inspector General of the state prison system (which then included both adult and juvenile corrections programs in the Youth and Adult Correctional Agency), from 1999-2003, White investigated a state prison system rife with abuse and mismanagement. “I was struck by the thousands and thousands of inmates who had mental-health issues that ran the gamut from serious to criminally insane,” he recalls. “Many  people ended up in prison because of, or largely a result of, their mental illness – some very serious crimes, multiple murders, and others who just couldn’t function on the outside.”

The man with the banana
He recalls the case of a man “going up and down K Street with a banana.” Clearly mentally ill, he was not feigning a gun, “just holding a banana and demanding money.” Despite efforts to dissuade him, some counseling, he was eventually sent to prison for robbery. “That was a failure.”

Several police reform bills are currently before the state Legislature, but none propose comprehensive changes in how law enforcement handles mental-health crises.

Appointed to the Sacramento Superior Court by then-Gov. Gray Davis in 2003, White continues to see the toll that untreated mental illness has on the criminal justice system — “the massive number of people with significant mental-health issues who are part of the criminal justice system.” He says current efforts throughout California to reform how police handle mental-health calls, with an aim to preventing incarceration, constitute “a moral and economic imperative.”

Like many judges and attorneys who work in the criminal justice system, White strongly supports including social workers and other clinicians in law-enforcement response to mental-health calls, as well as the increasing use of mental-health courts in many counties, to divert mentally ill defendants from the traditional criminal court system. But, like others, he said any real reform needs to be statewide.

Several police reform bills are currently before the state Legislature, but none propose comprehensive changes in how law enforcement handles mental-health crises. Continuing COVID restrictions and a dire state budget picture are likely to severely disrupt the remainder of the legislative session, which is scheduled to end Aug. 31.

AB 1506, by Assemblyman Kevin McCarty, D-Sacramento, would establish a separate unit within the state Attorney General’s office to investigate officer-involved use of force resulting in the death of a civilian. AB 1196, by Assemblyman Mike Gipson (D-Carson), would place a statewide ban on the use of carotid artery holds.  Both bills passed in the Assembly and now go to the state Senate.

The only bill directly addressing police response to mental-health emergencies is AB 2054 by Assemblywoman Sydney Kamlager, D-Los Angeles, which would establish pilot programs to eliminate police response to a wide range of crises involving homelessness, mental illness, natural disasters and domestic violence. It was passed by the state Assembly with bipartisan support, is sponsored by the ACLU and supported by numerous community organizations.

Substance abuse is a common cohort of mental illness, often reflecting efforts to “self-medicate.”

Called the C.R.I.S.E.S Act (for Community Response Initiative to Strengthen Emergency Systems), the measure would establish a three-year pilot program administered by the state Office of Emergency Services with grants to “no more than 12” community organizations. “We need to get away from police as first responders,” says ACLU legislative advocate Dennis Cuevas-Romero. And while he praised law enforcement “for trying to shift the narrative” with local programs that include clinicians, he said police “should focus on the real issues of danger to the community,” leaving other crisis response to clinicians and community groups.

One family’s nightmare
Rarely consulted about policy changes in how police respond to mental-health calls, family members of mentally ill relatives often tell the most compelling – and tragic — stories.

Susan Shaw Goodman – a former teacher who became an attorney, a school board member, a prosecutor and chief counsel to the Assembly Committee on Public Safety – is the mother of a 32-year-old son with severe mental illness who lives with her in Folsom.

As a former board member of the Sacramento chapter of the National Alliance on Mental Illness (NAMI), the nation’s most influential mental health organization representing families, her knowledge of the fraught state of mental-health care in California is both professional and deeply personal.

Her son, who was adopted as an infant, was a “meth baby,” the child of a methamphetamine addict who used meth during her pregnancy. He had learning difficulties in school and was placed in special education classes. His mental illness worsened in middle school, and his desperate parents spent thousands of dollars on treatment programs, at one point sending him to a highly regarded boarding school and therapy program for teens and children in Utah. Nothing seemed to help.

Using her legal skills and knowledge of the system, she has been able to get (her son) some treatment, but care is “very, very limited.”

In his early teens, he started smoking marijuana and stealing from his family – money, jewelry, family heirlooms – and getting arrested for minor crimes like petty theft. He tried different drugs – Ecstasy, heroin – and in his early 20s, he started using methamphetamine, which is highly addictive, widely available, relatively cheap and extremely destructive.

Substance abuse is a common cohort of mental illness, often reflecting efforts to “self-medicate.” He was diagnosed with depression, anxiety, anger-management issues and, ultimately, with paranoid schizophrenia, one of the most devastating of mental illnesses, often diagnosed in the late teens and early adulthood.

In telephone interviews with Goodman, her son can sometimes be heard yelling in the background. Other times, he would answer the phone, calm and courteous. “He’s not yelling because he’s angry,” says Goodman. “It just comes out.”

In 2016, he was homeless, living on the streets after another stint in jail, when he came to his mother’s Folsom home and started hurling bricks from the yard, breaking 22 windows. He was arrested and went back to jail. “I told him he couldn’t come home until I was sure he was not on drugs.”

“It’s a nightmare,” she says, “a terrible illness. . .He has very few filters, no sense of other people having feelings, no empathy – but not in a rude, nasty way. His brain just doesn’t go that far.” Using her legal skills and knowledge of the system, she has been able to get him some treatment, but care is “very, very limited.”

“To me, any officer is worth his weight in gold if he tries to keep the person out of jail.” — Susan Shaw Goodman

He sees a psychiatrist through TCORE (Transitional Community Opportunities for Recovery and Engagement) and the Hope Cooperative, nonprofit programs that partner with Sacramento County Behavioral Health to provide mental-health care and other services.

Many psychiatric medications have serious side effects, and one of the medications he is taking is known to cause involuntary yelling, which – in dangerous combination with methamphetamine use — has sometimes led to arrests. “He was arrested once while he was on meth, standing on top of a building, yelling, throwing things,” Goodman recalls.

There have been many experiences with the police. “I’ve had cops coming in and out of my house for about 15 years, including just a few weeks ago,” says Goodman. “The neighbors have called the cops twice because of my son’s yelling.”

When the police are called, Goodman says, officers’ responses “run the gamut,” from “bad attitude, telling me I need to leave town. . .” to others who engage her son in conversation, spend time with him, congratulate him on completing a drug-rehab program, come back to see how he’s doing. The latter, she said, “is so, so helpful, not to be treated like you’re the enemy and not to be trusted.”

“To me, any officer is worth his weight in gold if he tries to keep the person out of jail,” says the former prosecutor. “It can be, ‘You’re drunk, you’re high, I’m just going to take you downtown’ (to jail). That’s happened. Or, ‘Hop in the car, I’ll take you home.’ That has happened too.”

In one recent interaction, she said, in response to a complaint from a neighbor, the officer was accompanied by a social worker from Sacramento County’s Mobile Crisis Support Team, which partners with local law enforcement in responding to mental-health calls. “She listened,” says Goodman. “She showed empathy, creativity, compassion.”

Then the social worker went next door to talk to the neighbor who had filed the complaint. “About a week later,” Goodman recalls, incredulous, “the neighbor came over and handed my son a note in an envelope, and it said something to the effect, ‘Thank you so much for trying to work on your voice and keeping your windows closed, and we wish you well on your journey’.”

Goodman said she and the neighbor “hadn’t spoken in years, and my son had been a slime ball in their lives. I think it was the social worker who changed that.”

Ed’s Note:  Sigrid Bathen is a longtime Sacramento journalist and former Sacramento Bee reporter who has covered mental-health and related issues for several publications for more than 40 years. She has taught journalism and communications at Sacramento State since 1988. She has written for Capitol Weekly since 2005, on a variety of subjects, including education and health care. To see two of Bathen’s recent pieces in Capitol Weekly on mental health issues, click here and here.

Pressure Mounts on How Police Handle Mental-Health Crises

Published July 20, 2020 on Capitol Weekly.

 

Calls to ‘defund’ police gain traction, as protesters — and public officials — contend that money would be better spent if clinicians, social workers responded to mental-health 911 calls. Police say many such programs already exist, and that they need more staff and funding.  (First of two parts. Part 2 can be seen here.)

On the afternoon of May 8, 2017, the family of 32-year-old Mikel McIntyre called 911 for help in dealing with his increasingly erratic and threatening behavior. The former high school and college athlete, who lived in Antioch and had briefly played baseball in the minor leagues, had been showing signs of serious mental illness, and his mother was concerned. She hoped a visit with family in Sacramento might help.

The first call, shortly after 3 p.m., indicated a possible mental-health crisis: McIntyre had locked himself in a vehicle and was being “slightly combative,” but the firefighters who responded decided he was not a threat. When family members called again to say McIntyre was becoming increasingly volatile, Sacramento County sheriff’s deputies responded at 3:32 p.m., and they determined McIntyre’s behavior did not meet the criteria for him to be detained on a 72-hour mental-health hold, as a danger to himself or others. The deputies suggested he leave the house, which he did.

McIntyre fled on foot toward the Zinfandel Drive onramp to westbound Highway 50, then on the freeway shoulder.

Later that same day, at 6:47 p.m., McIntyre was observed hitting and choking his mother in her car outside a Ross store in Rancho Cordova, near a busy intersection at Zinfandel Drive and Highway 50. Several witnesses called 911, and deputies again responded.

This time, the confrontation rapidly escalated.

McIntyre walked across the parking lot, ignoring deputies.  There was a scuffle, and a deputy fell while attempting to detain McIntyre, who threw a large rock, hitting the deputy in the head. Dazed and bleeding from a head wound, the deputy fired two shots, but missed, as McIntyre fled on foot toward the Zinfandel Drive onramp to westbound Highway 50, then on the freeway shoulder. Officers from several agencies quickly swarmed the area.

At one point, McIntyre threw another, smaller rock from the piles of river rock near the freeway, that hit a sheriff’s deputy and a canine.  According to a highly critical Sacramento County Inspector General’s report on the incident, three deputies fired a total of 28 rounds at McIntyre as he fled the scene, running alongside the busy freeway during rush hour. He was hit by seven bullets in his torso and limbs, six of them in his back.

The scene along Highway 50 in Rancho Cordova where deputies shot and killed Mikel McIntyre on May 8, 2017. Three years after McIntyre’s death, Sheriff Scott Jones released videos and documents related to the case. (Photo: Sacramento County Sheriff’s Department)

Several rounds were found embedded in the roadway, and Inspector General Rick Braziel, a former Sacramento police chief who consults for law enforcement agencies throughout the U.S., said vehicles were passing on the freeway as shots were being fired.

“There are instances where the number of rounds fired at McIntyre were excessive, unnecessary and put the community at risk,” Braziel concluded in the detailed, 27-page report. The report infuriated Sacramento County Sheriff Scott Jones, who barred him from further investigation and issued a statement describing the findings of Braziel, a highly regarded former police chief, as “a lay opinion.” The county board of supervisors took no action to prevent Braziel’s precipitous firing, despite intense public pressure and demonstrations.

McIntyre was not armed and Braziel concluded “escape was unlikely,” and that officers had options other than lethal force to detain him.

“There were adequate resources on the ground with three officers on foot, six officers driving marked vehicles, and a canine, for a total of nine law enforcement officers, to isolate and contain McIntyre without firing additional shots,” Braziel wrote. There was also a sheriff’s helicopter and a CHP aircraft hovering over the scene.

Mikel McIntyre (Screen capture, Fox40 News)

The graphic videos of the pursuit are difficult to watch. They show McIntyre, who was Black, running alongside the freeway, pursued by multiple police vehicles and officers. The canine, which bit him, and several officers can be seen descending on McIntyre as he drops to the ground.  He was transported to UCD Medical Center, where he died shortly afterward.  In a detailed, May 28 Sacramento Bee account following release of the sheriff’s report and videos, a sheriff’s photo of the aftermath at the scene shows a pool of blood where McIntyre’s body had been, a pair of sneakers nearby.

“He did nothing but run for his life,” his mother Brigette McIntyre told reporters. “His death was senseless.” Sacramento District Attorney Anne Marie Schubert ruled the shooting justified.

McIntyre’s family sued, and the county settled for $1.725 million earlier this year, while not admitting fault. Despite a new state law requiring law enforcement agencies to release reports and videos of incidents that result in death or serious injury, Jones had refused to release the McIntyre reports or video, saying the case occurred before the law became effective in January 2019. The CHP released a redacted video, but the sheriff’s video was only released by Jones this past May, after the Sacramento Bee and the Los Angeles Times went to court, and more than three years after McIntyre’s death.

One in four
According to a 2015 study, “Overlooked in the Undercounted: The Role of Mental Illness in Fatal Law Enforcement Encounters,” by the nationally recognized Treatment Advocacy Center, “the risk of being killed during a police incident” is 16 times greater for people with untreated mental illness. “By all accounts – official and unofficial – a minimum of 1 in 4 fatal police encounters ends the life of an individual with severe mental illness.”

“We would never send a social worker to a bank robbery. Why would we send a police officer to a mental-health emergency?” — Maggie Meritt

The McIntyre case – and many like it, frequently involving the deaths of Black men at the hands of police — have become flashpoints in growing calls for major changes in police use of force and in the way law enforcement responds to mental-health crises. Black Lives Matter protesters and civil-liberties groups, including the American Civil Liberties Union, are calling for “defunding” the police, slashing police budgets to fund more social services and redirecting mental-health calls to social workers and clinicians better qualified to help.

“We would never send a social worker to a bank robbery,” says Maggie Merritt, executive director of the nonprofit Steinberg Institute in Sacramento, which was founded by former state Senate Leader Darrell Steinberg, now Sacramento’s mayor, to advocate for improved mental-health policy and programs. “Why would we send a police officer to a mental-health emergency?”

But Merritt and other mental-health policy experts caution against removing police officers entirely from the equation.

“There is a need for somebody in the process of responding to a call to do a threat analysis and public-safety assessment,” says Randall Hagar, legislative advocate for the California Psychiatric Association. “There is no doubt that we need a lot more clinicians on the street responding to crises that are derived from a person’s mental illness, but sometimes a clinician needs backup” by law enforcement, especially in incidents where a weapon is involved. “There always has to be a determination of whether a public-safety issue is involved.”

Hagar and others want more training for police and 911 dispatchers on how to respond to mental-health crises, perhaps with a clinician involved in screening the calls. A former president of the Sacramento chapter of the National Alliance on Mental Illness (NAMI), which advocates for families, Hagar said he once surveyed his members and found that more than half had experienced “some sort of law enforcement in the last year, and those were not always happy situations.”

Many law enforcement and mental-health professionals argue that existing programs already use clinicians and counselors who work with officers to respond to mental-health calls, often de-escalating potentially volatile situations. They emphasize that follow-up contact is essential to avoid future crises, and that the presence of mental-health professionals frees up officers to focus on violent, serious crimes, saving limited public funds by preventing incarceration, hospitalization and homelessness.

In reality, the 5150 statute is widely regarded as ineffective and outdated.

“Officers didn’t sign up to be social workers, or to determine people’s mental-health status,” says veteran San Diego police officer Brian Marvel, president of the influential Peace Officers Research Association of California (PORAC). For many years, Marvel worked as an officer in the San Diego Police Department’s Psychiatric Emergency Response Team (PERT), in which officers are paired with mental-health professionals to respond to and follow up on mental-health emergencies. “I’ve long been an advocate of sending mental-health calls to others first – let the people who are skilled in this area handle these calls,” he said.

“I don’t think we have to re-invent the wheel in California,” he adds. “It’s a matter of evaluating what the best program would be. But it’s really incumbent on elected officials to be sure it’s adequately funded. Elected officials have set up law enforcement to fail, because they’ve failed to properly fund services for homelessness and mental health.”

Officers are required to respond to so-called “5150” calls, a reference to the state Welfare and Institutions Code that sets criteria for detaining someone for 72 hours who is deemed “a danger to self or others.” In reality, the statute, which is widely regarded as ineffective and outdated, too often means an individual who is detained under a 5150 goes to an already overburdened hospital emergency room. There, an officer must stay with the patient, who frequently is released without treatment, medication, or a referral to overwhelmed mental-health programs and largely nonexistent housing. It’s an expensive, time-consuming and frustrating process for all concerned.

The SMART unit also has 60 clinicians, whose salaries are paid through the county’s Department of Mental Health with some funding from the state Mental Health Services Act.

“I’m very limited in what I can do in a 5150,” says Marvel. But when clinicians are involved in the response at the outset, as in San Diego’s PERT program, “that literally opens up all of the services available in the county.”

The Los Angeles Police Department, which has 9,000 sworn officers and 3,000 civilian employees,  has long had a mental-health unit that pairs officers in civilian clothes (a uniform of tan khaki’s and a black polo with the LAPD insignia, designed in consultation with NAMI) and clinicians – social workers and psychologists – to respond to mental-health calls.

Headed for the past five years by Lt. Brian Bixler, who was a youth pastor before he became a cop, the SMART (Systemwide Mental Assessment Response Team) unit currently includes 68 officers and 18 supervisors, also sworn officers, some with advanced degrees in social work and psychology, and 60 clinicians, whose salaries are paid through the county’s Department of Mental Health with some funding from the state Mental Health Services Act.

“We run it like a patrol division,” Bixler said, “with four shifts” around the clock. Like San Diego’s PERT program, they also partner with community programs that provide mental-health treatment and suicide prevention.

Depending on the time of the call and its location, regular patrol officers may be the first responders to a mental-health call, Bixler said, with SMART teams either joining them at the scene or following up soon afterward. Bixler has long believed “there’s gotta be a better way” for police to respond to mental-health crises, and current calls for major change “may be the impetus to do that.”

“I’m asked if we want more police officers (in the SMART program),” he adds, “and I say I’d rather have more clinicians [who can intervene] before someone gets to the point where they call 911. My whole goal is to work us out of a job.”

Some local agencies send mental-health and other “non-criminal” calls directly to community mental-health programs.

In Sacramento County, the Division of Behavioral Services has a Community Support Team – which includes licensed mental-health clinicians and peer-support specialists (lay counselors with personal experience) — who provide phone and community-based assistance, connecting people with mental-health and housing programs. Using state Mental Health Services Act funds, the county also has six Mobile Crisis Support Teams, consisting of licensed mental-health clinicians who work with local law enforcement to respond to calls and help de-escalate mental-health emergencies.

Mobile crisis teams expand
The Mobile Crisis teams, which the county is expanding to 11 teams, each include a senior mental health counselor paired with an officer or deputy, as well as a “peer navigator” (a lay counselor with personal experience) who helps to ensure connections with ongoing services.  As in other agencies throughout the state, staffing and funding are inadequate, and mental-health clinicians are spread thin in a large county with multiple police and fire agencies asking for help.

There are other, similar programs around the country, in which police collaborate with mental-health professionals on crisis calls. Some local agencies send mental-health and other “non-criminal” calls directly to community mental-health programs, with police backup if necessary.

Many point to the 30-year-old CAHOOTS (Crisis Assistance Helping Out on the Streets) program in Eugene, Ore., a collaboration between the police department and a 50-year-old community program, the White Bird Clinic, in which non-emergency and 911 calls that do not involve an extreme threat of violence or bodily harm are routed to a medical-crisis team (usually a nurse or EMT and a mental-health professional) trained in de-escalating mental-health crises and connecting individuals with services.

Myriad proposals have been made in cities and counties throughout California and the U.S. in the wake of massive national protests against historic police mistreatment.

As a result of national protests, the CAHOOTS program is getting a lot of press in recent weeks. According to a “Media Guide” on the White Bird Clinic website, CAHOOTS teams responded to 24,000 calls in 2019, about 20 percent of total non-emergency and 911 calls, and only 150 required police backup. The program is estimated to save the city about $8.5 million annually in public safety costs, plus some $14 million in ambulance trips and ER costs.

The coronavirus epidemic in many ways has served to shine a bright light on the historic lack of coordination between police and mental-health professionals, with growing national demands for changes in how police respond, particularly to calls involving people of color.

“When we have a loud response from a diverse community, there is this opportunity for looking at different ways of doing things,” says Jennifer Reiman, a licensed clinical social worker who is Sacramento County’s Mental Health Program Coordinator for the Community Support Team and Mobile Crisis programs. “Providing a spectrum of response is really important.”

Myriad proposals have been made in cities and counties throughout California and the U.S. in the wake of massive national protests against historic police mistreatment – and many deaths – of Black citizens, especially Black men and boys who are arrested and incarcerated at numbers far disproportionate to their numbers in the general population.

Some proposed changes involve nomenclature as well as pandemic-driven cuts and redirecting police spending. The Davis City Council is considering a proposal to rename the Police Department, calling it the Department of Public Safety. In Minneapolis, where the gruesome death of George Floyd under a policeman’s knee spurred national protests, the City Council has proposed the creation of a Department of Public Safety and Violence Prevention.

“We must reduce our reliance just on caging people.” — Supervisor Sheila Kuehl

New York’s City Council recently voted to shift $1 billion from policing to education and social services in the coming year. In Los Angeles, the City Council cut the LAPD budget by $150 million, ostensibly redirecting more funds to social services. The LA County Board of Supervisors proposed cuts of $162 million to the 2020-21 Sheriff’s budget, also with an eye to redirecting services from incarceration to treatment.

And LA Supervisors are revisiting plans to close the dangerous, cramped Men’s Central Jail, to focus more on diverting the huge percentage of mentally-ill inmates in the system into treatment and diversion programs. LA County’s jail system, overseen by the Sheriff’s Department, is often referred to as the largest mental-health facility in the world.

“We must reduce our reliance just on caging people,” said Supervisor Sheila Kuehl, a former state legislator, public-interest attorney and law professor. The once-controversial proposed closure of the 57-year-old Men’s Central Jail is no longer a “revolutionary concept,” she added, but rather “simply logical, fiscally prudent and another opportunity for community healing.”

In Sacramento, Mayor Steinberg, who has long advocated for more funding and resources for mentally ill Californians and their families, last month proposed hiring an Inspector General to provide oversight and investigation of Sacramento police, as well as a plan for “triaging” 911 calls from individuals and families in mental-health crises. The plan would shift police funding to create a new unit comprised of mental-health professionals who would respond to calls involving mental-health emergencies, homelessness and other “non-criminal,” non-violent issues.

“We are the 24/7 crisis call line,” she said. “You call, we come, regardless of the level of crisis the individual may be in.” — Bridgett Dean

“We’ve been hearing calls for ‘de-funding’ the police,” Steinberg said in a press release, “but I think it’s more productive to talk about the function of the police and let the money follow the function.”

Sacramento Police Chief Daniel Hahn recently hired a licensed clinical social worker, Bridgette Dean, to oversee a Mental Health Unit in the Police Department. Dean, who has worked in law enforcement for the past decade, filled a similar role in the Roseville Police Department when Hahn was chief there. She is one of the few – possibly the only — social-services administrators in Northern California with direct authority over police officers whose primary focus is on mental-health calls.

Dean heads a team of five officers with intensive training in how to deal with mental-health crises, as well as a homeless outreach team. They work with patrol officers to assess mental-health emergencies and help people in crisis get services. “We’re not going in to do an enforcement model,” she said, “We want to close the gap, get the services they need.” She stresses the importance of training for officers and dispatchers, who are “trained and experienced in listening to key words to understand that it’s a mental-health call.”

“We are the 24/7 crisis call line,” she said. “You call, we come, regardless of the level of crisis the individual may be in. If it’s a priority call – ‘I’m going to kill myself’—we go right now. If it’s not an emergency crisis on the patrol side, they will refer the call to the mental-health unit for follow-up.”

‘Major Issues’ at state level
Collaboration is the key to the success of programs like Dean’s, and state support.

“We have some major issues we have to resolve at the state level,” she said, including reforms in an outdated, ineffective system created with the closures of state mental hospitals in the 1960s and 70s, which resulted in strict legal protections for the rights of the mentally ill. But those changes assumed that a robust system of “community care” would replace the hospitals – which never happened, leaving thousands of mentally ill Californians homeless and untreated, shuttling among hospital emergency rooms, jails and prisons, at tremendous public expense and incalculable human suffering.

“The structure we have in place is so antiquated,” Dean said, referring to the 1967 Lanterman Petris Short Act that drastically altered California’s system of mental-health care and has never been substantively changed or updated. And the ambitious proposals currently advanced throughout the country to reorganize and/or defund the police often fail to recognize the reality of services on the ground.

“All of this is good talk. . .until we realize we have 50 detox beds in Sacramento city and county,” and extremely limited numbers of beds for psychiatric patients in crisis, much less for those needing long-term care. “When we talk about the need to get somebody off the streets, we’re not able to do that because of the lack of beds.”

TOMORROW: Solutions emerge in national push for major changes in how police respond to mental-health crises (Second of two parts)

Editor’s Note: Sigrid Bathen is a longtime Sacramento journalist and former Sacramento Bee reporter who has covered mental-health and related issues for several publications for more than 40 years. She has taught journalism and communications at Sacramento State since 1988. She has written for Capitol Weekly since 2005, on a variety of subjects, including education and health care. To see two of Bathen’s recent pieces in Capitol Weekly on mental health issues, click here and here.

Stronger ‘Laura’s law’ wins Assembly approval

 

Legislation to strengthen California’s 2002 “Laura’s Law,” which gives family members a legal tool to get treatment for their severely mentally ill relatives, has been approved 77-0 by the state Assembly, despite opposition from some California counties, behavioral health directors and a labor union representing employees in local mental-health programs.

The Assembly’s approval on Wednesday for the bill, AB 1976 by Assemblywoman Susan Eggman, D-Stockton, would also make “Laura’s Law” permanent, ending the sunset provision which required “reauthorization hearings” every five years. The measure was sent to the Senate.

The action comes nearly two decades after contentious hearings on the original law, by then-Assemblywoman Helen Thomson, D-Davis, which had intense opposition from disability rights groups and county mental health directors.

Some counties are balking at a key provision of the Eggman bill that would require them to publicly explain — in writing — why they are “opting out” of participation in the program, which has had considerable success in reducing hospitalizations, homelessness and incarceration in the 20 counties where it has been adopted.  Under current law, county participation is voluntary.

The bill earlier sailed through two major Assembly committees, despite opposition, and was unanimously approved in recent weeks by the Assembly Health Committee (15-0) and Appropriations Committee (18-0).

Laura’s Law is named for 19-year-old Laura Wilcox, who was a college student working in a Nevada County mental-health clinic during her winter break in 2001, when she was shot and killed by a severely mentally ill man who went on a shooting rampage that killed three and injured three others.

“Now is a good time. We are passing things we’ve never passed before.” — Susan Eggman

“This bill would bring it full circle,” said Laura’s mother, Amanda Wilcox, who with her husband Nick became tireless legislative advocates for mental-health and gun-control legislation in California.

A similar bill to strengthen Laura’s Law, also by Eggman, failed in 2015, but she is optimistic about the current legislation. Likening the mental-health crisis playing out in plain view throughout California to “a wildfire in our streets,” she said there is growing support for major policy improvements in the state’s historically fractured mental-health care system, brought into even sharper relief by a global pandemic — as thousands of mentally ill Californians cycle in and out of emergency rooms and jails, or wander the streets.

“How is that dignity for anybody?” said Eggman, a former social worker and Sacramento State professor, in an interview with Capitol Weekly. “The human rights and public-health crisis is not fair to families, and I think it has become a stark reality for everybody. Now is a good time. We are passing things we’ve never passed before.”

In a May 29 letter to Assembly Appropriations Chair Lorena Gonzalez, the California State Association of Counties and the County Behavioral Health Directors Association, said they were not opposed to making the nearly 20-year-old “Laura’s Law” permanent, eliminating the five-year sunset provision that has dogged the law since its inception. A subsequent letter June 8 from the behavioral health directors and the Service Employees International Union said they “regretfully” oppose the bill because it “would place a virtual mandate on counties to participate [in Laura’s Law],” and would “increase staff workload.”

The sweeping, bipartisan vote in the Assembly – with one abstention, by Assemblyman Ash Kalra, D-San Jose – clearly sent a message to the counties that Laura’s Law is here to stay in California.

“At the end of the day, the opposition was not compelling,” said Randall Hagar, longtime legislative advocate for the California Psychiatric Association, which supports the bill, along with the California Medical Association and the California Hospital Association.

The 20 counties that have “opted in” to start Laura’s Law programs account for an estimated 70% to 80%  of the state’s population, but some county mental health directors and employees continue to oppose the bill’s requirement that counties choosing to “opt out” of the program must state their reasons in writing after public discussion.

“The notion that [the law] interferes with the counties is bogus.” — Judge Thomas Anderson

They also dislike adding judges to the list of individuals – which currently includes family members, health-care professionals and law enforcement – who can ask the local mental-health director to file a civil court petition for treatment under Laura’s Law, which in many cases is voluntary and does not require judicial intervention. And advocates point to statistics that show the law saves court costs by reducing incarceration and preventing costly conservatorships and criminal interventions.

Farah McDaid Ting, health policy representative for CSAC, argued that the existing “opt-in” provision of the original law, constitutes a public declaration.

“The ‘opt-in’ process is on the record,” she said. “The county has to budget for it, and the board [of supervisors] has to do this in public session.” While ‘Laura’s Law’ has proven to save money in reduced hospitalizations, incarceration and homelessness — and is partially supported by state funding from the Mental Health Services Act, the “millionaire’s tax” passed by voters as Prop. 63 in 2004 — there is no state budget appropriation in the original law, or the current bill. Counties argue there are “up-front” costs to establish such programs, and have long been opposed to any perceived “mandate.”

“The notion that [the law] interferes with the counties is bogus,” says Nevada County Superior Court Judge Thomas Anderson, a former public defender who was the defense attorney for Laura’s killer, has long supported Laura’s Law and helped start Mental Health Courts in Nevada County, one of the first counties in California to adopt the law. “And they’re wasting money by not having these services.”

“We always listen to the concerns of opponents or other members,” he said, “but we think [Laura’s Law] has proven to be effective.” — David Stammerjohan

Hagar says some counties that have chosen not to adopt “Laura’s Law” programs – including Sacramento County, which is surrounded by other counties with successful programs —  have done so quietly and behind the scenes, with little or no public discussion. “All we’re asking is that the counties have a public dialogue, put it on the record, explain their reasons for ‘opting out’,” he said. “It’s not a mandate.”

In the lead-up to the floor vote, David Stammerjohan, Eggman’s chief of staff, said the the “opt-out” requirements would remain in the bill, despite opposition from the counties. “We always listen to the concerns of opponents or other members,” he said, “but we think [Laura’s Law] has proven to be effective. Let’s have the counties actually have a conversation [about opting out], examine it from a public perspective, and then make a decision.”

As Assisted Outpatient Treatment (AOT or Laura’s Law in California) has gained supporters throughout the country – and shown widespread success in providing needed treatment, reducing hospitalizations, homelessness and incarceration, with significant cost savings – it nonetheless remains a little-known option for families of the mentally ill, who are often desperate to get treatment for family members but are generally barred from helping, even to warn of potentially volatile behavior, although they often are expected to serve as de facto caretakers.

Before Laura’s Law, the only real resource for families under existing law was the so-called “5150,”  a reference to that section of the state Welfare and Institutions Code governing 72-hour mental-health holds for someone deemed a danger to “self or others.” But invoking that provision involves law enforcement and usually means that an individual is soon released back to the streets, long before being stabilized on medication, or getting any treatment at all. Often, they return to families ill-equipped to help them, with sometimes tragic results.

Following their daughter’s tragic death, Laura’s parents, Amanda and Nick Wilcox, were determined to see legislation passed in California to give families options to get mentally ill relatives into treatment.

The valedictorian of her high school class, Laura Wilcox was a college sophomore on Jan. 10, 2001, working in a Nevada County mental health clinic during her winter break from Haverford College in Pennsylvania, when she was killed by a delusional clinic patient whose family had repeatedly tried to alert local mental-health authorities about his rapidly deteriorating condition – but they had refused to listen.

Scott Thorpe, then 40, a former school custodian, showed up at the clinic for an 11:30 a.m. appointment, and opened fire with a 9 mm semiautomatic handgun, killing Laura and a caregiver who had brought another patient to an appointment, and causing serious injury to two other clinic employees. He then drove to a nearby restaurant – which he thought was poisoning him – and killed the assistant manager, severely wounding a cook who tried to flee.

Thorpe’s brother, Kent, then a Sacramento Police sergeant and hostage negotiator, and his wife Sharon, had repeatedly attempted to alert clinic therapists about Scott’s increasingly alarming behavior, to no avail. “They wouldn’t listen,” said Kent Thorpe, who ultimately helped convince his brother to surrender peacefully later that day.

Scott remains in Napa State Hospital for the criminally insane, where he was sent after pleading Not Guilty by Reason of Insanity in Nevada County Superior Court.

“Some of those early hearings were uncomfortable. We were personally accused of  being ‘violence mongers’ and ‘spreading stigma.’” — Nick Wilcox

Following their daughter’s tragic death, Laura’s parents, Amanda and Nick Wilcox, were determined to see legislation passed in California to give families options to get mentally ill relatives into treatment. The resulting “Laura’s Law” has since been adopted by 20 of California’s 58 counties, including several of the state’s largest counties. But it has always been a voluntary process for California counties to “opt in” to start the Assisted Outpatient Treatment (AOT) programs that have been widely adopted in various forms, with considerable success, in 46 states throughout the U.S.

It was based on a similar law in New York, “Kendra’s Law,” passed in 1999, following the horrific death of 32-year-old Kendra Webdale, who was pushed in front of a subway train by a deranged man who had been hospitalized at least a dozen times, including six weeks before Kendra’s death. Unlike California, the New York Legislature made the law mandatory throughout the state, with state funding and stunning results.

In California, the path to adopting “Laura’s Law” was arduous at best, although it was strongly supported by the families of the mentally ill – including Scott Thorpe’s – and by victims, like Amanda and Nick Wilcox. Counties balked – many still do — at what they saw as an additional burden on already overwhelmed local mental-health systems.

Disability rights activists opposed the law, saying it infringed on the rights of the mentally ill to refuse treatment, and held noisy demonstrations on the Capitol lawn and in hearings on the original bill, many wearing yellow t-shirts with the triangular symbol for concentration-camp inmates deemed “mentally defective.” Then-Assemblywoman Thomson, a former psychiatric nurse who is the author of the original law, was heckled and called “Nurse Ratched,” after the abusive nurse in Ken Kesey’s “One Flew over the Cuckoo’s Nest,” about a fictional psychiatric hospital.

“Some of those early hearings were uncomfortable,” recalls Nick Wilcox, then an environmental scientist for the state Water Resources Control Board. “We were personally accused of  being ‘violence mongers’ and ‘spreading stigma’.  The first time I testified in 2001, I told the Assembly Judiciary Committee that I believe in civil rights. But when your civil rights interfere with someone’s right to live, it’s gone too far. Laura had a right to live.”

Now experienced legislative advocates, responsible for helping to pass dozens of bills on mental-health and gun-control issues in California, the Wilcox’ are optimistic about the current bill. “Bills grow legs,” Nick Wilcox said, “and this has very sturdy legs.”

Editor’s Note: UPDATES earlier and RECASTS lead with Assembly approval, EDITS throughout to conform. Sigrid Bathen is a veteran Sacramento journalist and former Sacramento Bee reporter who has covered mental-health and related issues for several publications, for more than 40 years. She has taught journalism and communications at Sacramento State since 1988. She has written for Capitol Weekly since 2005, on a variety of subjects, including education and health care. 

Mental health care: From the snake pit to the streets

Published January 28, 2020 on Capitol Weekly.

“California began emptying its mental hospitals 30 years ago (in 1967), when community based care was touted as the more humane alternative. As thousands of homeless mentally ill wander city streets, or end up in jail or prison, policy-makers wonder: Where is this ‘community care’, and isn’t there a better way?” – California Journal, 1997

“There are a lot of pieces to this puzzle, and we need to look at it as a whole – courts, prisons, police, state hospitals, community programs – and re-engineer a system that works better.” Randall Hagar, California Psychiatric Association, Capitol Weekly, 2011

“The State of California is treating homelessness as a real emergency – because it is one.” Gov. Gavin Newsom, State Budget Preview, Jan. 8, 2020

The modern history of mental-health care in California begins more than half a century ago with passage of the landmark 1967 Lanterman-Petris-Short Act, an ambitious — but ultimately disastrous —  overhaul of a draconian “system” of hoary old mental hospitals throughout California.

Most of the hospitals were closed, but the “community care” that was to take their place never materialized. Laws were changed to prevent forced institutionalization, and increasing numbers of mentally ill Californians wandered the streets, or languished in jails and prisons. Skyrocketing housing costs forced more people out of their homes, and California now leads the nation in the number of homeless people on its streets.

Residents – “inmates” was a more apt term – shuffled around in grimy “day rooms,” watched TV, or were confined to bleak dorms with few programs.

As Gov. Gavin Newsom, with great fanfare and reams of statistics, launches his ambitious $1.4 billion budget plan targeting mental illness and homelessness, there is both hope and a question: Will it really mean lasting change?

The odds are not good.

First, some history.

For decades, thousands of mentally ill and developmentally disabled residents were confined in chronically overcrowded, understaffed facilities  that often looked more like prisons than hospitals, where powerful antipsychotics were routinely dispensed, to “keep them quiet.” Residents – “inmates” was a more apt term – shuffled around in grimy “day rooms,” watched TV, or were confined to bleak dorms with few programs, little therapy, poor supervision, and hardly any future.

They were frequently confined against their will. The hospitals could be dangerous places, where hundreds of people, including mentally ill and developmentally disabled children and teens (the accepted term then was “mentally retarded”), were injured or died under questionable circumstances, prompting highly critical media coverage. Finally, sweeping state investigations were launched in the late 1970s into dozens of “suspicious deaths” in state hospitals going back years.

Some major staffing changes were made, but few, if any, criminal charges were filed.

“The state hospitals went from 35,000 to 5,000, and the community was expected to deal with it, without the expertise or the resources.” — Dr. Stephen Mayberg

As the hospitals closed during the Reagan administration, and into the first Jerry Brown term, only a few remained, primarily to house those deemed criminally insane by the courts.

For the legions of discharged residents without families willing or able to help or house them, the streets – and jails and prisons – of California cities ultimately became the default “homes” for thousands of mentally ill Californians.

The “community care” touted by the Lanterman reforms was largely nonexistent, and new laws limited institutionalizing or forcing people into treatment against their will. 

“The state hospitals went from 35,000 to 5,000, and the community was expected to deal with it, without the expertise or the resources,” Dr. Stephen Mayberg, who then headed the state Department of Mental Health, told a California Journal reporter in 1997.  “It was a recipe for problems, and we’ve spent a long time trying to dig ourselves out of that hole.”

Yet that “hole” Mayberg described in 1997 only seems to get deeper, despite multi-billion-dollar infusions of taxpayer funds, myriad executive and legislative fixes, critical state audits and frequent reorganizations — including the breakup of the massive state Health Department in the 1970s and, decades later, eliminating the state Mental Health Department in 2011.  As oversight responsibilities were spread among several state agencies, the “problem” has worsened exponentially, complicated by the lack of affordable housing and the Byzantine bureaucracy of “community care.”

More than 150,000 Californians are homeless (many of them mentally ill), according to recent federal estimates. Homeless “counts” are constantly changing, notoriously unreliable, and the numbers likely are much higher. In Los Angeles County alone, recent estimates place the number of homeless people at 60,000. A recent poll by the Public Policy Institute of California ranked homelessness as the No. 1 priority for immediate state action.

Under tremendous pressure to take sweeping action, Newsom earlier this month unveiled one of the most ambitious state reorganizations yet, committing more than $1 billion in state funding and prioritizing homelessness and mental health in his 2020-21 state budget proposal, which includes a $750,000 fund “to get individuals off the streets and into supportive services quickly.”

“Californians are demanding that all levels of government. . .do more to get people off the streets and into services, whether that’s housing, mental health services, substance abuse treatment or all of the above.” — Gavin Newsom

Released Jan. 10 in an unprecedented three-hour briefing that featured the governor alone, Newsom cited reams of statistics and budget figures, displaying a rare command of the mind-numbing details typical of a new state budget, as reporters’ eyes glazed and policy-makers watched, astonished.

“In more than 20 years of working in and around state government, we’ve never had a governor who was such a champion of mental health issues, and as knowledgeable about even the minutiae of mental health policy,” said Sacramento Mayor Darrell Steinberg, a veteran champion of mental-health reforms. Steinberg, the former leader of the state Senate, authored major legislation, including the 2004 Mental Health Services Act.

Passed by voters as Proposition 63, which boosted taxes on those with $1 million or more in taxable income, the so-called “millionaire’s tax” has raised billions for mental health programs, while at the same time homelessness has become the scourge – and the shame – of California. The state has more homeless people roaming its streets, living in cars, languishing in jails and prisons than any other state, at tremendous public cost and personal pain.

“Californians are demanding that all levels of government. . .do more to get people off the streets and into services, whether that’s housing, mental health services, substance abuse treatment or all of the above,” Newsom said in his Jan. 8 budget preview. “That’s why we’re using every tool in the toolbox – from proposing a massive new infusion of state dollars in the budget that goes directly to homeless individuals’ emergency housing and treatment programs, to building short-term emergency housing on vacant state-owned land.”

The budget proposal must now wend its way through the Legislature, emerging in the spring and with final approval in June. “It’s heartening,” Steinberg said of Newsom’s proposals to radically restructure – and prioritize – California’s historically fraught, extremely complex system of mental-health care, “and will surely help our state improve the lives of people suffering from mental illness.”

Steinberg co-chairs, with Los Angeles County Supervisor Mark Ridley-Thomas, the governor’s Council on Regional Homeless Advisors, which on Jan. 13 issued an “interim report” generally praising the governor’s proposals, while also urging more focus on the prevention of homelessness.

“Prevention should focus particularly on the growing number of Californians becoming homeless due to economic displacement,” the council recommended, “as well as those discharging from our institutional settings into homelessness.”

“We were disappointed that the governor did not include a proposal to create a certification program for Peer Support Specialists in the budget proposal.” — Steinberg Institute

The advisory council, which includes local and state officials and advocates, urged the governor to “create a single point of authority for homelessness in California” – a “high-level” official and team “to coordinate housing, health and human services and other state responsibilities relating to homelessness,” answering directly to the governor.

Despite campaign  promises that he would appoint a “homelessness czar,” no such appointment has yet been made. When reporters again raised questions about the position during the budget briefing, Newsom rather testily responded that he is the homelessness czar.

In a separate statement issued shortly after the governor’s Jan. 10 budget briefing by the Steinberg Institute on mental health policy, the former Senate leader generally praised Newsom’s proposals.

But Steinberg, who founded the institute, also criticized the governor’s veto last year of a bill widely supported by mental-health advocacy groups to fund a  program of “Peer Support Specialists” – people with personal and family experience in mental health issues – to help the mentally ill get access to critical services.

The measure has passed the state Legislature unanimously three times, and last year Newsom told advocates that “he wanted the process to be handled through the 2020 budget.”

Thus far, that hasn’t happened.

“We were disappointed that the governor did not include a proposal to create a certification program for Peer Support Specialists in the budget proposal,” the institute said, adding that, “We will take him up on his offer to work with us on this important issue and are determined to add this program to the budget.”

The ‘invisible’ families bearing the brunt of care
Limited peer-support programs have long been used successfully in local programs. They can cost far less than other staffing and support services for mentally ill individuals and their families, who bear the brunt of care for mentally ill relatives with little government support or even consultation.

“We knew the conversations were happening, and we tried to get involved.” — Jessica Cruz

Failure to include peer-support funding in the budget (a cost which the Steinberg Institute says is “modest”) highlights a historic policy misstep in efforts to restructure and improve the state’s convoluted and poorly monitored mental-health bureaucracy – failing to include the mentally ill and their families in policy discussions.

Families and many clinicians, social workers and administrators who work in well-regarded local programs, have long said that ignoring, or giving short shrift to, families in policy and budget discussions often torpedoes effective restructuring of the fractured system, with its long history of massive reorganizations, huge infusions of taxpayer funds – and limited accountability.

“We are going to advocate very heavily for family and consumer representatives” to be included in the budget discussions, said Jessica Cruz, California CEO of the influential National Alliance on Mental Illness (NAMI), which provides advocacy and support for families of people living with mental illness, who say they were not actively consulted in the run-up to the budget proposal.

“We knew the conversations were happening, and we tried to get involved,” Cruz said, attending several informational and “stakeholder” meetings and hearings. At one legislative hearing, she said dozens of mental-health advocates, including family members, were present, saying, “Hey, slow down, let us be part of the conversation.”

The governor’s veto of the peer-support legislation – and his failure to include it in the budget proposal – especially troubles family members.

She said families are often “the hidden, invisible population,” providing the bulk of housing and care for their mentally ill family members, with little support – or even acknowledgement — from public agencies. “When we don’t provide treatment for loved ones, everybody suffers. God forbid something happens to their family.”

She said that concern is particularly acute for aging family members caring for mentally ill relatives, often their adult children. “Many of our members are this invisible population that nobody sees or talks about,” Cruz added. “The family voice is so important, as 99 percent of the time we’re the caretakers, the ones providing housing, treatment, transportation.”

The governor’s veto of the peer-support legislation – and his failure to include it in the budget proposal – especially troubles family members.

“Peer support is huge for families,” Cruz said.  Individuals with “lived experience” as someone living with mental illness or as a family member “can help families navigate through difficult times. We are not trained professionals – we are experts in our own experience. We have to be taken seriously, thoughtfully and strategically as a part of these conversations.”

Kaino Hopper is an artist and former college art teacher – and a longtime Sacramento NAMI volunteer who leads family support groups. Her severely mentally ill adult daughter lives at home with her parents, who are in their 60s, when she is not hospitalized or temporarily institutionalized (there are few long-term, or even adequate short-term, facilities for the mentally ill). “We work 24/7 with no breaks,” Hopper said.

Under current law – which many experts say is an over-reaction to past, forced institutionalization — mentally ill people in crisis can only be detained on a 72-hour “5150” hold.

After horrific media accounts of mentally ill patients being discharged to the street, often with disastrous consequences, recent legislation now prohibits health-care facilities from discharging mentally ill patients without housing, which usually comes down to “a bed” that is often hard to find. Addressing the closure of many so-called “board and care” homes for the mentally ill in California cities because the state reimbursement rates are too low – particularly in urban areas where housing costs have skyrocketed — is part of the governor’s budget proposal, but with few details.

“When the person is released from a hospital, we [family members] become ‘the bed’,” Hopper said. “We need help at that point. . .There are ‘stepdown services’ (post-discharge services) after acute care, but they’re few and far between. It’s hard to get on the list.”

Under current law – which many experts say is an over-reaction to past, forced institutionalization — mentally ill people in crisis can only be detained on a 72-hour “5150” hold, a reference to a provision in state law affecting individuals deemed a threat to themselves or others.

Too often, that has meant languishing on a gurney in an overcrowded hospital emergency room. 

Exhausted family members often step in, with devastating results. When they try to get help, restrictive confidentiality laws routinely prevent consultation with families of adult relatives.

“It’s an impossible situation for families,” Hopper said. “The way the system is set up right now, our family members will receive more services” if they refuse to “house” their mentally ill relatives. “It’s emotional blackmail, and families find ourselves in the crosshairs.  We want to be part of the recovery process, but we are not allowed to be part of that process, although we are pressured to provide housing, with no support. Our homes become burnout zones.” Many parents work, many others are single parents, and there are frequently other children in the home. “Families could do more if we had a way to call for help in the home,” says Hopper.   

An explosive state audit in 2017 found that California counties were often “hoarding” millions in MHSA funds ($126 million in Sacramento County alone).

Cruz praised the governor for “prioritizing mental health and homelessness,” but cautioned against “lumping all people with mental illness together as homeless,” although mental health and substance abuse “are a big piece” of the puzzle.

Cruz and other mental-health advocates are also concerned about tapping into funds raised by the landmark 2004 Mental Health Services Act, from which money already has been diverted by California’s Proposition 2, a legislative measure passed by voters in 2018 to use MHSA funds for housing.  “We have to be extremely careful how we use MHSA funds,” Cruz said.

While vague on the details, Newsom’s budget recommended revisions to both Lanterman-Petris-Short and the MHSA, which the Steinberg Institute supported in concept, saying the MHSA funding should focus more on “the soaring number of people with serious mental illness who are also grappling with homelessness or have been involved in the criminal justice system, as well as the rising number of at-risk children and youth who are coping with mental illness.”

And there is widespread agreement that more accountability and state oversight are essential to tracking both funding and progress.

An explosive state audit in 2017 found that California counties were often “hoarding” millions in MHSA funds ($126 million in Sacramento County alone), and the flow of funding has subsequently, though inconsistently, increased from the counties to expand local programs.

Newsom’s budget urges better accountability. His advisory council recommends legal remedies, including sanctioning local governments that fail to move quickly to meet state benchmarks. Many critics and advocates blame the lack of oversight on the 2011 elimination of the state Mental Health Department, during the administration of Gov. Jerry Brown – a reorganization which dispersed the responsibility for monitoring mental health programs and spending among multiple state agencies, making accountability difficult

“We really need to synchronize mental-health services with housing and shelter services.” —  Steve Watters

The governor’s advisory council is adamant that a cabinet-level appointee – a “single point of authority” (e.g., a “homeless czar”) — be named by and report directly to the governor.

‘Shelter’ vs. ‘Housing’
Advocates also emphasize the distinction between “shelter” and “housing,” and Newsom attempts to address both in his budget proposal.

Short-term shelter – like the 100 travel trailers from the “state fleet” and an unspecified number of “complementary modular tent structures” that Newsom proposes be deployed throughout the state – are by definition not permanent housing, which takes much longer to realize and is much more expensive.

Many local agencies and nonprofits around the state work to provide permanent housing, and many others are focused on temporary shelter. Both, however, emphasize the importance of “wraparound services” for residents facing myriad physical, mental-health, social-services and substance-abuse issues.

“We really need to synchronize mental-health services with housing and shelter services,” says Steve Watters, a longtime CEO of Sacramento-area nonprofits (Safeground Sacramento and, more recently, First Step) that provide shelter, housing and other services for the homeless, many of whom are mentally ill.

“It should be easy, but it isn’t. . .Affordable, permanent housing takes a long time to develop. We’re trying to develop interim housing, a form of shelter, and wraparound services. We can’t wait for affordable housing. Our clients can’t wait,” he said.

The specter of epic tensions between the Newsom and Trump administrations also haunts the governor’s ambitious plans to tackle homelessness and mental illness in California.

On Jan. 1, First Step opened an 80-bed shelter on North A Street in Sacramento, funded through the county, and is working with the Sacramento Housing and Redevelopment Agency and the Sacramento City Council to establish “villages” of tiny homes, sleeping cabins — collaborating with other organizations to provide medical and other services.

“It’s much easier to engage clients [in services],” he says, “when you know where they are.”

State and federal funds are often distributed by the cities and counties, and navigating the funding maze can be an exercise in frustration even for the most experienced nonprofit administrators. 

“The city and county have funds coming from the state, with some requirements, and then the city and county decide how to spend the money,” Watters says. “There needs to be more involvement from the service providers [at the local level]. We actively campaign for solutions that involve sheltering and services that can be helpful – intensive case management for each individual, tied in with collaborators on the medical side for mental health counseling and primary care. . .But it’s difficult to navigate the system.”

The specter of epic tensions between the Newsom and Trump administrations also haunts the governor’s ambitious plans to tackle homelessness and mental illness in California, as federal funding is a key element, particularly in Newsom’s lofty plan to “transform Medi-Cal.”

“That three-hour press conference is one-way, directional. The only way you get to a solution is through communication, negotiation.” — Barbara O’Connor

The Los Angeles Times recently revealed that Los Angeles Mayor Eric Garcetti has been quietly negotiating with federal officials for funding to address the especially visible and acute homeless crisis in L.A. The efforts initially appeared to be bearing fruit, until the Trump administration placed myriad, but vague, “conditions” on actual funding, which included more involvement by law enforcement and reducing regulations on housing construction. Those conditions appear to have stymied the negotiations.

“But at least they’re communicating,” says Barbara O’Connor, a longtime political adviser and commentator and former communications professor at Sacramento State University.

“These are all great ideas,” O’Connor says of Newsom’s proposals, “but the coordination is lacking, with so much money and nobody to really run it. [Newsom] is not interactive, too much into one-way communication. That three-hour press conference is one-way, directional. The only way you get to a solution is through communication, negotiation. And there must be a project manager, which is true of any project — someone must be fully in charge of it. The homeless problem is not one solution for all. Modesto is not L.A., and the governor hasn’t even talked about federal money. The fact he hates Trump is not an excuse.”

Increasingly criticized for “big ideas,” and few actual accomplishments in his first year in office, the governor’s current proposals have enormous consequences for Newsom’s political future. O’Connor points to recent columns by influential L.A. Times political columnist George Skelton, who has both chastised the governor (for too many big ideas, too few actual accomplishments) and cautioned him (the current budget proposal initially appeared to be more focused on a few key issues, but the three-hour budget “briefing” should have been condensed to 30 minutes max.).

On the day after a preview of the 2020 budget, Skelton quoted two political veterans about prospects for Newsom’s second year:

From Republican political lawyer Steve Merksamer, who was chief of staff to Gov. George Deukmejian: “This governor made more promises than any governor I’ve seen. . .This is not a criticism, but it’s the time to put up or shut up. Taking on issues other people haven’t is fine, but that’s not the question. It’s taking them on and solving them. It’s time to fish or cut bait. It’s the second year.”

From Democratic political consultant Steve Maviglio, who was communications director for Gov. Gray Davis (like Newsom, Davis was a former college baseball player): “When you swing at a lot of pitches, you hit a lot of foul balls. He should focus on hitting a few out of the park.”

Advocates for the homeless mentally ill, meanwhile, always hoping for more state funding, are hesitant to publicly criticize public agencies.

Daniel Zingale, a top political adviser to two previous governors and former senior vice president of the California Endowment, reportedly has worn many hats in the Newsom administration, although his title was director of strategic communication and public engagement. He announced his retirement last week, but said he would stay on through Newsom’s State of the State message next month and may continue in an advisory capacity.

In his previous, equally high-profile jobs, Zingale was accessible, often quoted in news accounts, though less so during the first year of the Newsom administration.

Earlier this month, Zingale spoke to Skelton about the 2020 budget – and, perhaps, attempt some damage control over all of those reports of unfocused governing. He told Skelton that Newsom would be focused this year on three priorities: homelessness, health-care affordability and wildfires.

And then, a day later, Newsom delivered that marathon, one-man, three-hour budget “briefing,” showing a remarkable command of governmental minutiae, going well beyond his three “priorities” into the wonky details of the vast state bureaucracy. Not a good sign for actually accomplishing those priorities.

Advocates for the homeless mentally ill, meanwhile, always hoping for more state funding, are hesitant to publicly criticize public agencies and elected officials who help pay for their programs, although many are distressed by what O’Connor called Newsom’s “one-way communication.”

So they are waiting in the wings, hoping for the best, focused on keeping their clientele off the streets, connected with services.

“If you’re going to navigate the system and put things in place to help people,” says First Step’s Watters, “you can’t stand on the corner all the time with a bullhorn.”

Ed’s Note: 
Sigrid Bathen is a Sacramento journalist who teaches at California State University, Sacramento. She has written about mental-health issues for more than 40 years. Her investigative reporting has appeared in many publications, including the Sacramento Bee and the California Journal.  She has received several major awards, including a Pulitzer Prize nomination and recognition from the state and national mental health associations. Bathen has written about mental health, education, health care and state government for Capitol Weekly since 2005.

Sacramento State News

Professional Activities, April-June 2019

Sigrid Bathen, Communication Studies, was the guest speaker for the California Writers Club (Sacramento area chapter) on March 1, speaking on the topic, “Magazine Writing: Then and Now, Print to Digital,” describing her experiences “then and now” as a longtime journalist who has been a writer and editor for many local and state newspapers, magazines and other media, both print and online, including the Sacramento Bee, the Los Angeles TimesCalifornia JournalCapitol WeeklySacramento MagazineCalifornia Lawyer, the American Lawyer Newspapers GroupComstock’sMagazine,California MedicineMagazine, the Sacramento Business Journal, the California Health Care Foundation, and many others . She also recently completed a major oral-history project – a 90-minute video interview with legendary former lobbyist Clay Jackson, who for many years was one of the most prominent, highest paid lobbyists in California, and later served more than five years in federal prison following a massive “ Capitol Sting” investigation of political corruption in which many legislators, staffers, and one lobbyist were convicted on federal corruption charges. The oral-history series is funded by the Institute of Museum and Library Services through the California State Library, and is posted on the Capitol Weekly website http://capitolweekly.net/oral-history-project-clay-jackson/  Jackson had declined all interviews since his release from prison in 1999, and he was last interviewed by Bathen in prison in 1995, for a lengthy article published in the California Journal, a magazine about state politics and government where she was senior editor. That article received a first-place award for “enterprise reporting” from the Society of Professional Journalists, Central California chapter, and is linked in the oral history. https://secureservercdn.net/166.62.115.254/9c5.6e2.myftpupload.com/wp-content/uploads/2016/01/Clay-Jackson-1.pdf And Bathen recently wrote an in-depth article for the California Health Care Foundation, which publishes a variety of online health-care media, about the accomplishments of the late Herrmann Spetzler, who for decades directed (and vastly expanded) the “Open Door” health-care clinics in rural Humboldt and Del Norte Counties, which have become a national model for effective rural health care https://www.chcf.org/blog/herrmann-spetzler-visionary-rural-clinics/  The article was recently cited by the foundation as one of its “top ten” 2018 blogs.  Bathen has been an adjunct professor of Journalism and Communications at Sacramento State since 1988, and was also communications director for three state agencies.

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