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Author: Sigrid Bathen (Page 1 of 4)

‘Laura’s Law’ okayed in 30 counties — a major statewide turnaround

In a significant policy shift spanning nearly two decades, 30 counties in California – including all of the larger counties, with an estimated 80 percent of the state’s population – have now adopted a 2002 state law giving families a legal avenue to get severely mentally ill relatives into treatment.

That’s 10 more than had previously adopted “Laura’s Law” in the 19 years since it was originally enacted, inspired by the Nevada County murder of a young woman by a mentally ill gunman. The law has received growing public support, and legislation was passed unanimously last year to strengthen the law and finally make it permanent.

“It’s a remarkable turnaround,” said Randall Hagar, longtime legislative advocate for the state’s psychiatrists and the father of a severely mentally ill adult son. “It’s been 20 years in the offing, and it opens the door for many families… It’s just the beginning, really, of finding better solutions.”

Efforts to update the highly restrictive law – often called the “third rail” of mental-health policy – have mostly failed over the years.

Of California’s 58 counties, 30 have adopted Laura’s Law, 24 have rejected it and four remain undecided. Counties could still “opt in” before the new law takes  effect July 1.

 

Battling stigma, misconceptions and heartache, family members and mental-health policy experts have slogged through decades of controversy to convince legislators and local officials that supporting court-ordered intensive treatment – “Laura’s Law” in California — was not a return to the notoriously abusive system of state mental hospitals, where thousands of people were involuntarily housed, often for years, even decades.

It was a particularly ugly chapter in the tortured history of mental-health care in California. Hospital “residents” were routinely overmedicated, neglected, suffered injuries or death, too often under “suspicious” circumstances. The legislative solution, when it finally came in the form of the 1967 Lanterman-Petris-Short (LPS) law, severely limited involuntary treatment and has guided California mental-health policy, largely unchanged, for decades.

Chevon Kothari, Sacramento County’s director of health services, addressing the Board of Supervisors in May. The board adopted “Laura’s Law.” (MetroCable)

 

Efforts to update the highly restrictive law – often called the “third rail” of mental-health policy – have mostly failed over the years, although recent legislation, energized by a sharply critical state Auditor’s report last year, is beginning to change that.

“There has never been a point in time in which the interest in getting this right has been so keen, among the general public as well as elected policy makers,” said Hagar, who has labored in the trenches of mental-health policy and legislation for decades. “That gives us hope that we can make the system more responsive and provide the services people deserve.”

Many are severely, clinically ill, often self-medicating with street drugs, refusing help, so sick they are unaware of the severity of their condition.

It helps to understand the history. Following widespread news reports and multiple state investigations of abuse and deaths, the state mental hospitals were largely closed in the 1960s and ‘70s, and now house primarily those deemed criminally insane by the courts.

The “community care” which was vaguely envisioned but not specifically required by LPS, never materialized for the vast numbers of formerly institutionalized mentally ill Californians, leaving them — and their families — to fend for themselves, often with disastrous results.

The failures of the state’s fractured mental-health policies and laws are starkly visible today in cities throughout California, where an intractable, ever-growing population of homeless mentally ill people wander the streets — overwhelming hospital emergency rooms, cycling through jails and prisons ill-equipped to house, much less help, them.

Many are severely, clinically ill, often self-medicating with street drugs, refusing help, so sick they are unaware of the severity of their condition (called “anosognosia” in clinical terms). Although few become violent or commit serious crimes – they are much more likely to be victims of crimes — those that do dominate the headlines, reinforcing entrenched stereotypes, fear and stigma.

Early intervention a growing focus
One of those notorious cases served to illustrate why early intervention – a growing focus of both public policy and legislation — is essential.

Laura Wilcox, for whom “Laura’s Law” is named, was 19, working in a Nevada County mental health clinic in 2001, during her winter break from college, when the high school valedictorian and two others were killed and three people seriously injured during a psychotic rampage by a clinic patient.

Disability rights activists testified vehemently against the law, saying it violated the right to refuse treatment.

The family of the killer, Scott Thorpe, had desperately tried to convince Nevada County mental health authorities to intervene in the weeks before the murders, but were ignored.

During a lengthy trial, Thorpe, now 60, ultimately pleaded not guilty by reason of insanity and was sentenced to Napa State Hospital, where he will likely spend the rest of his life. Laura’s parents, Amanda and Nick Wilcox of Penn Valley, joined forces with legal and policy experts – and Thorpe’s family, including a brother who was a Sacramento police sergeant — to change the law.

It would become a 20-year battle for Laura’s parents, who tirelessly lobbied legislators and local officials, many of whom opposed any legislation they perceived to infringe on the rights of the mentally ill.

Laura Wilcox, whose shooting death in Nevada County inspired “Laura’s Law.” (Family photo)

Disability rights activists testified vehemently against the law, saying it violated the right to refuse treatment. They 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-state Assemblywoman Helen Thomson, D-Davis,  a former psychiatric nurse and Yolo County supervisor 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,” recalled 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.”

By last year, after nearly two decades, 20 of California’s 58 counties had adopted Assisted Outpatient Treatment (AOT or Laura’s Law in California).

The resulting bill, while ground-breaking, was not a mandate – counties could quietly “opt out,” as most did – and it included no funding, which guaranteed county resistance. It also carried a “sunset” provision, which meant additional hearings were required to renew it every five years.

By last year, after nearly two decades, 20 of California’s 58 counties had adopted Assisted Outpatient Treatment (AOT or Laura’s Law in California). Those that did, including most of the state’s large counties, reported strikingly positive results in sharply reduced hospitalization, incarceration and homelessness, as well as significant cost savings. In San Francisco alone, savings of $400,000 a month were reported.

Then-Assemblywoman, now state Sen. Susan Talamantes Eggman, D-Stockton, introduced legislation last year which significantly strengthened Laura’s Law, adding judges to the list of those who could make referrals, streamlining the procedures for county action, and finally making the law permanent. Unanimously passed in both houses of the state Legislature, and quickly signed by Gov. Newsom last September, AB 1976 represented a major reversal of mental health policy over decades.

“The human rights and public-health crisis is not fair to families, and I think it has become a stark reality for everybody.” — Susan Talamantes Eggman

Opposition remained, mostly from disability rights groups who were considerably less vocal than during those raucous hearings about the original law.

‘A wildfire in our streets’
Likening the mental-health crisis playing out in plain view throughout California to “a wildfire in our streets,” Eggman noted growing support for major policy improvements in the state’s historically patchwork mental-health care system, brought into even sharper relief by a global pandemic and an epidemic of homelessness.

“How is that dignity for anybody?” said Eggman, a former social worker and Sacramento State social work professor, in an interview with Capitol Weekly last year.

“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.”

And that momentum continues during the current session, with several bills sailing through the Legislature to further strengthen Laura’s Law and revise some provisions of the long-outdated LPS law.

“Many of us, myself included, have evolved in our thinking on Laura’s Law.” — Phil Serna

Rather than being able to quietly “opt out” of AOT, counties now are required by AB 1976 to hold public hearings, which became particularly intense in recent months as counties without Laura’s Law programs faced looming state deadlines to formally “opt out,” with specific reasons why, or be automatically “opted in.”

The state Department of Health Care Services (DHCS) gave the counties until May 15 to make their decisions, and many did, but several asked for extensions of that deadline. Under the law, counties deciding to implement programs must prepare plans to do so  — or formally “opt out” — by July 1.

Nowhere has the debate over the newly strengthened Laura’s Law been more intense than in Sacramento and Santa Clara counties,  the only two large counties which did not have such programs. In a complete reversal of decades-old opposition, county supervisors in both counties unanimously adopted Laura’s Law in May, following months of public hearings, online surveys and reams of written public comments.

A homeless man in Sacramento’s Cesar Chavez Park, across the street from City Hall. (Photo: Supervisor Phil Serna)

“Many of us, myself included, have evolved in our thinking on Laura’s Law,” Sacramento Supervisor Phil Serna said in a lengthy May 18 board meeting. “I am convinced it is the right thing to do, for the right reasons, to help people who are suffering, to help families.”

Sacramento board chair Sue Frost, a former emergency room nurse who had long opposed the law, said she too was convinced, pointing to other Laura’s Law counties with successful programs that have saved public funds, and lives. “Criminalizing mental illness is not the right path,” she said.

“It’s getting harder and harder to justify opting out when 20 different counties across the state have already implemented this program…” — Joe Simitian

“I’ve had concerns in the past about civil liberties and due process issues with AOT,” Santa Clara County Supervisor Joe Simitian, who voted for Laura’s Law as a state legislator in 2002, said in a written statement prior to the May 25 board vote. “But I’m now convinced that the law is crafted narrowly enough, and has enough protections built into it, that these concerns have been alleviated.”

Simitian echoed other local officials around the state when he noted the positive results of AOT programs in other counties.

Santa Clara County Supervisor Joe Simitian.

“We now have the benefit of their experience,” he said. “It’s getting harder and harder to justify opting out when 20 different counties across the state have already implemented this program and can show that they are having real, positive effects on reducing psychiatric emergency services, crisis episodes, and hospitalizations.”

The newest member of the Sacramento board, Rich Desmond, said his long career in law enforcement, as a California Highway Patrol officer and administrator, often put him in situations involving mentally ill residents, when he had few options.

“I recall many situations when we either had a 5150 hold (the state code section for 72-hour involuntary LPS “holds” for those deemed a danger to themselves or others), or a criminal charge. There was nothing in between.”

Public support for Laura’s Law has grown exponentially in recent years, as more programs have been adopted in California — and in 46 other states.

Representing the Arden-Arcade area of Sacramento County, which has been particularly hard hit by homeless street encampments, Desmond said he and his daughter were recently driving through the area when they encountered  “a clearly mentally ill individual,” and she asked, “Dad, can’t we do something?”

“We now have an opportunity to do something here in Sacramento County,” Desmond said. “It’s not a panacea, but part of a continuum, a tool that allows us to save some people who are in desperation.”

Nick and Amanda Wilcox at a memorial for their daughter, Laura. (Laura Mahaffy, The Union)

Public support for Laura’s Law has grown exponentially in recent years, as more programs have been adopted in California — and in 46 other states, according to the Treatment Advocacy Center, a national mental-health advocacy organization which has worked to develop AOT programs throughout the country, with widespread success but varying levels of government support, funding and oversight. Laura’s Law is based on a similar New York law – Kendra’s Law, named for a young woman who was pushed to her death from a subway platform by a severely mentally ill man who had been repeatedly hospitalized. Unlike Laura’s Law, the New York law is mandated and funded statewide.

Based on DHCS numbers and local news accounts, the 10 “new” counties — Fresno, Humboldt, Kings, Mariposa, Napa, Riverside, Sacramento, Santa Clara, Siskiyou and Tulare – that have voted to start AOT programs since the passage of AB 1976 last year, bring to 30 the total number of Laura’s Law counties. Twenty-four counties have voted to “opt out,” according to DHCS spokesman Anthony Cava, and four had yet to make a decision. Many of those have requested, and been granted, extensions by the state until July 1.

Too late for some families
The sharp increase in the number of California counties with AOT programs comes too late for some parents who believe their seriously mentally ill adult children would have benefited from the law, if it had been available in their counties.

Authorities said they advised Hopper to file a restraining order against her daughter, so she could be arrested, which she refused to do.

Kaino Hopper, a Carmichael textile designer and mental health activist who teaches family support classes for the Sacramento chapter of the influential National Alliance on Mental Illness (NAMI), was interviewed at length  by Capitol Weekly earlier this year, when her severely mentally ill, now 32-year-old daughter Christine was homeless on the streets, and her mother was desperately trying to get help for her.

Christine Hopper, who has lived with serious neurological and schizoaffective diagnoses since she was a teenager — and graduated in the top of her high school class – was a few units short of a UC-Davis sociology degree when her condition seriously deteriorated in recent years.

Christine Hopper (Family photo)

Existing county programs were ineffective, and Hopper was convinced the intensive, court-ordered treatment available through Laura’s Law could help her daughter, who refused treatment, and had become increasingly delusional and combative. In January, during major storms in Sacramento, Hopper said county sheriff’s deputies rebuffed her efforts — and the strong recommendation of a licensed clinical social worker — to have her hospitalized on a 72-hour 5150 hold. She said they advised Hopper to file a restraining order against her daughter, so she could be arrested, which she refused to do.

A few months later, on April 19, Hopper was speaking in support of Laura’s Law during a Sacramento County public hearing, when she stunned the large virtual audience by announcing “with a very sad heart, that last week on April 14, Christine received a county service for her mental illness – incarceration.”

After allegedly attacking a male resident at an apartment complex where she once lived (he was not seriously injured and did not require treatment), she was charged with assault with a deadly weapon and jailed until May 11, when she was sent to the Sacramento County Mental Health Treatment Center and UC-Davis Medical Center on a 72-hour mental health hold. As a Kaiser member through Medi-Cal, she was transferred to Kaiser Hospital in Sacramento, which released her on May 14, at the end of the 72-hour hold, during which she refused treatment and would not speak with clinicians. Her release to the streets did not include a treatment plan or housing.

“This didn’t have to happen. Christine could have gotten better treatment long ago. AOT could have been the key. . .” — Kaino Hopper

Two days later, her mother learned, Christine had somehow made her way to the Central Coast, where she was treated in a San Luis Obispo hospital ER on May 16, and released the same day – at a cost of nearly $8,000. Hospital financial statements of public Medi-Cal benefits go to her parents’ Carmichael address, which is her legal address, and so far have amounted to at least $20,000 for three hospital visits in less than a week after she was released from jail. Back in Sacramento, she remains homeless on the streets, incapable of caring for herself.

“This didn’t have to happen,” Hopper added quietly. “Christine could have gotten better treatment long ago. AOT could have been the key. . .”

Hopper hopes her daughter’s case will be heard in Mental Health Court, “if she can last until the hearing on July 21.” Mental Health Court is a criminal court process in which defendants who qualify are diverted from the traditional court system into treatment. Laura’s Law is a civil court program to get severely mentally ill people into intensive treatment before they are arrested on criminal charges.

Susan McCrea was appointed to the Sacramento County Mental Health Board, which advises the board of supervisors on mental health policy, in 2008, drawn to accept the appointment because of her own family’s experiences. She currently serves on the county’s Mental Health Services Act Steering Committee, which advises the department of behavioral health on distribution of state MHSA funds raised by the 1 percent “millionaire’s tax” on incomes over $1 million, which was passed as Proposition 63 in 2004 and has since raised billions of dollars for mental health care in California.

She has strongly supported Laura’s Law throughout a frustrating, years-long series of failed attempts by supporters to convince supervisors to adopt the law, which might have helped her own daughter, Christianne.

Christianne McCrea. (Family photo)

“Our family witnessed Christianne’s increasing revolving door episodes of hospitalizations, missing person reports, incarcerations for minor offenses and even homelessness before she returned to our home in 2007,” McCrea wrote in a recent Sacramento Beeopinion article published shortly after Sacramento County finally, unanimously adopted Laura’s Law. “My presence on the Mental Health Board helped us navigate the intricate and often pockmarked mental health system in an attempt to help our daughter receive support during this wrenching, vicious cycle.”

In 2010, more than a decade after her first psychotic break at 22, and 11 years before Laura’s Law would be adopted in Sacramento County, Christianne Noel McCrea — “our beautiful Christmas Day child” — committed suicide.  She was 33.

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

Letter to the Editor: Mental health care

Editor:

I want to commend reporter Sigrid Bathen for her thorough and excellent reporting on an issue important to so many people: providing mental health care for our loved ones.

Ms. Bathen’s two-part series shined a critical light on some counties’ resistance to adopting Laura’s Law to enhance outpatient services to those with severe mental health issues.

It is mystifying that two of California’s largest counties – Sacramento and Santa Clara – have declined to implement a program that has proven to be effective in reducing  hospitalizations, homelessness and incarceration. I understand the concerns over our state’s history of “warehousing” the mentally ill. But we have moved well past that approach to mental health services. As the State Auditor made clear in a blistering report last year, California must do more to ensure that those with serious mental illness receive adequate ongoing care through Laura’s Law.

Today our state tolerates a different kind of abuse: neglecting the needs of people with mental illness and then steering too many of them into our court and prison system, as Ms. Bathen’s reporting shows. Too many structural incentives are still in place that force police to handle the mentally ill after they’ve reached a crisis rather than equipping mental health professionals to work with people in a preventive and holistic way.

I voted last year with my legislative colleagues to encourage all 58 counties to avail themselves of Assisted Outpatient Treatment programs, and I hope Sacramento and Santa Clara counties ultimately agree to implement this program.

This year I have authored three bills to offer more state support for those suffering from mental illness, but also to put in place accountability measures to keep an eye on agencies to ensure they are providing needed services. They are:

SB 21, which would increase funding for public schools’ mental health services financed by purchases of a mental health awareness license plate (you can register your intent to buy the license plate here: https://beingwellca.org/);

SB 749, which would create a comprehensive tracking program for county spending on mental and behavioral health programs and services;

SB 782, which follows on last year’s legislation by allowing individuals exiting conservatorship to be eligible for involuntary Assisted Outpatient Treatment as a bridge to fully independent living.

I hope we can all agree that mental health services are one of California’s most vital needs – especially as we continue to maneuver through the effects of the Pandemic. Solutions are in sight. The State Auditor made that much clear in its scathing report last year. We just need to seize the moment and do the right thing.

Steven Glazer,
State Senator, 7th District (Contra Costa and Alameda counties)

Legacy of a young woman’s murder: Will the counties step up?

Editor’s Note: The death of 19-year-old Laura Wilcox, shot by a gunman with a history of psychiatric problems, inspired a 2002 California law to make it easier for families to get help for a mentally ill relative. The issue is this: Will the counties — including Sacramento and Santa Clara — agree to strengthen the original law? The deadline looms. (Second of two parts. Part I can be viewed here.)Sue Frost, chair of the Sacramento County Board of Supervisors, did not originally support a 2002 state law that provides family members with one of the few legal avenues to get severely mentally ill relatives into intensive treatment. Like other public officials, she was concerned about patient rights and cost.

But she supports it now.

“There are people in our world who cannot take care of themselves, and they need help,” the former emergency room nurse said in a recent interview with Capitol Weekly. “You can’t exercise your civil rights if you’re seriously mentally ill or in a drug-induced psychosis.”

The original law was strengthened by legislation last year that requires counties to start such programs or publicly provide specific reasons why they are not

Faced with looming state deadlines to adopt “Laura’s Law,” California counties are scrambling to hold required public hearings and report back to the state Department of Health Services by May 2, two months before programs are set to begin July 1.

The 2002 law is named for 19-year-old Laura Wilcox, who was gunned down in 2001 in a Nevada County mental-health clinic by a deranged mental patient whose family had desperately sought treatment for him, but were rebuffed by local mental health officials. Scott Thorpe went on to kill two more people, seriously injuring three, and will likely spend the rest of his life in Napa State Hospital for the criminally insane.

The original law was strengthened by legislation last year that requires counties to start such programs or publicly provide specific reasons why they are not. Previously, counties could quietly decline to adopt Laura’s Law, which most did. Twenty California counties now have such programs and report significant success in reducing hospitalizations, incarceration and homelessness for a small subset of individuals who are resistant to treatment, at huge public and human cost.

Now widely adopted throughout the country, 46 states have Assisted Outpatient Treatment programs (AOT, or Laura’s Law in California).

Counties that fail to “opt out” of Laura’s Law will automatically be required  to start AOT programs. Most of California’s larger counties now have such programs, accounting for an estimated 65-to-70 percent of the state’s population.

The two remaining major holdouts, Sacramento and Santa Clara, are each surrounded by counties with successful Laura’s Law programs. With state deadlines approaching, debate in both counties is intensifying, and advocates complain that requirements for a full airing of public comment have been stifled by county mental health officials long resistant to AOT programs.

While many legislators opposed the original law because of concerns about involuntary treatment, opposition has waned as the law demonstrated significant success

Although Santa Clara County officials appear to be well on the way to a final decision next month, Sacramento County recently requested – and was granted — an extension until the statutory deadline of July 1. The 2020 law , by then state Assemblywoman (now state Sen.) Susan Eggman, D-Stockton, was passed unanimously by the state Legislature and took effect Jan. 1, but  the author gave the counties six months to prepare and implement programs – or publicly explain why they are not.

Joe Simitian, member, Santa Clara County Board of Supervisors

Two virtual public meetings of the Health and Hospital Committee of the Santa Clara County Board of Supervisors, on Feb. 17 and March 24, included intense public discussion, with considerable public comment, almost entirely in support of Laura’s Law. One of several letters to the committee was signed by San Jose City Councilman Matt Mahan  and 40 other mental health, business and environmental leaders. They noted that other Bay Area counties have had “great success” with AOT, and that San Francisco reported saving more than $400,000 a month in reduced hospitalizations, incarceration and homelessness among clients receiving intensive AOT services.

Clearly dissatisfied with county behavioral health staff recommendations that the Santa Clara board “opt out” of Laura’s Law, committee chair Joe Simitian said at the Feb. 17 meeting that he was “not persuaded” by county recommendations. Both members of the Health and Hospital Committee – Simitian and Supervisor Otto Lee – strongly recommended during the March 24 meeting that the five-member Board of Supervisors adopt Laura’s Law when the full board meets on May 25.

Simitian was a state Assemblyman (and later a state Senator), who voted for Laura’s Law when it was passed in 2002. It had no funding and included a five-year “sunset” provision that has been repeatedly renewed. The law was finally made permanent in last year’s legislation.

The mental health court judges in the criminal courts are among the strongest supporters of Laura’s Law.

While many legislators opposed the original law because of concerns about involuntary treatment, opposition has waned as the law demonstrated significant success, and compliance was mostly voluntary in a civil court process that aimed to keep people out of prisons and jails ill-equipped to house, much less help, them.  California jails and prisons are often described as “the new asylums” because of the large number of inmates  (as many as half) who are mentally ill.

“Because we have other large counties with programs, we now have some experience,” said Simitian in an interview with Capitol Weekly, “and the experience in other counties is encouraging. It’s very clear to me that there is a need that our current programs do not address.”

Judges support ‘Laura’s Law’
Ironically, while the two county governments – mainly the Behavioral Health departments in both counties – have resisted adopting Laura’s Law, both counties operate highly regarded Mental Health Courts, which seek to divert mentally ill defendants from jail into treatment, but only after they’ve been arrested for crimes.

The mental health court judges in the criminal courts are among the strongest supporters of Laura’s Law, a civil court process designed to intervene before individuals — whose crimes are a result of their mental illness and/or “self-medicating” with illegal street drugs — become ensnared in the criminal justice system. AB 1976 also adds judges to the list of individuals who can make referrals, and creates a mechanism for several counties to collaborate on Laura’s Law programs.

“There is very little a judge is specifically able to do under the law, other than lend our black robe (often called the ‘black robe effect’) to the treatment effort.” — Lawrence Brown

In a strongly worded letter of support for AB 1976 last year, Sacramento Superior Court Judge Lawrence Brown,  a former prosecutor who has long presided over Sacramento’s Mental Health Court, said the new law “will shift the burden in the debate to squarely where it belongs, namely on those seeking to prevent its implementation.”

Brown talks openly about his own family’s experiences with his schizophrenic sister. He attributes county resistance to Laura’s Law to  “misunderstanding or unfounded fears,” and said Sacramento County’s “failure to enact AOT has not been for want of trying, by NAMI (the influential National Alliance on Mental Illness) and many families with loved ones suffering from serious mental illness.”

In several interviews with Capitol Weekly, Brown said a judge’s role in Laura’s Law is generally minimal,  since most cases are voluntary. “There is very little a judge is specifically able to do under the law, other than lend our black robe (often called the “black robe effect”) to the treatment effort,” he said. “It gives families an opportunity to have their loved one connected to treatment, even if they are initially resistant.

“It is lost on me how anyone could be opposed to that.”

Other judges in the mental health court system strongly support AOT as another “tool” in efforts to reduce the increased incarceration of people, often for petty or drug-related crimes, whose mental illness is the root cause of their criminal behavior. “We have this huge gap,” says Santa Clara County Superior Court Judge Stephen Manley, who is frequently described as creating “the gold standard” in mental health courts. “Why should people have to commit a crime to get treatment?”

Nevada County, where Laura Wilcox was killed, became the first Laura’s Law county in California in 2008, six years after the law was passed.

County behavioral health directors point to other mental-health programs as doing the work of AOT, but Laura’s Law advocates say those programs, while important, lack the judicial component of Laura’s Law — with limited judicial intervention.

Santa Clara County has numerous, well-funded mental-health programs, which Manley praises, and regularly works with in his court. But he says Laura’s Law “provides for more intense treatment for those who cannot or will not participate in treatment, or think there isn’t really anything wrong with them.” While they are a small percentage of the mentally ill population, Manley added, “they cost society so much money – in arrests, hospitalizations.”

Nevada County, where Laura Wilcox was killed, became the first Laura’s Law county in California in 2008, six years after the law was passed. Nevada County Superior Court Judge Tom Anderson, a former public defender who represented Laura’s killer, Scott Thorpe, now presides over the county’s Mental Health Court and has actively advocated for Laura’s  Law (as did his former client’s family, an unusual alliance between the families of the victim and her killer, which Anderson helped to facilitate).

Laura Wilcox in her high school yearbook. (Family photo)

“The statistics are very clear,” he said. “You save more money than you spend because AOT is effective in reducing the costs of hospitalization, which are enormous, as well as police costs, not to mention the human effects on a person’s family and neighbors.” He is blunt in his criticism of county governments that oppose Laura’s Law, attributing their reluctance to “bureaucratic stubbornness.”

“It’s mystifying that they would not adopt a program that has been proven to be very effective and saves money. What other programs can you say that about?”

Counties cite controversy, start-up costs
Dr. Ryan Quist, a psychologist who is director of the Sacramento County Behavioral Health Department, declined to be interviewed for this article, citing “the long history and complexity of this subject.”

He responded to questions instead in a lengthy email that emphasized the “passionate advocates both for and against AOT” – ostensibly pitting family members against “consumers of services” who oppose involuntary treatment (which some do, but certainly not all). “Sacramento County staff are having discussions with advocates on both sides. . .in determining how to move forward.”

Like officials in other counties, Quist also pointed to existing programs that are “as effective” as AOT in providing “intensive case management.” One program cited by Quist and other Sacramento County mental health officials is CARE-Plus (Community Alternatives for Recovery and Engagement-Plus), which is for clients who are in conservatorships, one of the most restrictive categories under Lanterman-Petris-Short, the largely unchanged 1967 law that has governed state mental health policy for decades. Conservatorships are rare, legally difficult to obtain, and generally not part of Laura’s Law programs.

“It’s constantly puzzling to me that Sacramento County is so stuck in opposition when there is so much support for the efficacy of [AOT]. It’s really disheartening.” — Carol Stanchfield

Funding is also an issue for the counties, although AOT supporters say most programs are funded through Medi-Cal and the state Mental Health Services Act, passed as Proposition 63 in 2004. “The people who this would serve already qualify for services,” says Carol Stanchfield, who has long directed Nevada County’s AOT programs, and provides training for other counties starting such programs. “There are other sources [of funding]. They can’t lean on those excuses anymore.

“It’s constantly puzzling to me that Sacramento County is so stuck in opposition when there is so much support for the efficacy of [AOT]. It’s really disheartening.”

Laura’s Law requires that county programs not reduce other services in order to start AOT programs, but county officials argue there are start-up costs for any new program. And Quist said in his email that counties may see “dramatic cuts” in MHSA funding as a result of the economic impact from the pandemic – a contention disputed by Laura’s Law supporters.

While Sacramento County behavioral health officials have not yet made a recommendation to the Board of Supervisors, Laura’s Law supporters are cautiously optimistic about the board’s ultimate action, as are supporters in Santa Clara County about the vote there.

Like many public officials with long history in the Laura’s Law debates, who originally opposed the law at the county level, Sacramento board chair Frost now  supports it, and she has advocated with other board members and county officials for action to establish AOT programs in the county.

Frustrated by the county’s staff response to the new law, she wrote a strongly worded letter to Behavioral Health Director Quist on March 18, just days after two Behavioral Health department public hearings which gave short shrift to public comment and generated widespread outrage from the many advocates who had signed up to comment, ask questions.

Quist responded in a March 25 letter describing the county’s public outreach, and noted that in community responses to an online survey (172 responses by March 22), 74 percent favored opting in to an AOT program, 11 percent were opposed, and 15 percent “neutral or unsure.” He said more than 180 people registered for the March 15  and 16 hearings. Frost also requested “further public outreach” from county mental health officials, who have since scheduled another “virtual forum” on April 19 for public comment, before the issue goes to the full board.

“It is disappointing to see that these discussions have not been conducted in a way that is conducive to actual discussion,” Frost, who attended one of the virtual hearings last month, wrote in her two-page letter. “AOT was not explained, questions from the public were not addressed, the meetings were less than 30 minutes long (while being advertised for a full hour), and…were not recorded for later viewing.

“I was counting on being able to utilize these public hearings to help me come to a better understanding of AOT and my eventual position on it, but was left with nothing of value as a result. . .It is rare that a program has so much support that it receives unanimous support in the Legislature, but that is what happened with AB 1976, and I do not wish to see Sacramento County take it lightly. At this point, public perception is that we are not interested in actually considering adopting AOT. I hope that is not the case.”

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

For the mentally ill, a life-and-death debate over Laura’s Law

Editor’s note: A new California law pressures more counties to adopt mental-health programs to reduce hospitalizations, homelessness and incarceration — and save money. (First of two parts. Part 2 can be viewed here.)

When Kaino Hopper’s 31-year-old daughter Christine adamantly refused – as she often has — the mental health treatment she so desperately needs, it was a rainy, blustery January day in Sacramento, and she was homeless, sleeping in fields and suburban parks. Her mother had few choices, and contacted her daughter’s caseworker for help.

But Christine again declined treatment or housing – although she accepted her mother’s offer of food, a sleeping bag and tarp. She could no longer live at home because of her combative, sometimes violent and assaultive, behavior.  A client then of Telecare, a mental health and recovery program with services in multiple counties and several states, she has been diagnosed with schizoaffective disorder, a complex combination of symptoms characterized by delusions, hallucinations, depression and wild mood swings.

 

All are treatable with medication and therapy, and Hopper says Christine has enjoyed periods of stability when she accepts treatment.

Like many mental-health diagnoses, hers include a combination of psychiatric and neurologic conditions that began to surface in her early teens, but were not fully diagnosed until she was 18. The youngest of three children, she receives federal disability payments and has lived independently for short periods, but mostly with her parents through much of her young adulthood. Her mother says she was recently dropped as a Telecare client because she was not responding to offers of help.

“Families are too often the designated caregivers,” Hopper, 64, says bitterly of California’s broken system of mental health care. “Yet we get very little acknowledgement or support.”

Kaino Hopper’s daughter, Christine, 5th grade.(Photo: Hopper family)

Her daughter was diagnosed with ADHD in high school, and with a type of neurological epilepsy, characterized by a “dream-like” state, rather than classic epileptic seizures. “She would just stare into space,” Hopper recalls. “I thought I just had a dreamy kid.”  Her daughter had below-average grades in elementary school, but thrived in an Independent Study program in middle school, and was placed in Advanced Placement classes in high school, graduating with honors and a 4.3 GPA.

An active volunteer with the Sacramento chapter of the influential National Alliance on Mental Illness (NAMI),  Kaino Hopper coordinates family support groups and advocates for changes in mental health laws. She is in the forefront of current local and state efforts to convince recalcitrant California counties – including Sacramento – to “opt in” to the recently strengthened “Laura’s Law.”  The statute provides for court-ordered, intensive treatment programs aimed at a small population of treatment-resistant mentally ill people, like her daughter, who comprise an outsized number of repeat hospitalizations, incarceration, homelessness and deaths.

If Sacramento County had such a “Laura’s Law” program, as 20 California counties do, Hopper is convinced Christine would get the help she needs.

“Other county programs don’t work for her. She has zero insight into her condition. She forgets how she gets better with treatment, but she cannot get treatment in Sacramento County without going to jail,” said Hopper, a textile artist  who has been published and exhibited internationally and served as a guest lecturer in design at UC-Davis and other area colleges. Focused professionally – and personally — on making life easier for the disabled, her Master’s project at UCD was on simplifying fashion design for women with disabilities.

Christine Hopper at her 8th birthday party, with her pet cockatiel perched on her shoulder. (Photo: Hopper family)

Like so many parents of mentally ill adult children, Hopper has had little time for her design work in recent years, as her daughter’s condition deteriorated.  She was hospitalized in psychiatric facilities six times during the first eight months of 2020 — never longer than 14 days under California’s outdated and highly restrictive Lanterman-Petris-Short (LPS) law, which has been largely unchanged since it was passed as a sweeping “reform” measure in 1967. She had four failed “room and board” placements, usually private residences with rooms to rent, where she either left, was evicted or denied housing because she refused to take a COVID test.

So, on Jan. 5, Hopper and the Telecare caseworker, a licensed clinical social worker, took the only path available to the families of severely mentally ill relatives in most California counties. They called 911, asking that she be detained on a 72-hour involuntary “hold” under LPS, which places strict limits on involuntary treatment and offers few if any alternatives. But the law enforcement officers who respond to such calls make the ultimate decision under the law, often regardless of recommendations by mental health professionals, and Hopper said they decided she “didn’t meet the criteria” to be taken to a hospital on a “5150,” the state code section governing involuntary holds for those deemed a danger to themselves or others.

“There is this terrible disconnect between what the mental-health professionals recommend, and what actually happens. [The officers] told me she knows her name, she has a sleeping bag, she’s eaten, and she’s not comatose,” recalls Hopper, who followed up with repeated calls and emails to Sacramento County Sheriff’s Department supervisors. “They said I should get a restraining order, so then she could be arrested.”

Lisa Dailey, an attorney who heads the national, Washington, D.C.-based Treatment Advocacy Center — and whose sister’s mental illness propelled her into mental-health law and advocacy — says family members “are entirely shut out of the system. A police officer who comes to the scene has no experience with this person, gets only a snapshot view.”

Christine Hopper in a photograph taken last year in Sacramento. (Photo: Hopper family)

From the streets to jail – and back again
Dailey says Assisted Outpatient Treatment (AOT, or Laura’s Law in California) services are  “misunderstood” by local and state behavioral health officials, who are often opposed to such programs because of funding issues and patients’ rights concerns.  “The services that are incorporated into an AOT plan already exist in many counties,” she says. “The difference is the court order. There is a real stubbornness to even try the program, despite its proven success.”

Multiple state and national studies of AOT programs indicate significant success in reducing hospitalizations, incarceration and homelessness among clients of local programs, but data collection is limited and inconsistent. In a scathing report on state mental health care last year by state Auditor Elaine Howle, she was particularly critical of poor or nonexistent follow-up and data collection for the thousands of people who are “processed” through a haphazard system of care.

In its most recent report last year, covering 10 county programs in 2018-19, the state Department of Health Care Services, which is required to issue regular reports on Laura’s Law programs (as are the counties, although many reportedly fail to provide data, with limited state sanctions), found significant reductions in homelessness, incarceration, hospitalization – including a 90 percent reduction in mentally ill clients becoming victims of crimes. The report also noted a 29 percent reduction in hospitalizations and 56 percent “fully engaged” in services, usually voluntarily, without the need for judicial intervention.

And AOT programs are widely known to save public funds, since those most in need of services are also the people who are repeatedly hospitalized, incarcerated and homeless.

Criminalizing the mentally ill is a tragic result of a state mental health system that lacks residential treatment facilities or adequate housing, and strictly limits involuntary treatment. It is a decades-old reaction to the forced detention and abuse of thousands of mentally ill residents in state mental hospitals, which were largely closed in the 1970s, leaving only a few facilities for those deemed criminally insane by the courts.

The “community care” touted as a replacement for the hospitals was largely nonexistent, leaving mentally ill Californians wandering the streets, cycling through hospital ER’s and jails, at huge public and human cost, exponentially worsened during the pandemic.

For nearly two decades,  Laura’s Law has been one of the few legal avenues available to families of severely mentally ill relatives — a non-criminal, civil court process designed to get family members into intensive treatment. While surrounded by counties with successful Laura’s Law programs, Sacramento County has steadfastly refused to adopt AOT, one of only two large California counties – the other is Santa Clara — without a Laura’s Law program.

Christine Hopper sleeping in a park in January. (Photo: Hopper family)

Now estimated to cover 65-to-70 percent of California’s population in 20 counties, the 2002 law is named for Laura Wilcox, a 19-year-old college student and high school valedictorian, who was killed in 2001 by a deranged mental patient in a Nevada County mental health clinic where she worked.

Although her killer’s family had been trying for weeks to warn local mental-health authorities about his alarming mental decline, the family (including a brother who was a Sacramento police sergeant) was ignored, and Scott Thorpe went on to kill two more in that rampage, seriously injuring three. In a lengthy, expensive court process, he ultimately pleaded Not Guilty by reason of Insanity, and will likely spend the rest of his life in Napa State Hospital for the criminally insane.

Amanda and Nick Wilcox, Laura’s parents, channeled their grief into changing the law, testifying in California and throughout the country for measures to reform mental health and gun laws. Nearly 20 years later, they say they are finally seeing real results, and were honored last year for their work in a California State Assembly ceremony.

They plan to retire this summer, moving to Colorado to be near their two sons. “It’s been a long struggle,” Nick Wilcox said in a recent Capitol Weekly interview about the law that bears their daughter’s name. “The way it’s set up, every county is on its own, so there has to be advocacy, holding [county officials] accountable, holding their feet to the fire.”

The original Laura’s Law, by then-state Assemblywoman Helen Thomson, D-Davis, a former psychiatric nurse and Yolo County Supervisor, is based on New York’s “Kendra’s Law,” named for a young woman pushed from a subway platform into the path of a moving train by a mental patient with more than a dozen previous psychiatric hospitalizations, one just six weeks before 32-year-old Kendra Webdale, a journalist from Buffalo, was killed in 1999. Forty-six states now have some form of AOT.

Intense debate in counties lacking ‘Laura’s Law’
Until this year, California counties could choose to quietly “opt out” of Laura’s Law, with limited or no public notice. Those counties that chose to “opt in” have shown significant cost savings and reductions in hospitalizations, incarceration and homelessness for a small subset of severely mentally ill people who refuse treatment. Many don’t acknowledge they are sick – a condition called anosognosia – and often “self-medicate” with street drugs.

But with the unanimous passage last year of AB 1976, by then-Assemblywoman (now state Senator) Susan Talamantes Eggman, D-Stockton, a former social worker and Sacramento State University social work professor, the law was considerably strengthened and finally made permanent, eliminating a “sunset” provision that required hearings every five years.

Counties can no longer “opt out” without providing specific reasons to the state Department of Health Care Services, which oversees Laura’s Law compliance in the counties. Perhaps most important, under the new law, county Behavioral Health Departments and Boards of Supervisors must hold public hearings.

With a May 2 deadline for submission of AOT plans to the state – or county board resolutions to “opt out” – counties throughout California are debating whether to adopt Laura’s Law. Nowhere is that debate more intense than in Sacramento and Santa Clara counties, where county officials and mental health advocates are speaking out in myriad, often heated public discussions that began in February, intensifying in March and April.

All of the public debate is virtual during COVID, and AOT supporters say much of it is controlled by county behavioral health officials long opposed to Laura’s Law. They complain that “public-input” hearings have been perfunctory and limited, with lengthy presentations, mainly on programs other than AOT, by local mental-health officials. Depending on the format in each county, public comments and questions have often been relegated to virtual, small-group “brainstorming” sessions and written submissions or completion of an online survey.

In two recent Sacramento County “community input” Zoom sessions on March 15 and 16, each one-hour hearing ended abruptly after 30 minutes, following brief presentations by county behavioral health officials, who provided short answers to a small number of questions posed by only a few of the many citizens who had signed up to participate (according to the county, 180 people signed up for the March 15 and 16 hearings).

At the end of each hearing, a link was provided to a survey in which to submit comments, and survey links were also sent by email, with 172 responses by March 22 — 74 percent supporting creation of an AOT program. County mental-health officials are reportedly planning another “public forum” in the coming weeks as a result of complaints from advocates and at least one county supervisor.

“Nearly 100 people participated [in the March 16 meeting], yet only a few questions were responded to,” said Carol Stanchfield, who has long directed California’s first Laura’s Law program, in Nevada County, under a contract with Turning Point Community Programs, a highly regarded nonprofit. “I asked multiple questions, but none were addressed.” She said the lack of public input prompts “many people to believe that Sacramento County Behavioral Health lacks the intent, or the will, to objectively consider AOT.”

Stanchfield’s objections mirrored many who signed up to testify and were troubled by the local limitations on a public-hearing process required by the new law. “There must be meaningful opportunity” for public comment under AB 1976, said Randall Hagar, longtime legislative advocate for the California Psychiatric Association, which sponsored the measure. While a “specific procedure” for public comment is not described in the law, he said many of the county hearings “clearly violate the spirit of the law. It’s supposed to be a robust public discussion, and this is turning out to be anything but.”

Next: Dispute intensifies over new Laura’s Law requirements as state deadlines loom. Click here for Part 2.

 Editor’s Note: Corrects spelling to Christine sted Christina throughout. 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.

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.

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