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Passing ‘grave disability’ reform was hard – getting counties to implement it has been harder

Family members from throughout California converged on the state Capitol on Jan. 31st to protest delays in implementation of a landmark new law, SB 43 by Sen. Susan Eggman, D-Stockton. Passed last year with broad, bipartisan support, the new law expands the definition of “grave disability” in determining whether a severely mentally ill person who is clearly unable to care for themselves and/or is addicted to drugs, can be compelled to receive treatment. This is the latest in a continuing Capitol Weekly series on major changes in California’s patchwork system of mental health care.  

Diana Staros died at 28 after overdosing in the restroom of an East Oakland laundromat last September. She had been addicted to methamphetamine since she was in her late teens, likely “self-medicating” to escape the persistent voices in her head. Among her many delusions, she insisted she was pregnant (she wasn’t) and that meth was “good for the baby.” Toward the end, she said it was good for her too, and that doctors recommended it.

Diana Staros in 2010. Photo courtesy of Alison Monroe

Her last dose of methamphetamine, on Sept. 27, was laced with highly potent, deadly fentanyl – reportedly not her drug of choice – and she lingered on life support in Highland Hospital until she was declared legally dead on Oct. 4, kept on life support for several more days to harvest her organs.

 

Diagnosed in her late teens with schizophrenia and schizoaffective disorder – serious mental illnesses characterized by delusions and erratic behavior, treatable with medication – she had been in dozens of psychiatric facilities, treatment centers, group homes and shelters in the decade preceding her death. Those usually short, frequently repeated stays were interspersed with long periods of homelessness and several arrests.

More consistent – and longer – treatment was strictly limited by a 1967 state law, Lanterman-Petris-Short (LPS) which severely restricts “involuntary treatment.” Senate Bill 43, by state Sen. Susan Talamantes Eggman, D-Stockton, passed last year, is the first major LPS reform, expanding the limited standards for “grave disability” which have governed mental health care in California for more than 50 years, consigning thousands to repeated hospitalizations, jail, and the streets.

Staros’ childhood and early teens were fraught with family tragedy and frequent moves. Born in Russia to Russian-American parents, she was 10 when her American mother died of an aneurysm. She moved as a young teen, with her brother and sister, and later her father, to Pinole in Contra Costa County.  When she was 15, her father returned to Russia, and she lived with her aunts in Pinole and El Cerrito. She had dual citizenship, and was returned to Russia by her aunts to live with her older half-brother.

“Diana and her siblings (two brothers and a sister) were very troublesome teenagers,” says Monroe, a well-known Alameda County mental health activist. “She was my son’s girlfriend in high school, and she wanted to come live with us, but her relatives wanted her to go back to Russia. I asked them if I could bring her back to the U.S., and they said only if I agreed to be her legal guardian.”

After returning from Russia, Staros lived with Monroe (who became her legal guardian in 2012) in her Oakland home for several years, attending Oakland Technical High School. She began to experience anxiety attacks, and was initially diagnosed with PTSD. Serious mental illness commonly strikes in late teens or early adulthood, and she became increasingly psychotic, starting her meth use a few months later.

More consistent – and longer – treatment was strictly limited by a 1967 state law, Lanterman-Petris-Short (LPS) which severely restricts “involuntary treatment.”

When hospitalized for longer periods, Monroe said, she would stabilize and become more rational, only to be released to a loosely supervised group home or shelter or the streets, where she would stop taking her psychiatric meds and resume using meth. This despite the fact that she was often under a county conservatorship – as she was when she died.

“She needed to be in a locked facility,” Monroe said. “She was medication-compliant for two years when hospitalized at Villa Fairmont, a locked mental health recovery facility in San Leandro. She still had delusions, but when she was in a locked facility she took her psych meds and did not use meth, except once in a while when it was smuggled in.

“I had repeatedly told [Alameda County officials] that she would die if she could not be kept from meth. I told them that in the last few weeks of her life, when she was under a county conservatorship. They did not put her in a locked facility, or a supportive unlocked facility. Instead, they put her in an unlocked, adult residential facility in Oakland called ‘Great Expectation’, with almost no activities other than watching TV.” It would be her last placement.

Diana in September 2023, shortly before her death. Photo courtesy of Alison Monroe

Like most group homes, licensed or not (and many are not, as the number of state-licensed homes dwindles due to rising real estate costs), residents are allowed to leave. She had been placed in several such homes or shelters over the years, but she would often leave, wandering the streets of Oakland, sometimes hanging out in San Francisco’s notorious open-air drug markets in the crime-ridden Tenderloin.

Monroe would frequently set out to find her.  “I found her in People’s Park [in Berkeley] once, and walking down Telegraph Avenue. . . She would call me and ask me to pick her up, in Oakland, San Francisco, once in Tracy, where she was with a guy who was planning to traffic her (prostitution) in another city in the Central Valley.”

The tragically common revolving-door pattern of brief hospitalization, limited (or no) treatment, followed by release, would be endlessly repeated at huge public and human cost. She would frequently come home during her years of hospitalizations, homelessness and arrests. But she never stayed long, always searching for her next fix.

“She’d say she had to go somewhere, which meant she had to get meth,” Monroe says.

Monroe has kept a detailed, 13-year timeline of Staros’ descent into the medical and bureaucratic quagmire which passes for a mental health system in California. With multiple Bachelor’s and Master’s degrees in English and Creative Writing, Energy and Natural Resources from UC-Davis and UC-Berkeley, Monroe has worked as a writer and editor for online media. She is an articulate and vocal mental-health advocate, sending letters to county and state officials, writing articles, speaking at legislative hearings and demonstrations, repeatedly insisting on better care – any care – for Staros, and just as repeatedly being rebuffed by Alameda County mental health officials.

The tragically common revolving-door pattern of brief hospitalization, limited (or no) treatment, followed by release, would be endlessly repeated at huge public and human cost.

“I don’t know why the county went after me, probably because I complained a lot, wrote letters,” Monroe said in interviews with Capitol Weekly. “The county would refuse to talk to me – or even allow me to visit her when she was brain-dead in the hospital, although I managed to do that anyway, and was with her when she was declared dead. They told me she wasn’t my daughter, and this wasn’t ‘my business’.”

Alexis Gabriel, public information manager for Alameda County, declined to comment on the Staros case, “due to confidentiality laws.”

Like so many families of severely mentally ill and drug-addicted adult children, nothing Monroe did – not the letters and articles, nor the calls and public testimony – seemed to have lasting impact as Staros was propelled to an early death in a failed system.

“They always told me they couldn’t keep her forever,” Monroe says.

Monroe believes the expanded “grave disability” standards in SB 43 would have helped, since they include substance abuse and/or serious mental illness, as well as the inability to care for one’s physical health.

“Diana was physically unsafe, shooting drugs, getting abscesses, having sex,” she says. “They were always having to patch her up at a hospital.”

Thus far, only two counties have not delayed adoption of the new standards. San Francisco is actively implementing SB 43 this year, strongly supported by Mayor London Breed.

San Luis Obispo County Behavioral Health Director Dr. Star Graber, a psychologist who has been with the department for 35 years, previously managing drug and alcohol services, told Capitol Weekly the county “will not delay” and is working to implement the new standards.

“We are training mobile crisis [teams] to recognize co-occurring substance use disorders and mental health conditions, many of which are interwoven,” she said in an interview. “We do need more staff to do this, there will be an impact in the public guardian arena. But we are working together – and that’s the key – with the hospitals, family members and individuals to lay out different choices for treatment.”

Long ignored or blocked by local officials and confusing laws – while tacitly expected to provide care for severely mentally ill relatives – families are mobilizing in growing numbers, exerting major influence over state legislation and public policy, and protesting county resistance to strong new laws mandating intervention, care and treatment.

Counties insist that a spate of new laws fails to recognize the lack of “infrastructure” – facilities, beds, staff. And disability rights groups continue to condemn any form of “involuntary treatment.” Families acknowledge those concerns, but point to a broken system with little accountability or data collection, despite huge infusions of funding for mental health and homelessness in recent years. And they say critics who support that failed system are short on alternatives.

Monroe’s legal guardianship officially ended when Staros turned 18, although Monroe repeatedly offered to serve as her guardian, once spending $8,000 on a lawyer to help her get a conservatorship, which she said Alameda County refused to approve. Staros was under a county conservatorship when she died, Monroe said, and had previously been conserved by the county, only to be removed and then reinstated.

Monroe believes the expanded “grave disability” standards in SB 43 would have helped, since they include substance abuse and/or serious mental illness, as well as the inability to care for one’s physical health.

Conservatorships are a major part of SB 43, if other treatment methods are unsuccessful. Local officials say county Public Guardian offices are woefully understaffed, and argue that implementation of the expanded grave disability standards must be delayed until the required, statewide adoption in January 2026, so they can develop programs.

“It’s unnecessary to go to the extreme of waiting two years when there are so many people who could be helped by SB 43,” said Randall Hagar, a veteran legislative advocate who represents psychiatrists, and has helped write much of the important mental-health legislation passed in recent years. “The counties should be working harder to make that happen. No one is begrudging them the fact that they need more beds, more facilities, but the needs are dire and urgent and should be addressed now.”

Counties are particularly resistant to the addition in SB 43 of substance abuse treatment as part of the bill. “That’s the part that is giving the counties heartburn,” says Hagar. “They haven’t developed programs, they haven’t prepared for this. Yet the crossover [the combination of mental illness and substance abuse] is huge. . .There is always going to be anxiety and depression when you’re on some sort of drug, which can cause psychotic reactions. Meth certainly, even marijuana if used heavily.

“We’ve been hearing the same refrain from the counties for decades. These are people they already know, and they could bring them in even with the previous, restricted criteria. Many of them have been in and out of the county system for years. It’s not as if they just dropped in from Mars.”

Many legislators and public officials – including Eggman, a former social worker and Social Work professor at California State University, Sacramento, who is the author of many major mental-health laws in her nearly 12 years in the Legislature – strongly urge immediate adoption of SB 43, which was originally written to take effect this year.

“I don’t see why all counties could not at least get started,” former state Senate President pro Tem and current Sacramento Mayor Darrell Steinberg, the author of major mental health legislation over decades, told Capitol Weekly. “There are people on our streets who obviously meet the criteria and are in need of help now. We don’t have the luxury of waiting until all the pieces are perfectly built out. . .That ignores the suffering of people on the streets who need help now.

“You can write the most impressive laws, but their success is dependent, not only on the words of the law itself, but more importantly, how it is implemented. It’s not a binary choice. We need to get started.”

Calling the measure the “most significant reform of Lanterman-Petris-Short since it was passed in 1967,” David Stammerjohan, Eggman’s chief of staff, acknowledged that “counties have had a lot thrown at them.” Many major mental health reforms have been enacted by the Legislature, and introduced by Gov. Gavin Newsom, who has made mental health and homelessness his signature issues.

“It’s a challenging task to work a bill like this through the Legislature, and one of those challenges was delaying implementation,” Stammerjohan said. “Earlier implementation is a local decision. It’s frustrating that more counties aren’t adopting it.”

Eggman’s office has long worked with families on mental health reforms, and Stammerjohan praised family members for their persistent advocacy. He said many reforms “would not have happened” without family involvement.

Newsom has been particularly critical of county delays in adopting the new standards, holding a December press conference in which he strongly criticized counties for the delays. “The state has done its job,” he said. “It’s time for the counties to do their job.”

Despite its strong, bipartisan support, the original measure was amended only in the final, chaotic weeks of the session last year, the deadline extended to ensure passage – after fierce objections by the counties, represented by the influential California Behavioral Health Directors Association (CBHDA).

CBHDA Director Michelle Doty Cabrera responded to Capitol Weekly’s repeated requests for comment on the delays with a brief emailed statement sent through the association’s designated media representative, Sacramento public affairs firm Paschal/Roth.

“You can write the most impressive laws, but their success is dependent, not only on the words of the law itself, but more importantly, how it is implemented. It’s not a binary choice. We need to get started.”

“With SB 43 signed just three months ago, counties immediately began efforts to implement substantial legal changes and significantly expand physical and workforce capacity under the new law,” she said. “The Legislature recognized the complexity of the expansion by giving counties until Jan. 1, 2026 to fully implement.”

Kaino Hopper is a veteran Sacramento mental health advocate and mother of an adult daughter with schizoaffective disorder. For the past decade, Christine Hopper, 34, has been in and out (mostly out) of disparate county treatment programs, sleeping in parks, on the street, in jail, despite her family’s persistent efforts to help her get consistent treatment.

Hopper is getting to be an old hand at Capitol demonstrations, as coalitions of family members like her are increasingly influencing legislation and generating media attention. She is an organizer of the Jan. 31st Capitol demonstration, which included a visit to CBHDA’s downtown headquarters, much like another Capitol demonstration last year for mental health reform by the same consortium of advocacy groups, who walked to the downtown offices of Disability Rights California (DRC), which has long opposed involuntary treatment of any kind.

When the large, peaceful group – mostly family members displaying signs with photos of their mentally ill relatives, often adult children, many of them dead from untreated mental illness – arrived at DRC offices, they found a locked, darkened building. After widespread media coverage, including photos of the group standing in front of the locked, darkened DRC offices, DRC officials apologized, and later met with the group.

“Every day that we don’t have the modernized version of SB 43 will lead to tragedy, loss of freedom, incarceration, and loss of life,” Hopper says. “The counties say they aren’t ready. But they do have services.

“You can’t help someone unless they’re alive. We can’t even consider recovery if they’re dying on the street, or in a back bedroom. We have to do it differently. And soon.”

Editor’s Note: Sigrid Bathen is an award-winning Sacramento journalist who has long covered mental health issues, for several publications. She has written for Capitol Weekly since 2005. www.sigridbathen.com

The Capitol Weekly interview: Sen. Susan Eggman’s long battle for mental health reform

Widely regarded as the most knowledgeable and effective state legislator on mental health issues in the Legislature, Sen. Susan Talamantes Eggman (D-Stockton) is credited with major, bipartisan legislative accomplishments over nearly 12 years, first in the Assembly, now in the Senate, where she chairs the Senate Health Committee.

Despite bipartisan and often unanimous support, there has also been intense opposition, mainly from disability rights groups opposed to any kind of “involuntary” treatment and counties concerned about funding and deadlines. Two major Eggman bills are currently before the Legislature, in the final days of the legislative session, reportedly well on their way to passage and the governor’s desk, after facing procedural hurdles and last-minute amendments.

 

The Legislature adjourns on Sept. 14.

“She’s risen to meet every challenge no matter how daunting,” says veteran legislative advocate Randall Hagar, who represents psychiatrists and has helped write much of the state’s mental health legislation. “There’s no pretense or calculation with Susan. She has profound lived experience, lending her great credibility. And she’s a straight shooter, able to inspire others to see and believe in her vision.”

Eggman championed a major bill in 2020 to significantly strengthen the two-decades-old Laura’s Law (Assisted Outpatient Treatment or AOT). Named for Laura Wilcox, a 19-year-old college student working in a Nevada County mental health clinic who was gunned down in 2001 by a deranged mental patient whose family’s pleas for intervention were ignored by clinic officials, it is one of the few legal avenues for family members attempting to help mentally ill relatives.

Most states now have AOT programs, which have been increasingly successful in getting treatment for severely mentally ill people throughout the country, generally voluntarily. Treatment programs are overseen by civil rather than criminal courts, before someone ends up in jail or prison as a result of untreated mental illness.

Under the original law passed in 2002, counties could quietly “opt out” of Laura’s Law, as many did, with no public hearings. The 2020 Eggman legislation required hearings for counties to “opt out,” generating a flurry of contentious local public hearings that resulted in widespread adoption of AOT programs in California counties.

Partly based on Laura’s Law, the even broader Community Assistance, Recovery, and Empowerment (CARE) Act, co-authored by Eggman and Sen. Tom Umberg (D-Santa Ana) and strongly backed by Gov. Gavin Newsom, was passed last year. Unlike Laura’s Law, the CARE Act is required statewide, with financial sanctions for counties that fail to create programs. Newsom has made mental health reform – and substantial, related funding – a centerpiece of his administration.

Rolling out in eight California counties by the end of this year, statewide in 2024, the CARE Act requires counties to create a new system of civil courts to oversee intervention, treatment and housing for thousands of severely mentally ill Californians wandering the streets, cycling through hospital ER’s, or in jails and prisons ill-equipped to help them.

Newsom has said he does not plan to attempt major changes in the 1967 Lanterman-Petris-Short Act that has governed mental health care in California for more than 50 years. But Eggman has introduced many bills over the years to modify LPS’ strict restrictions, and most new programs are voluntary. Many have passed and been signed by the governor.

Eggman has repeatedly – and this year, apparently successfully – attempted to expand the extremely restrictive LPS definition of “grave disability,” which mental health advocates say prevents meaningful intervention and treatment, too often leaving people to die on the streets.

Expansion of the “grave disability” standard under Eggman’s SB 43 includes substance abuse, which often accompanies and exacerbates severe mental illness, as well as the inability to care for oneself. The measure is key to Eggman’s legislative package, with several co-authors and broad, bipartisan support.

Eggman has repeatedly – and this year, apparently successfully – attempted to expand the extremely restrictive LPS definition of “grave disability,” which mental health advocates say prevents meaningful intervention and treatment, too often leaving people to die on the streets.

While Newsom has not specifically stated his position on the bill, it is expected to pass and be signed by the governor. Intense, often behind-the-scenes negotiations – mainly over the timeline for implementation of the new standards – continued well into the chaotic final weeks of the legislative session. Ultimately, in last-minute amendments, the timeline for counties to adopt the expanded standards became “optional” in 2024, but mandatory by Jan. 1, 2026. Counties resisted earlier deadlines favored by advocates.

One of Eggman’s most controversial measures this year is SB 326 (the Behavioral Health Modernization Act)  to update the landmark Mental Health Services Act (MHSA), the so-called “millionaire’s tax” passed in 2004 as Proposition 63. Despite strong support, it continued to face major hurdles in the waning days of the legislative session, and vocal opposition from disability rights groups and counties concerned about funding.

The legislation is tied to a proposed $4.68 billion bond measure, the Behavioral Health Infrastructure Bond Act, AB 531 by Assemblywoman Jacqui Irwin, D-Thousand Oaks, co-authored by Eggman. Both bills are central to Gov. Newsom’s efforts to address California’s growing mental health, homelessness and substance abuse crisis, and are expected to be combined as a single measure, Proposition 1, targeted for the March ballot.

A licensed clinical social worker with a PhD in social work, Eggman, 62, is a tenured professor of Social Work at California State University, Sacramento. A longtime community activist, she was the first Latina and the first lesbian to be elected to the Stockton City Council in 2006, in a surprise upset victory following a tough campaign replete with rank homophobia.

She was born in Castro Valley, and raised in Turlock, Stanislaus County, where her family owned a small almond orchard and apiary (bee-keeping). Her interest in mental health issues developed while working at a psychiatric facility during her senior year at Turlock High School. After graduating, and from a family of veterans, she joined the U.S. Army at 18, training as a medic. After four years in the Army, she earned a Bachelor’s degree in Psychology and a Master’s in Social Work at California State University, Stanislaus, later completing a PhD in Social Work at Portland State University.

She wrote her doctoral dissertation on end-of-life care for Latinos. Her mother was her research assistant, and Eggman worked as a medical social worker with patients in hospice care at the University of Oregon Hospital (now Oregon Health and Science University, a trauma center and teaching hospital). She started her PhD program in 1997, when Oregon’s landmark end-of-life bill – the Death with Dignity Act – was taking effect.

Eggman was teaching at Sacramento State when she won a seat in the California State Assembly in 2012. Among her major bills during eight years in the Assembly was California’s 2015 End of Life Option Act, which for the first time gave terminally ill patients the right to end their lives. She was easily elected to the Senate in 2020.

And she is true to her three-generation family roots in agriculture and natural resources, serving on the Senate committees on Natural Resources and Water, and Energy, Utilities and Communication, and authoring a 2018 bill while in the Assembly to provide funding for solar energy in disadvantaged communities.

She lives in Stockton with her partner of more than 30 years, Renee Hall (they were married in 2014) and their 15-year-old daughter Eme.

Eggman is termed out of the Senate next year. She plans to continue her mental health advocacy and perhaps return to teaching at Sacramento State, or possibly run for statewide office.

Editor’s Note: Sen. Eggman was interviewed on Aug. 15 in her state Capitol office by Sacramento journalist Sigrid Bathen. The interview has been lightly edited for clarity:

CW: In the final weeks of the current legislative session, two of your major mental health bills are pending final approval, both with bipartisan, often unanimous support. One of the most controversial measures is SB 326, to update the Mental Health Services Act (MHSA), the so-called “millionaire’s tax” passed in 2004 as Prop. 63. Despite strong support, it has faced major hurdles, and opposition from counties and disability rights groups. It is tied to a proposed $4.68 billion bond measure which is central to Gov. Newsom’s ongoing efforts to address California’s growing mental health and homelessness crisis. Comment?

Eggman: We have been working with all of the stakeholders in this (SB 326), trying to get it right, and one of the things we have repeatedly said – and Dr. Ghaly (state Health and Human Services Director Dr. Mark Ghaly) has been very firm on this – if you can show us what is not going to be funded, we can have a conversation.

Oftentimes, there is fear about things not getting funding, but when you really look at it, the funding may be in a different “bucket.” We are prioritizing people with higher needs.

CW: MHSA has been in place for nearly two decades, raising billions for mental health, but with persistent concerns about accountability, how the money has been spent, whether it is reaching those who most need help, how the counties are – or are not – managing this huge funding stream. How will that change with SB 326?  

Eggman: I think both myself and the governor are pretty unabashed in saying we are making those with the greatest need a higher priority for all of this taxpayer money, and all other [state and local programs] need to be utilized before we go to MHSA money, in order to be able to focus on those with the higher needs. . . We need to be sure that the counties aren’t automatically using MHSA money when there are other sources of funding.

CW: Mental health funding is notoriously complex, and opaque, with multiple funding streams and inconsistent follow-up, data collection, accountability. How has recent legislation improved – or will improve – the existing system?

Eggman: There are more federal and private dollars available than historically. . .The treatments have evolved. Newer medications are much more effective. Most kids are on some kind of insurance plan and/or on Medi-Cal, which now reimburses for a lot of things they did not before, so we want to be sure the counties aren’t just automatically using MHSA money, when you can pull in federal dollars, private dollars for a lot more than we have historically been doing.

CW: How have the state’s ongoing Cal-AIM reforms (California Advancing and Innovating Medi-Cal), a multi-year state program to improve Medi-Cal services, and coordinate with other services, been incorporated into mental health reform?

Eggman: Cal-AIM is a major component of this, and we would be remiss not to discuss the importance of programs such as Cal-AIM, CARE Court and SB 43 [to expand the definition of grave disability]. It just makes perfect sense to talk about a re-do of MHSA, as that is a major funding and care stream. Add CARE Court to the continuum of care, the Cal-AIM re-do, it makes much more sense to talk about the re-do of MHSA.

CW: Although most mental health funding is state and federal, the counties are responsible for providing mental health care at the local level. But county behavioral/mental health departments – and influential statewide advocacy associations of counties and local mental health directors – are often criticized for “foot-dragging,” opposing reforms, and bureaucratic delays in implementation of state-mandated programs. Comment?

Eggman: I think anytime we change systems, it’s hard, especially in something as big and complex as the behavioral health system in a state with 40 million people. There were articles in the 1980s about Lanterman-Petris-Short (LPS), and about grave disability, and how, “oh my God, we got it so wrong.” We could already see the growing number of people on the streets, coming from the state hospitals, but there was no thought about housing.

CW: As the state hospitals were closing in the 1960s and ‘70s, the Lanterman Act, by Frank Lanterman, a co-author of LPS, helped to create a statewide Regional Center system of care for developmentally disabled residents discharged from state hospitals. No such system was created for the mentally ill population, leading to the crisis we see today on the streets, in hospital ER’s, jails and prisons. That Regional Center system provides statewide placement and treatment options, which many advocates say should be the model for a similar system to house and treat mentally ill people.

Eggman: That’s what we’re talking about with the bond portion of [SB 326 and AB 531], to build out those villages and cottages that should have been built a long time ago, but never were. (Editor’s Note: The two bills are expected to be combined as Proposition 1, for the March ballot).

There will always be those among us who will need supportive care, who are not going to be able to live totally independently. As you said, we have accepted that with the developmentally disabled community. We have not accepted it as well with the mental health community.

I think anytime we change systems, it’s hard, especially in something as big and complex as the behavioral health system in a state with 40 million people.

CW: Then you factor in substance abuse, which often accompanies – and exacerbates – severe mental illness. . .The importance of treating “dual diagnosis” (mental illness and substance abuse) was poorly acknowledged in mental health care for decades, and that disconnect persists today.

Eggman: When the initial LPS law was created, there was a provision for substance abuse, but only for alcoholism. Why not include a more broad definition of substance abuse? Which is what we’re trying to do now with SB 43, for people who are found to be gravely disabled by severe substance abuse, such as the severe psychosis often induced by methamphetamine. And in SB 326, we say explicitly that you can also use that funding for substance abuse in addition to mental health.

CW: You have been instrumental in strengthening provisions of Laura’s Law, the 2002 legislation  that provided one of the few avenues for family members to get help for severely mentally ill relatives, but originally allowed counties to “opt out” – quietly, without public discussion. Partly based on the civil-court system created in Laura’s Law (by then-Assemblywoman Helen Thomson, D-Davis), counties are required to establish CARE Courts, and there are financial sanctions if counties fail to comply with the law.

Eggman: Yes, $1,000 a day. . .

CW: How is the CARE Act rollout progressing – in eight counties by the end of this year, the rest of the state next year? The state Health and Human Services agency is coordinating a series of statewide CARE Act “working groups,” involving a wide range of mental health providers and advocates, legal experts, many others.   

Eggman: We have the working groups, which are ongoing [to implement the CARE Act], but we’re not there yet.

CW: Much of your mental health legislation in recent years has gone through the policy committees and both houses of the Legislature with unanimous or near-unanimous bipartisan support. But until recently, some, including a measure last year to expand grave disability standards, were blocked by committee chairs and never heard by the full committee, over concerns about “involuntary” treatment.

Eggman: There were a few abstentions but we didn’t have any no votes this year on SB 43 in any policy committee or on the floor. (Editor’s Note: SB 43 now includes amendments that counties can “opt out” in 2024, but must do so publicly, and the new standards must be adopted statewide by Jan. 1, 2026).

CW: Historically, LPS reform measures have often failed over the years in the Legislature, which tends to regard LPS as the “third rail” of mental health policy in California. Why is the grave disability definition so important in getting severely mentally ill people off the streets and into treatment? And why has that been so difficult to do? The governor has said he decided not to attempt to change LPS because of the volatile nature of LPS debate.

Eggman: I don’t think he (Newsom) thought we could do it before. Sometimes you have to dream and other times you have to try to do what is politically possible. But SB 43 is a major reform.

CW: In the Assembly, but not in the Senate, committee chairs could block a bill by refusing to hear it, which is what happened to your bill last year to expand the definition of grave disability under LPS. While the bill had wide support, it was blocked by the chair toward the end of the legislative process, which happened to other bills despite broad bipartisan support.

Eggman: That’s correct. We couldn’t get a hearing before the former Assembly Judiciary chair on the grave disability bill. A lot of my mental health bills couldn’t get a hearing before the former Judiciary chair (Assemblyman Mark Stone (D-Santa Cruz), since retired, who opposed any “involuntary” treatment).

CW: New Assembly Speaker Robert Rivas reportedly plans a different approach than the previous speaker, Anthony Rendon, playing a more active role in determining the legislative agenda in the Assembly.

Eggman: I approached him very early-on, before the transition. I said this is very important to me, where are you going to be? And he expressed nothing but support.

CW: LPS was passed following decades of controversy over state mental hospitals, where mentally and developmentally disabled individuals could be detained indefinitely without consent and little treatment. Those concerns about “forced” treatment remain the principal opposition to LPS reform today. The community care that was to replace the hospitals never happened, a direct precursor to the crisis on our streets today. Comment?

Sometimes you have to dream and other times you have to try to do what is politically possible. But SB 43 is a major reform.

Eggman: Everyone would agree, voluntary treatment is best. I never argue with that. This whole idea of “forced” treatment, is not correct, there are many legal protections in the CARE Act. If you’re unable to provide for your own self-protection, your medical care, and you’re suffering and don’t even know that you are ill, then it is only compassionate and humane to provide treatment until you can make the right decisions.

People die every single day. This heat wave we’re having right now, people will die, because they don’t understand that it’s too hot and they shouldn’t be outside. And they don’t have other options, or hydration, they have infections, get dehydrated. People will die. . .It goes on and on and on. . ..

If you ask average Californians, legislators, as I have, they agree that the current system isn’t working.

CW: Should there be a re-thinking of the role of state hospitals? Some provided important programs, treatment, although most were closed in the 1960s and 1970s.

Eggman: The hospitals had recreational activities, they had community, food, shelter. . .Our state hospitals are now basically only treating those deemed [criminally insane] or incompetent to stand trial.

I don’t think we’re going to change anything overnight, but I do think with all the reforms, [that] eventually the burden upon closing the state hospitals will change, and we will open up more capacity for more current treatment, to help people earlier, before they get so sick or hurt other people. Like the young man in Davis. Clearly, this young man just spiraled down, in front of everybody. And killed two people. (Editor’s Note: Carlos Dominguez, charged with murdering two Davis residents and attempting to kill a third, has been declared Incompetent to Stand Trial and is awaiting court-ordered mental competency treatment.)

CW: Family members attempting to get help for mentally ill relatives – often adult children – say they have been historically ignored in policy debates, although that is changing as family members organize and demonstrate, demanding inclusion and recognition of their roles as default caregivers, advocates, with no support or even acknowledgement. Comment?

Eggman: The narratives, and the telling of family stories, have always been powerful. We hear from Disability Rights, and they’re always speaking for people who are not there with them, for the most part. Family members I think speak from a reality-focused place. As we’ve let our mental health system spiral out of control, there are more and more of those who have experience with somebody who is very ill, and/or have experience with a family member who has struggled to get somebody help, and there just don’t seem to be any avenues. The saturation of those kinds of stories make people think, oh, yeah. . .

CW: How does your background as a social worker and college professor – and family member (your aunt, who died on the streets of San Francisco) – inform your work as a legislator?

Eggman: I think all of those things make me the human being that I am, and that’s a lot of years of experience to bring to the process, and the workplace – because this is a workplace – and to be as successful as I can to make the greatest good. I term out next year, and I know I have an expiration date on me, and I want to get as much done in order to leave the system in a much better place than it was. I have experience, it would be a sin for me not to use every ounce of energy I have to make as much of a difference as I can, to improve the lives of people all across the country.

I don’t think we’re going to change anything overnight, but I do think with all the reforms, [that] eventually the burden upon closing the state hospitals will change, and we will open up more capacity for more current treatment, to help people earlier, before they get so sick or hurt other people.

CW: What has been the biggest obstacle to advancing meaningful mental health legislation? And what has your approach been to gain broad bipartisan support?

Eggman: I think for me it’s been tenacity, and building relationships. As a social worker, I have to ask myself every day, am I in service, through relationships, to reach that  higher level? If you’re not working for a good, and in service, and you’re not maintaining and sustaining all the relationships that you need to maintain, then you’re not going to make progress. That’s something I’ve always tried to focus on. Because in sustaining and maintaining relationships, we can go far together. The [progress] on mental health issues is a testament to that.

CW: Has it become easier over the years to convince other legislators to adopt mental health reforms?

Eggman: It’s been a very bipartisan journey, and these are relationships I’ve been nurturing for years.

CW: And you bake bread for colleagues.

Eggman: Yes, I bake bread, unabashedly!

CW: What are your future plans?

Eggman: That’s a big question. I will continue to do mental health advocacy. My plan right now is probably to go back to Sacramento State and teach. As you said, I’ve developed a statewide reputation, maybe somebody will have other things for me to do too.

CW: I understand you have a campaign committee for lieutenant governor?

Eggman: Yes. I want to keep my options open.

CW: What do you do to take care of herself after the stresses of work, other than your famous bread-making? 

Eggman: I like audiobooks, I like to cook. I try to get outside, nature really sustains me. We just did a week-long RV trip. I fish. I just took up golfing. Something to get me outside. If I’m outside doing something active, my brain can rest. I have a hard time sometimes shutting off. . .

CW: You have deep personal and professional ties in the San Joaquin Valley, in Stockton, where you live. How is your family?

Eggman: My spouse struggles mightily with health issues – a spinal cancer that resulted in neurologic after-effects, so I’m pretty much a fulltime caregiver too. Every day is a different adventure.

CW: Do you have home health care, or do you care for her yourself.

Eggman: I do it all.

And today, I took our daughter to the first day of her sophomore year in high school!

Editor’s Note: Sigrid Bathen is an award-winning journalist who taught journalism at Sacramento State for 32 years. She is a former Sacramento Bee reporter who has covered mental-health issues for several publications and health care, education and state government for Capitol Weekly since 2005. Her web site is www.sigridbathen.com. She can be reached at mailto:[email protected].

 

The growing push for major action on mental health and homelessness

Brian Bloom was an Alameda County public defender for nearly three decades, part of a specialized mental health unit whose clients suffered from severe mental illness, many unable to understand – or even acknowledge – that they were sick, becoming mired in an overwhelmed criminal justice system ill-equipped to help them.

Often deemed “incompetent to stand trial” by the courts, they stayed in jail, because there was nowhere for them to go, despite judges’ orders that they be released to treatment. The vast network of state mental hospitals, widely criticized as inhumane and abusive – were mostly closed in the 1960s and ‘70s – and those that remain primarily house defendants judged criminally insane, leaving little room for inmates stuck in jails and prisons, awaiting evaluation and treatment.

 

The “community care” touted to replace the hospitals in landmark 1967 “reform” legislation never materialized, and seriously mentally ill patients suddenly discharged after decades in state hospitals, ended up on the streets in a rapidly spiraling homelessness crisis.

This may be the year that changes, as the Newsom administration, state legislators and local officials – pushed by escalating homelessness and the increasing clout of family members – propose major reforms in a broken system of care that many say is no care at all.

A growing chorus of critics say well-intentioned but archaic laws – designed to protect individual rights, with stiff restrictions on what constitutes “grave disability” – prevent desperate families from getting severely mentally ill relatives into treatment, leaving them to suffer and die on the street.

This may be the year that changes, as the Newsom administration, state legislators and local officials – pushed by escalating homelessness and the increasing clout of family members – propose major reforms in a broken system of care that many say is no care at all.

Bloom has long advocated for a “collaborative, coordinated approach” to divert mentally ill defendants to mental health courts, which are among the many “alternative courts” responsible for cases involving mentally ill defendants, often self-medicating with street drugs. And he is a strong supporter of a growing body of state law that encourages – even requires – local intervention and treatment before someone is arrested.

“It requires collaboration among systems that don’t ordinarily have much coordination – prosecutors, public defenders, county mental health, law enforcement – for that to work,” he said, “so that cases are sent directly to mental health court, determining at the outset what level of treatment a person needs, instead of [mentally ill defendants] descending into the criminal justice labyrinth for months, even years.”

In such a model – increasingly supported by public opinion, policy and law – that intervention would be early, swift and coordinated, sometimes facilitated by a civil (not criminal) court judge. “Many people are already in the county system,” Bloom added. “They’ve been arrested before, or hospitalized. It’s not that the counties don’t have experience. Collaborative courts shouldn’t be some kind of fringy thing on the side. They should be the norm.”

Now retired from the public defender’s office, Bloom chairs the Alameda County Mental Health Advisory Board, which advises county officials on how to address a growing crisis in homelessness and mental illness, starkly visible in the mental and physical disintegration of thousands on the streets of Oakland, where the population of homeless residents has mushroomed in the past five years.

It’s one of the worst local crises in a state with the largest concentration of homeless people in the nation, exacerbated by huge disparities between great wealth and grinding poverty. In a 2022 report on homelessness in the U.S., the Department of Housing and Urban Development estimated that 172,000 people were homeless in California in January 2022, a nearly 13% increase since 2019.

Reports on income inequality paint an equally grim picture. “The gap between high- and low-income families in California is among the largest in the nation – exceeding all but four other states in 2020,” the Public Policy of Institute of California said in a recent report. The income gap worsened during the pandemic, and exorbitant housing prices pushed increasing numbers of Californians into homelessness.

Statistics on the percentages of mentally ill people who are homeless – and those in jail – are notoriously unreliable, from one-fourth to one-half, particularly if common “co-occurring” substance abuse is also involved. In many cities, law enforcement is joining with social workers and other mental health clinicians to help de-escalate mental health calls, which too often end in incarceration, injury and death.

As jails and prisons have become the primary source of mental health “treatment” in a broken care system – and homelessness continues to expand despite huge public expenditures – policy-makers struggle with solutions. One of the most far-reaching is Gov. Gavin Newsom’s CARE (Community Assistance, Recovery and Empowerment) Act being rolled out in eight California counties this year, becoming statewide in 2024.

Central to any significant LPS reform is expanding the definition of “grave disability” – the highly restrictive standard for even limited involuntary mental health holds.

Although Newsom did not propose substantive changes to the 1967 Lanterman-Petris-Short (LPS) law that has governed – many say hamstrung – mental health policy for more than five decades, the administration is working with key legislators to address elements of the law that severely restrict interventions to get people off the streets, into treatment, and keep them out of jail.

Central to any significant LPS reform is expanding the definition of “grave disability” – the highly restrictive standard for even limited involuntary mental health holds.

Modest legislation to expand the standard to include physical as well as mental health – and the ability to care for basic health needs – has repeatedly stalled in the Legislature despite broad, often unanimous, bipartisan support among legislators.

Sen. Susan Talamantes Eggman, D-Stockton, a former social worker and college professor who chairs the Senate Health Committee and is widely acknowledged as the state’s legislative leader on mental health legislation, almost succeeded in expanding the grave disability standard in legislation last year. Her SB 1416sailed through the state Senate with bipartisan support, and was unanimously passed by the Assembly Health Committee. But it died without being heard in Assembly Judiciary, then chaired by Assemblyman Mark Stone, D-Santa Cruz.

Long opposed to involuntary treatment, Stone, who has since retired, reportedly utilized an Assembly rule that allows committee chairs to determine whether or not a bill is heard in committee. “No such rule exists in the state Senate, they have to hear it,” says veteran legislative advocate Randall Hagar, who represents psychiatrists and has helped write many mental health bills, spanning decades.

LPS reform supporters are optimistic that new members and leadership changes in the Assembly – including a new Judiciary Committee chair, Assemblyman Brian Maienschein, D-San Diego – will mean more support for reforming the grave disability standard, as well as other related mental-health measures. Maienschein strongly supported Eggman’s bill last year, calling it a “hugely important tool” in reducing homelessness, getting people into treatment.

He pointed to his many years as a San Diego city councilman and as the city-county Homelessness Commissioner, who saw firsthand the human devastation caused by untreated mental illness, substance abuse and homelessness.

“The ability to provide food and shelter (the existing LPS standard for determining whether someone is “gravely disabled”) doesn’t amount to much if you’re dying of lung disease,” he said in an Assembly Health Committee hearing last year, noting increasing deaths “from hypothermia, cardiac arrest, respiratory issues, starvation – all of which are treatable.”

Under current law, local jurisdictions interpret the vague, outdated “grave disability” standard in wildly different ways, either placing people in limited LPS “5150” mental-health holds – a reference to the state Welfare and Institutions Code governing involuntary, 72-hour holds in overcrowded hospital ER’s – or, more often, leaving them to fend for themselves on the streets.

Speaking “as someone who spent much of my professional career walking into these canyons  [where homeless encampments have proliferated in his district], to try to talk somebody into coming in for treatment who is schizophrenic,” Maienschein said, “they believe they’re making decisions in a logical way. It’s not humane to have these individuals on the street where they aren’t getting medical treatment, and are more likely to be victims of crime.

Under current law, local jurisdictions interpret the vague, outdated “grave disability” standard in wildly different ways, either placing people in limited LPS “5150” mental-health holds….or, more often, leaving them to fend for themselves on the streets.

“And I think we would all like to see law enforcement working on different issues than someone urinating in public.”

Eggman is preparing to announce a package of bills in early March, with her major focus on expanding the grave disability standard. Reflecting the distinctly bipartisan push for mental health reform, newly elected state Sen. Roger Niello, R-Sacramento, a former state assemblyman and Sacramento County supervisor, has also introduced a bill, SB 232, to expand the standard. He said he is working with Eggman to craft a bipartisan measure, calling homelessness and mental illness “a very high priority.”

Early in his Senate term, Niello reached out to a longtime colleague, former state Assemblywoman Helen Thomson, D-Davis, also a former Yolo County Supervisor, who championed major mental health legislation during a contentious time in the late ‘90s and early 2000s. She was vilified by other legislators who said her legislation infringed on the civil rights of mentally ill people and by activists who demonstrated loudly on the Capitol lawn, calling her “Nurse Ratched” (the abusive nurse in “One Flew Over the Cuckoo’s Nest”).

The protests nearly derailed Thomson’s most important bill, Laura’s Law, passed in 2002, named for 19-year-old Laura Wilcox, a college student working in a Nevada County mental health clinic when a deranged patient, Scott Thorpe, killed her and two others, seriously injuring three more. Thorpe’s family, including a brother who was a Sacramento police sergeant, had repeatedly attempted to warn local mental health officials about his deterioration, but they refused to listen, much less intervene.

A model for the more expansive CARE Act, Laura’s Law (Assisted Outpatient Treatment or AOT) created a civil-court process for getting seriously mentally people into treatment, ultimately adopted by 31 California counties.

Thomson, a former psychiatric nurse married to a psychiatrist, said expanding the grave disability standard “is the foundation of LPS reform,” noting that public sentiment has significantly shifted over the years as California’s homelessness crisis has escalated. She praised Niello for “stepping out of this terrible ‘we vs. them’ mentality’” in partisan politics.

“I remember observing her attempts to reform LPS,” Niello recalled in an interview with Capitol Weekly. “She was treated very badly. People weren’t ready.”

Niello, who was vice-chair of the Budget Committee when he was in the state Assembly, said homelessness and mental health must be given high priority. “I am not sure the state is facing a greater priority now than homelessness,” he said. “Even though there is a deficit, there is room to fund these programs. We still have a sizable general fund.”

Eggman is preparing to announce a package of bills in early March, with her major focus on expanding the grave disability standard.

While Newsom’s office does not “typically comment on pending legislation,” spokesman Daniel Lopez said in a statement that Eggman, a co-author of the CARE Act, has been “a key partner as the Administration works to implement this paradigm shift in mental health services.” He said the governor “is confident that Senator Eggman’s leadership on this critical issue will continue to deliver thoughtful, empathetic measures that uphold the dignity and rights of those suffering from the most severe forms of mental illness and substance use.”

Managing the complex implementation of the CARE Act is the task of the state Health and Human Services Agency, headed by agency Secretary Dr. Mark Ghaly. The plan – if it’s not blocked by the courts – involves a dizzying array of sometimes resistant state and county agencies, as well as health plans and non-profits that actually implement many local treatment and housing programs. At the first meeting of the 26-member CARE Act Working Group Feb. 14, demonstrators filled the room – mainly family members frustrated by decades of dealing with a patchwork system to get help for severely mentally ill relatives.

The large, peaceful group held a rally at the Capitol before the meeting, and marched to the nearby state offices of Disability Rights California, which is the lead organization attempting to block the CARE Act by filing a lawsuit in the California Supreme Court. A Capitol Weekly reporter arrived a few minutes before the protestors, and the doors were locked. She rang the doorbell, and a receptionist emerged briefly from the darkened offices.

She said nobody would be available to speak with reporters or, presumably, with protestors, who say they have been ignored despite frequent attempts to establish a dialogue. The doors remained locked as the group stood quietly holding signs demanding better care and featuring family members who had died of untreated mental illness and physical decline.

DRC legal director Christian Abasto said in a later phone interview with Capitol Weekly that DRC “listens to all people. We’re glad to meet with any group.”

At the working group meeting, a long line of CARE Act supporters from the demonstrations waited to speak during a “public comment” period at the end of the meeting. They told horrific, deeply personal stories of their attempts, largely unsuccessful, to get help for their severely mentally ill relatives, often adult children. Many strongly objected to the lack of family representation on the working group, and to the inclusion of a DRC representative when DRC is attempting to block the law in court.

Sacramento activist Elizabeth Kaino Hopper, an organizer of the demonstration, spoke about her severely mentally ill daughter, Christine – who had graduated at the top of her class in high school, was about to graduate from UC Davis when her symptoms worsened. She was present with her parents at the Capitol rally.

Christine, 33, was released in January after nine months in jail, declared “incompetent to stand trial,” following years in and out of hospitals, homeless on the streets. Her family struggled to get help, as authorities repeatedly insisted Christine was not “gravely disabled” under the rigid requirements of an outdated law. Her assault case is now in Mental Health Court, and she is receiving intensive treatment in a local program. Charges will be dropped if she completes the program.

“All of this could have been avoided,” her mother said, “had the laws been changed, and the CARE Act in place.”

“Being out is really nice,” Christine told a San Francisco Chronicle reporter at the Capitol rally. “I can see the stars at night. … I’m really happy to be out and lucky to have my mom.”

Editor’s Note: Sigrid Bathen is an award-winning journalist who taught journalism at Sacramento State for 32 years. She is a former Sacramento Bee reporter who has covered mental-health issues for several publications and health care, education and state government for Capitol Weekly since 2005. Her web site is www.sigridbathen.com She can be reached at [email protected]

 

California Health, September 13, 2022

California Health – Panel 2: CARE Courts from Capitol Weekly on Vimeo.

Governor Newsom’s Care Court Proposal

The legislature passed SB1338, which creates the Community Assistance, Recovery and Empowerment (CARE) Court, a new system which could dictate treatment for 7,000-12,000 people suffering from addiction or severe mental illness per year.

Speakers: Corrin Buchanan, California Health and Human Services Agency; Randall Hagar, Psychiatric Physicians Alliance of California; Dr. Le Ondra Clark Harvey, California Council of Community Behavioral Health Agencies; Elizabeth Kaino Hopper, Sacramento Chapter, National Alliance on Mental Illness

Moderated by Sigrid Bathen, Capitol Weekly

View entire event here

Program and Speaker’s Bios available here 

Capitol Weekly Interview: Randall Hagar and mental health care

 

 

 

 

 

Randall Hagar has been in the forefront of major mental health policy and legislation in California for decades. As the father of a severely mentally ill adult son and longtime legislative advocate for California psychiatrists, he has deep knowledge of both family struggles and the complex intricacies of mental health policy.

He represented the California Psychiatric Association for nearly 20 years, and since 2020 represents a successor organization, the Psychiatric Physicians Alliance of California. He also actively advises community groups, families and legislators and has written much of California’s major mental health legislation.

With intense public and legislative interest in mental health this year, dozens of bills affecting a wide range of state and local mental health services have been debated in the state Legislature. The most prominent, comprehensive – and controversial — proposal this year to reform California’s fractured system of care is Gov. Newsom’s CARE Court plan (Community Assistance, Recovery and Empowerment).

Introduced as SB 1338 by Sens. Susan Talamantes Eggman (D-Stockton) and Tom Umberg (D-Santa Ana), the measure was overwhelmingly approved by the state Legislature on Aug. 31, the final day of the session. It would create an entirely new civil court system to get treatment for thousands of severely mentally ill Californians, many living – and dying – on the streets, cycling through hospital emergency rooms and jails.

It also adds $57 million in the 2022-23 state budget for counties to implement programs, and $65 million for the judicial system. Strongly supported by public officials and mental health reform advocates, it has been criticized by disability rights activists as coercive. Billions in additional funding have been included over the past two years for homelessness and mental health treatment. Newsom is expected to sign the bill.

Hagar discusses the long, tortured history of mental health care and policy in California, his own family’s experiences, and the path forward.

He was interviewed beginning on Aug. 17 by Sacramento journalist Sigrid Bathen, who has long covered mental health issues for several publications and is the author of a continuing Capitol Weekly series on mental health. The interviews have been lightly edited and updated.

When did you become interested in mental health advocacy?

I think I caught the buzz from my mother, Phyllis Hagar, who was a first-generation legislative advocate for the Sacramento chapter of the California Mental Health Association. She was a volunteer, a member of the  board of directors, and served on the state legislative council. She was active in the Democratic Party. She testified in the Legislature on mental health issues and prison overcrowding, wrote letters to editors, won awards for her advocacy.

She also suffered from depression and anxiety and was drawn to improving conditions. She became severely depressed, suffered from at least one anxiety disorder, and was twice hospitalized in psychiatric hospitals for several weeks at a time. She and my father, Kenneth, met at Northern Arizona University, and their first teaching jobs were in a one-room school in Rocklin (Placer County). He was a junior high school vice-principal in the San Juan Unified School District in Sacramento County.  She taught second grade in Citrus Heights for 15 years, then quit teaching and devoted her life to serving the mental health association.

How did your mother’s illness affect the family?

She had struggled with her illness for a long time, and as it episodically grew worse, my dad ended up being her caretaker, and, as the oldest son, I became the caretaker for my two younger brothers. As a family, we coped as best we could.

I came home from school one day in the seventh grade, and I went into the back bedroom and found her trying to get the safety off of one of my dad’s pistols. She was obviously intent on putting an end to her suffering. I asked for the gun, called my dad, and she was hospitalized at Sutter Center for Psychiatry. She was prescribed medications, such as they were then (in the 1960s), which didn’t seem to work. So she was subjected to old-fashioned electroconvulsive treatment (ECT). Compared to today, it was pretty crude. But after her second series of treatments, it seemed to work for her, she seemed less depressed, was never depressed in the same way ever again. After the ECT treatments, she had what I thought was OCD (obsessive-compulsive disorder), and started hoarding things. We had stacks of newspaper clippings in our living room, kitchen, her bedroom, pretty much everywhere except the bathrooms. And there were odd thought patterns. But she would still cook dinner, drive a car, other normal activities.

How did you and your brothers cope?

Not real well. I had some anxiety issues of my own, some depression, and was very, very pleased to leave home when I went to UC-Davis in 1970. My youngest brother also got out of the house at an early age, and later died of AIDS in his 30s. My other brother committed suicide in his mid-40s, not long after our mother died in 2009. He suffered from severe depression and anxiety, used heroin, never got sufficient mental health treatment until the last year of his life. But by then he had what I thought was hepatitis and liver cancer. He was in a lot of pain, didn’t want to go on anymore.

Describe your time as a student at UC-Davis.

Like my mom, I almost had more education outside of the classroom than in. At UCD, I got involved w/the Associated Students, doing research on the incursions of the Regents and Chancellors on campus media. Media boards are the designated publishers of student media, and the boards were faculty-dominated, with prior restraint of articles, censorship. There was a lot of “clamping down” on student media, and it became really egregious throughout the UC system. Collectively, the presidents of Associated Students on UC campuses were very receptive to changing the existing bylaws, and I ended up drafting a set of model bylaws. These were eventually adopted by the Regents, giving students majority control on campus media boards, and reducing the dominance of faculty on the boards. I was a member and then chair of the UCD campus media board  under the new bylaws.

I was also working on a degree in behavioral sciences – an individual major which I designed that included anthropology, sociology, psychology and education. After several years at UCD, I took some time off, did more volunteer work, and got together with a group of faculty and students — with the support of Yolo County Mental Health Director Dr. Cap Thomson,  a psychiatrist — to create a halfway house for people living with serious mental illness. They were student age, but their illnesses were pretty severe, and they couldn’t manage being students(Editor’s Note: Thomson’s wife Helen, a former psychiatric nurse, was later elected to the state Assembly, where Hagar worked with her on major mental health legislation).

Students living in the house were to provide positive role models, help residents with daily tasks, teach social skills. One resident had just been released from an inpatient psychiatric unit in Woodland, and one came from a state hospital. Many of the state hospitals (which were largely closed in the 1960s and ‘70s) were still open. . .There were 11 of us in the house, and five of us were enrolled at UCD. It was a cooperative, we cooked meals together, cleaned house.

I received a nominal stipend as the house manager/coordinator. And the work qualified as independent study, for course credit. The house received some county funding, with oversight by a board of directors, and there was community fundraising. Enough funds were raised for a down payment on a house, students paid rent, and residents’ rent was paid with their Social Security and disability benefits. I stayed rent-free as house manager.

I got married before my last quarter at UCD in 1978, and my wife lost her job and found she was pregnant. I had to withdraw from school, didn’t actually get my degree until nearly 20 years later. My son was born in 1979, and I worked various jobs to support my family. His mother and I divorced when he was quite young, and my ex-wife moved to Marin, so I moved there to be closer to my son. He was 15 when he was diagnosed with “psychotic disorder not otherwise specified,” which became a diagnosis of schizophrenia several years later, in 1996. They didn’t – and still don’t — like to do specific diagnoses for under 18. There had been a lot of acting out, drugs, shoplifting, withdrawing from the family, running with a bad crowd. He lived with his mother for a while, but he was too much for her behaviorally, she couldn’t really handle him. So I became pretty much a single father.

I had a varied career during that period, was a waiter in a Japanese sushi bar in Mill Valley, cooked for a children’s center, became a building contractor – my dad had built both of our houses, and I had the skills. I completed my UCD undergrad degree in 1995, and enrolled in coursework for a film program at San Francisco State, for a Master’s in Fine Arts.  Because of family responsibilities, I delayed applying and was not able to follow through.

How did you become involved in mental health advocacy as a career?

When my son was diagnosed, like many family members facing that news, I didn’t know what to do. He was living with me, and I struggled to figure out how to cope with him. I was desperate, and I enrolled in a family education course through the Sacramento chapter of the California Alliance on Mental Illness (the National Alliance on Mental Illness, or NAMI, is an influential organization representing families, with state and local chapters throughout the U.S.), which I learned about when my son had been hospitalized at Sutter. I became a volunteer for the Sacramento chapter,  and I was trained to teach those courses, then became a trainer for other teachers, eventually a national trainer for the first family educators at affiliates in Nevada and Hawaii. The family-to-family courses taught survival skills for family members, understanding how the brain works, communication, coping and advocacy skills. I eventually became the program director for family education in California.

Because of my interest in politics, and my earlier work with the Associated Students at UCD, I started working with psychiatrists on legislative issues. I told them they needed to become members of NAMI, to learn what it’s like on the other side of the fence where the family is. My first issue as a California advocate was to advocate for fair housing, learning the intricacies of the 1968 fair housing amendments to the U.S. Civil Rights Act of 1964.

I became a NAMI-California board member in 1998, and was president of the Sacramento chapter. I couldn’t be both an employee and on the board, so I chose to be actively involved with legislation and chaired the state board’s legislative committee, working with  [then-Assemblywoman] Helen Thomson (D-Davis) on Laura’s Law. (Editor’s Note: Laura’s Law, one of the few legal avenues for family members to get help for mentally ill relatives, was named for 19-year-old Laura Wilcox, who was working in a Nevada County mental health clinic when she was killed in 2000, along with two others, by a clinic patient whose family had tried to warn local mental health officials of his dangerous decline, but were ignored).

How did your experiences with your son inform your work as a legislative advocate?

During my testimony in legislative hearings on Laura’s Law in 2001-02, I said that my son had been arrested in three counties, was homeless for 18 months, hospitalized seven or eight times in five different counties. I was educated, well-connected, and there was nothing I could do. He was totally on his own journey, and I was helpless to keep him in the hospital. I testified that one feature of his life that made a huge impression on me is that until age 18, he was under the jurisdiction of the juvenile court, and a probation officer would regularly come out, interview us both, ask how he was doing, if he was keeping appointments, taking his meds. That was a kind of  structure that kept him from getting into worse trouble. I learned that a legal structure could be very helpful in keeping a person stable and avoiding worse outcomes. But when he turned 18, and was no longer under the jurisdiction of the juvenile court, he stopped taking his meds, and entered the cycle of homelessness, hospitalizations, arrests.

What role did the news media play in passage of the bill?

There were many articles and editorials in major media markets, but also in local and regional newspapers. The Los Angeles Times and the San Francisco Chronicle set the bar and for 18 months relentlessly covered mental health. [LA Times reporter] Dan Morain wrote many articles, and introduced me to a Times editorial writer.  The Times and the Chron did dueling articles, in-depth reporting. In one edition of the Chronicle, I recall that both facing pages of the editorial section (editorials and op-eds) were on mental health issues, telling legislators to “pay attention, support Laura’s Law.”

Editorial boards of newspapers throughout California supported Laura’s Law, and the LA Times won a Pulitzer for editorial writing, for a series of editorials urging mental health reform. I remember one of the headlines in that series, based on my interviews and testimony, was “Make Chris Take His Meds.

You have represented psychiatrists for more than two decades. What are the major themes of that advocacy?

My agenda has been consistent from my time with NAMI. There are signature themes. The first mental health insurance parity bill (requiring that physical and mental illness be treated equally by insurers and providers) was my bill, Laura’s Law was my bill. I helped write and get them on the governor’s desk. CPA (the California Psychiatric Association) was one of the first groups questioning why we are putting so many mentally ill people in jail.  We supported bills for mental health offender programs, for better outreach to severely mentally ill people who were homeless, bills against suspending or curtailing Medi-Cal benefits for people in jails. We advocated for rational release times, not 2 a.m. with no shoes. We worked with the California Sheriff’s association to get the state to underwrite psychotropic medication costs in jail, where newer, more effective antidepressants and antipsychotics weren’t fully available.

Jails and prisons are often called “the new asylums.” How have you addressed the criminalizing of mental illness?

We were very early in the effort to improve mental health care in jails. In 1978-80, a San Mateo psychiatrist was writing about the influx of a new patient population – severely mentally ill people — into the San Mateo County Jail. We addressed conditions on the ground that weren’t sufficient to keep people who had been released from state hospitals stable in the community. The huge influx of severely mentally ill people into jails and prisons was a pretty well-known phenomenon among local officials and psychiatrists, but not so much among policy-makers, legislators. . . Counties were very hit and miss with medication in jails and did little to prevent people going to jail in the first place. There was limited legal structure in the community to prevent that.

By the ‘80s, the Legislature and other elected officials woke up to the criminalization of mental illness. There is an early statute still on the books, but not utilized, which authorizes courts to consider petitions requiring that individuals be evaluated for severe mental illness. That was one of the signs that there was a wakeup call among public officials. [Santa Clara County Superior Court] Judge [Stephen] Manley  started his first drug court in the early 80s, then mental health courts, many other alternative courts, which became models for other counties and states. That was an acknowledgement of the problem – that mentally ill people ending up in jail is not therapeutic or humane, and very costly, and we need to do something about that.  There was an ability in the ‘80s to refer a defendant to a civil court under the law, but we’re still talking about the same issue.

By the late 1990s, the mentally ill offender crime reduction statute was passed, which appropriated $55 million annually for treatment programs to prevent re-offending. In 2000-2002, Darrell Steinberg(now Sacramento mayor, former state Senate president) authored a series of three bills which provided assertive outreach and community treatment for homeless individuals with mental illness. Then Helen Thomson offered a package of four mental health bills, one of which was Laura’s Law (Assisted Outpatient Treatment or AOT) in 2002. All relate back to release of people from state hospitals and lack of resources for them in the community. Collectively, these measures signaled a renaissance in public policy to provide adequate support for people with severe mental illness. Steinberg and Thomson were the leaders for a long time, since they first were elected.

There were fits and starts with the legislation. We introduced a huge omnibus bill, AB 1800, in 2000, affecting outpatient treatment and commitment, conservatorships, expanding the “grave disability” standard under Lanterman-Petris-Short  (LPS, the massive 1967 legislation which rigidly controls health care policy in California), and streamlining the process for certifying further intensive treatment. Those were only a few of many bills during that period.

There was considerable bipartisan support for reform measures by legislators during that period – and intense resistance from others. Elaborate.

There were a lot of reforms touched on by the LPS Reform Task Force in 1999, which was when we got John Burton’s attention, and he shut us down. He was Senate president, and he shut us down several times. He wasn’t having any of this, messing with people’s civil rights, and the omnibus bill (AB 1800) went nowhere.  We came back with a package of bills — one of which was Laura’s Law – and it was a three-year battle with him. There was overwhelming legislative support for AB 1421, Laura’s Law, in the Assembly, but it was blocked in the Senate.

Did Burton’s views ever change?

No. Most of the Legislature was really good, we had strong support, overwhelming, bipartisan majority votes.  He was obstinate and obstructive. But as we became more powerful, the Chron and the Timeswere both running articles, editorializing, we had hundreds of letters from families, a support list that ran for three pages, from cities, churches, police chiefs, sheriffs, families. We worked it really hard. It was kind of a speeding train that John Burton finally had to take cognizance of, because there is a lot of political muscle in that kind of support.

He did not really come around, as there were various poison pills in Laura’s Law that we only recently took care of. He left his mark on it, and he made it really hard. He did eventually step aside, and let it get to the governor’s desk, but the way it was written, with so many limitations, LA County was the only county to start a very small pilot program in the jail in 2004, which only lasted a couple years. Nevada County adopted it in 2008 only because of a lawsuit by Laura’s parents.

As a result of recent legislation to strengthen it – and data showing significant success, cost savings — Laura’s Law has been widely adopted by the counties. And Gov. Newsom’s current CARE Court plan to expand civil court referrals has received widespread support among legislators. Does this mean major change?

It’s a work in progress, still, but I feel hopeful that CARE Court really puts the onus on counties to step up programs for the most severely mentally ill, people in the streets and in jail. It has the potential to be very effective. It will take good implementation. Counties are going to have to have their noses to the grindstone and be very diligent, or there will be sanctions. The state’s ability to fine counties for non-performance — or even put programs in receivership — is another key feature. SB 1338 (the governor’s CARE Court bill, by Sen. Susan Eggman, D-Stockton, and Sen. Tom Umberg, D-Santa Ana) was passed overwhelmingly by the Legislature, and is expected to be signed by the governor.

$65 million was also recently added in the 2022-23 state budget to help the courts create CARE Court programs, with legal representation for participants, but the actual legal mechanism has been fuzzy from the start. Have those issues been clarified?

The current version engages [local] Legal Aid Societies through the state Bar, which funds them, to provide representation. But there are no clear criteria. It is clear that the governor would prefer that Legal Aid provide representation, or (as a last resort), a public defender.

Very recent amendments to CARE Court legislation require the counties of Glenn, Orange, Riverside, San Diego, Stanislaus, and Tuolumne and the City and County of San Francisco to implement the program beginning Oct. 1, 2023, and the remaining counties to start programs no later than Dec. 1, 2024.  $57 million was also added in the state budget for local implementation.

The bill requires that each participant be assigned a support person, who can be a family member. How will that be implemented?

There are no restrictions for who can be a support person, and the state will provide training in court processes, county services, and the law, but a support person is not required to get training. It’s unclear whether they would be paid, the bill is silent on that, though I believe that is the intent. $65 million in the state budget is linked to the bill for court services.

I think it (the CARE Court bill) has been much improved over the initial version, which lacked specifics. It’s been a difficult needle for the administration to thread. The court procedures have been amended, made much more specific, and there is now explicit authorization for a medication order by a judge, but it’s not really enforceable. If a person is noncompliant, there is no immediate remedy – so, for instance, they can’t be held in contempt of court.

Bureaucracy in mental health policy has always been confusing and duplicative, with limited data, poor accountability. Is this likely to become yet another ineffectual bureaucracy?

There is always the danger of that. The governor is looking for performance. To the extent they can overcome their bureaucratic tendencies, in those counties where performance lags, he’s really put them on notice that there will be consequences. To the extent that they don’t perform, there can be serious consequences. I’m hoping lessons have been learned from performance issues identified in prior programs — Laura’s Law, the Mental Health Services Act  (MHSA, the so-called “millionaire’s tax” passed in 2004 as Proposition 63).

In that respect, it’s a grand experiment.

Yet another bill failed this year to change the definition of “grave disability” in the 1967 LPS law, which severely limits “involuntary” detention, treatment. Why?

There are personalities and people in the Legislature who have the power to obstruct. John Burton was one. Assembly Judiciary Committee chair Mark Stone (D-Monterey Bay), said this year’s bill (by Sen. Eggman,  author of many important mental health bills) was not going to be heard. No rationale. And this is not unusual.

But Stone will not be returning in 2023, and there may be a completely different environment next year, hopefully a chair who will work with us in crafting a bill that will work, rather than just saying no. We’re holding our breath. Legislators have been much more amenable on the Senate side, much more willing to work with us on crafting a bill, not just saying, I don’t like it, you can’t have it.

Why does LPS and the definition of “grave disability” need to be changed?

It’s very tight and restrictive. Some people who are gravely disabled – and who lack the capacity to take care of their medical disorders because of their mental illness — are unable to access the benefits of LPS because of the strict, narrow definition of grave disability.  They need our help. We are unable to step up and do what we would do for other people with medical conditions who are  not mentally ill. Their medical condition may well be a treatable condition in early stages, but can become life-threatening if left unattended, and we see too many tragedies on the streets of mentally ill people who die because of untreated medical illness.

Overall, has there been progress after all these years?

For the first time, we’re making more progress than in past years.  There is so much interest. This is the first year in which we’re actually going to get data from the counties on MHSA. We’re actually going to get accountability, data, get more time for people in inpatient units. That’s going to be very helpful. Strategic planning based on the information that we get is going to be really important.

In terms of the atmosphere in the Legislature, the fact is that there are so many bills. Sixty-nine bills are on my watch list that have to do with mental health: mental health of firefighters, effects of COVID on mental health, sharing data with the state Department of Justice. There is so much interest, so many bills. If half of them get signed, this will be a renaissance. Not all are big global shifts, like CARE Court, but they’re all important.

A community-based Regional Center system for developmentally disabled residents leaving the state hospitals was created decades ago. Is that regional model getting more attention today in mental health care?

Requiring local agencies to do planning on a regional basis would be a departure, and more regional planning – a regional government model — for people with mental illness, would be helpful.  One of our bills would harness the association of local governments into the planning process so you get regional planning. These are local elected officials getting together to talk about shared problems.  People with mental illness don’t always stay in one place, they are wandering from county to county, yet services vary from county to county and are not coordinated.

For example, one can’t access a psychiatrist in some of the smaller, more remote or rural counties. Some more remote counties share a child psychiatrist. Staffing shortages are acute in many areas of the state, as are housing and inpatient treatment. It’s important that we view this through a regional lens, using local governments to set up a mechanism for regional planning.

Can families expect more support in the current atmosphere?

If I’ve learned anything, it’s how much the families are the unspoken, unacknowledged, exploited partners in the care system, often hoping their family member commits a crime so they will be arrested and get treatment in jail.  Families have long been default social workers. The experience of trying to get care in the community can be overwhelming. When things don’t work, the families are there, they have to step in when no one else will. They struggle, and they don’t have resources or support or training.  My son has been in an inpatient psychiatric unit on a conservatorship for 18 months, and is now in a locked facility that provides rehabilitation services. His condition is improving, and I’m not having the same issues.

When my wife and I lived in midtown, roughly 2004-12, sometimes we’d wake up and my son would be sleeping on our front porch. We had options that other families didn’t have. I could call somebody in a treatment program and someone would come over and pick him up. But other families lack this type of support. I remember thinking about the family that contemplated urging their ill family member to throw a brick through a window so he could be arrested and get treatment. In many ways, that’s still where we are.

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 [email protected].

 

Randall Hagar has been in the forefront of major mental health policy and legislation in California for decades. As the father of a severely mentally ill adult son and longtime legislative advocate for California psychiatrists, he has deep knowledge of both family struggles and the complex intricacies of mental health policy.

He represented the California Psychiatric Association for nearly 20 years, and since 2020 represents a successor organization, the Psychiatric Physicians Alliance of California. He also actively advises community groups, families and legislators and has written much of California’s major mental health legislation.

With intense public and legislative interest in mental health this year, dozens of bills affecting a wide range of state and local mental health services have been debated in the state Legislature. The most prominent, comprehensive – and controversial — proposal this year to reform California’s fractured system of care is Gov. Newsom’s CARE Court plan (Community Assistance, Recovery and Empowerment).

Introduced as SB 1338 by Sens. Susan Talamantes Eggman (D-Stockton) and Tom Umberg (D-Santa Ana), the measure was overwhelmingly approved by the state Legislature on Aug. 31, the final day of the session. It would create an entirely new civil court system to get treatment for thousands of severely mentally ill Californians, many living – and dying – on the streets, cycling through hospital emergency rooms and jails.

It also adds $57 million in the 2022-23 state budget for counties to implement programs, and $65 million for the judicial system. Strongly supported by public officials and mental health reform advocates, it has been criticized by disability rights activists as coercive. Billions in additional funding have been included over the past two years for homelessness and mental health treatment. Newsom is expected to sign the bill.

Hagar discusses the long, tortured history of mental health care and policy in California, his own family’s experiences, and the path forward.

He was interviewed beginning on Aug. 17 by Sacramento journalist Sigrid Bathen, who has long covered mental health issues for several publications and is the author of a continuing Capitol Weekly series on mental health. The interviews have been lightly edited and updated.

When did you become interested in mental health advocacy?

I think I caught the buzz from my mother, Phyllis Hagar, who was a first-generation legislative advocate for the Sacramento chapter of the California Mental Health Association. She was a volunteer, a member of the  board of directors, and served on the state legislative council. She was active in the Democratic Party. She testified in the Legislature on mental health issues and prison overcrowding, wrote letters to editors, won awards for her advocacy.

She also suffered from depression and anxiety and was drawn to improving conditions. She became severely depressed, suffered from at least one anxiety disorder, and was twice hospitalized in psychiatric hospitals for several weeks at a time. She and my father, Kenneth, met at Northern Arizona University, and their first teaching jobs were in a one-room school in Rocklin (Placer County). He was a junior high school vice-principal in the San Juan Unified School District in Sacramento County.  She taught second grade in Citrus Heights for 15 years, then quit teaching and devoted her life to serving the mental health association.

How did your mother’s illness affect the family?

She had struggled with her illness for a long time, and as it episodically grew worse, my dad ended up being her caretaker, and, as the oldest son, I became the caretaker for my two younger brothers. As a family, we coped as best we could.

I came home from school one day in the seventh grade, and I went into the back bedroom and found her trying to get the safety off of one of my dad’s pistols. She was obviously intent on putting an end to her suffering. I asked for the gun, called my dad, and she was hospitalized at Sutter Center for Psychiatry. She was prescribed medications, such as they were then (in the 1960s), which didn’t seem to work. So she was subjected to old-fashioned electroconvulsive treatment (ECT). Compared to today, it was pretty crude. But after her second series of treatments, it seemed to work for her, she seemed less depressed, was never depressed in the same way ever again. After the ECT treatments, she had what I thought was OCD (obsessive-compulsive disorder), and started hoarding things. We had stacks of newspaper clippings in our living room, kitchen, her bedroom, pretty much everywhere except the bathrooms. And there were odd thought patterns. But she would still cook dinner, drive a car, other normal activities.

How did you and your brothers cope?

Not real well. I had some anxiety issues of my own, some depression, and was very, very pleased to leave home when I went to UC-Davis in 1970. My youngest brother also got out of the house at an early age, and later died of AIDS in his 30s. My other brother committed suicide in his mid-40s, not long after our mother died in 2009. He suffered from severe depression and anxiety, used heroin, never got sufficient mental health treatment until the last year of his life. But by then he had what I thought was hepatitis and liver cancer. He was in a lot of pain, didn’t want to go on anymore.

Describe your time as a student at UC-Davis.

Like my mom, I almost had more education outside of the classroom than in. At UCD, I got involved w/the Associated Students, doing research on the incursions of the Regents and Chancellors on campus media. Media boards are the designated publishers of student media, and the boards were faculty-dominated, with prior restraint of articles, censorship. There was a lot of “clamping down” on student media, and it became really egregious throughout the UC system. Collectively, the presidents of Associated Students on UC campuses were very receptive to changing the existing bylaws, and I ended up drafting a set of model bylaws. These were eventually adopted by the Regents, giving students majority control on campus media boards, and reducing the dominance of faculty on the boards. I was a member and then chair of the UCD campus media board  under the new bylaws.

I was also working on a degree in behavioral sciences – an individual major which I designed that included anthropology, sociology, psychology and education. After several years at UCD, I took some time off, did more volunteer work, and got together with a group of faculty and students — with the support of Yolo County Mental Health Director Dr. Cap Thomson,  a psychiatrist — to create a halfway house for people living with serious mental illness. They were student age, but their illnesses were pretty severe, and they couldn’t manage being students(Editor’s Note: Thomson’s wife Helen, a former psychiatric nurse, was later elected to the state Assembly, where Hagar worked with her on major mental health legislation).

Students living in the house were to provide positive role models, help residents with daily tasks, teach social skills. One resident had just been released from an inpatient psychiatric unit in Woodland, and one came from a state hospital. Many of the state hospitals (which were largely closed in the 1960s and ‘70s) were still open. . .There were 11 of us in the house, and five of us were enrolled at UCD. It was a cooperative, we cooked meals together, cleaned house.

I received a nominal stipend as the house manager/coordinator. And the work qualified as independent study, for course credit. The house received some county funding, with oversight by a board of directors, and there was community fundraising. Enough funds were raised for a down payment on a house, students paid rent, and residents’ rent was paid with their Social Security and disability benefits. I stayed rent-free as house manager.

I got married before my last quarter at UCD in 1978, and my wife lost her job and found she was pregnant. I had to withdraw from school, didn’t actually get my degree until nearly 20 years later. My son was born in 1979, and I worked various jobs to support my family. His mother and I divorced when he was quite young, and my ex-wife moved to Marin, so I moved there to be closer to my son. He was 15 when he was diagnosed with “psychotic disorder not otherwise specified,” which became a diagnosis of schizophrenia several years later, in 1996. They didn’t – and still don’t — like to do specific diagnoses for under 18. There had been a lot of acting out, drugs, shoplifting, withdrawing from the family, running with a bad crowd. He lived with his mother for a while, but he was too much for her behaviorally, she couldn’t really handle him. So I became pretty much a single father.

I had a varied career during that period, was a waiter in a Japanese sushi bar in Mill Valley, cooked for a children’s center, became a building contractor – my dad had built both of our houses, and I had the skills. I completed my UCD undergrad degree in 1995, and enrolled in coursework for a film program at San Francisco State, for a Master’s in Fine Arts.  Because of family responsibilities, I delayed applying and was not able to follow through.

How did you become involved in mental health advocacy as a career?

When my son was diagnosed, like many family members facing that news, I didn’t know what to do. He was living with me, and I struggled to figure out how to cope with him. I was desperate, and I enrolled in a family education course through the Sacramento chapter of the California Alliance on Mental Illness (the National Alliance on Mental Illness, or NAMI, is an influential organization representing families, with state and local chapters throughout the U.S.), which I learned about when my son had been hospitalized at Sutter. I became a volunteer for the Sacramento chapter,  and I was trained to teach those courses, then became a trainer for other teachers, eventually a national trainer for the first family educators at affiliates in Nevada and Hawaii. The family-to-family courses taught survival skills for family members, understanding how the brain works, communication, coping and advocacy skills. I eventually became the program director for family education in California.

Because of my interest in politics, and my earlier work with the Associated Students at UCD, I started working with psychiatrists on legislative issues. I told them they needed to become members of NAMI, to learn what it’s like on the other side of the fence where the family is. My first issue as a California advocate was to advocate for fair housing, learning the intricacies of the 1968 fair housing amendments to the U.S. Civil Rights Act of 1964.

I became a NAMI-California board member in 1998, and was president of the Sacramento chapter. I couldn’t be both an employee and on the board, so I chose to be actively involved with legislation and chaired the state board’s legislative committee, working with  [then-Assemblywoman] Helen Thomson (D-Davis) on Laura’s Law. (Editor’s Note: Laura’s Law, one of the few legal avenues for family members to get help for mentally ill relatives, was named for 19-year-old Laura Wilcox, who was working in a Nevada County mental health clinic when she was killed in 2000, along with two others, by a clinic patient whose family had tried to warn local mental health officials of his dangerous decline, but were ignored).

How did your experiences with your son inform your work as a legislative advocate?

During my testimony in legislative hearings on Laura’s Law in 2001-02, I said that my son had been arrested in three counties, was homeless for 18 months, hospitalized seven or eight times in five different counties. I was educated, well-connected, and there was nothing I could do. He was totally on his own journey, and I was helpless to keep him in the hospital. I testified that one feature of his life that made a huge impression on me is that until age 18, he was under the jurisdiction of the juvenile court, and a probation officer would regularly come out, interview us both, ask how he was doing, if he was keeping appointments, taking his meds. That was a kind of  structure that kept him from getting into worse trouble. I learned that a legal structure could be very helpful in keeping a person stable and avoiding worse outcomes. But when he turned 18, and was no longer under the jurisdiction of the juvenile court, he stopped taking his meds, and entered the cycle of homelessness, hospitalizations, arrests.

What role did the news media play in passage of the bill?

There were many articles and editorials in major media markets, but also in local and regional newspapers. The Los Angeles Times and the San Francisco Chronicle set the bar and for 18 months relentlessly covered mental health. [LA Times reporter] Dan Morain wrote many articles, and introduced me to a Times editorial writer.  The Times and the Chron did dueling articles, in-depth reporting. In one edition of the Chronicle, I recall that both facing pages of the editorial section (editorials and op-eds) were on mental health issues, telling legislators to “pay attention, support Laura’s Law.”

Editorial boards of newspapers throughout California supported Laura’s Law, and the LA Times won a Pulitzer for editorial writing, for a series of editorials urging mental health reform. I remember one of the headlines in that series, based on my interviews and testimony, was “Make Chris Take His Meds.

You have represented psychiatrists for more than two decades. What are the major themes of that advocacy?

My agenda has been consistent from my time with NAMI. There are signature themes. The first mental health insurance parity bill (requiring that physical and mental illness be treated equally by insurers and providers) was my bill, Laura’s Law was my bill. I helped write and get them on the governor’s desk. CPA (the California Psychiatric Association) was one of the first groups questioning why we are putting so many mentally ill people in jail.  We supported bills for mental health offender programs, for better outreach to severely mentally ill people who were homeless, bills against suspending or curtailing Medi-Cal benefits for people in jails. We advocated for rational release times, not 2 a.m. with no shoes. We worked with the California Sheriff’s association to get the state to underwrite psychotropic medication costs in jail, where newer, more effective antidepressants and antipsychotics weren’t fully available.

Jails and prisons are often called “the new asylums.” How have you addressed the criminalizing of mental illness?

We were very early in the effort to improve mental health care in jails. In 1978-80, a San Mateo psychiatrist was writing about the influx of a new patient population – severely mentally ill people — into the San Mateo County Jail. We addressed conditions on the ground that weren’t sufficient to keep people who had been released from state hospitals stable in the community. The huge influx of severely mentally ill people into jails and prisons was a pretty well-known phenomenon among local officials and psychiatrists, but not so much among policy-makers, legislators. . . Counties were very hit and miss with medication in jails and did little to prevent people going to jail in the first place. There was limited legal structure in the community to prevent that.

By the ‘80s, the Legislature and other elected officials woke up to the criminalization of mental illness. There is an early statute still on the books, but not utilized, which authorizes courts to consider petitions requiring that individuals be evaluated for severe mental illness. That was one of the signs that there was a wakeup call among public officials. [Santa Clara County Superior Court] Judge [Stephen] Manley  started his first drug court in the early 80s, then mental health courts, many other alternative courts, which became models for other counties and states. That was an acknowledgement of the problem – that mentally ill people ending up in jail is not therapeutic or humane, and very costly, and we need to do something about that.  There was an ability in the ‘80s to refer a defendant to a civil court under the law, but we’re still talking about the same issue.

By the late 1990s, the mentally ill offender crime reduction statute was passed, which appropriated $55 million annually for treatment programs to prevent re-offending. In 2000-2002, Darrell Steinberg(now Sacramento mayor, former state Senate president) authored a series of three bills which provided assertive outreach and community treatment for homeless individuals with mental illness. Then Helen Thomson offered a package of four mental health bills, one of which was Laura’s Law (Assisted Outpatient Treatment or AOT) in 2002. All relate back to release of people from state hospitals and lack of resources for them in the community. Collectively, these measures signaled a renaissance in public policy to provide adequate support for people with severe mental illness. Steinberg and Thomson were the leaders for a long time, since they first were elected.

There were fits and starts with the legislation. We introduced a huge omnibus bill, AB 1800, in 2000, affecting outpatient treatment and commitment, conservatorships, expanding the “grave disability” standard under Lanterman-Petris-Short  (LPS, the massive 1967 legislation which rigidly controls health care policy in California), and streamlining the process for certifying further intensive treatment. Those were only a few of many bills during that period.

There was considerable bipartisan support for reform measures by legislators during that period – and intense resistance from others. Elaborate.

There were a lot of reforms touched on by the LPS Reform Task Force in 1999, which was when we got John Burton’s attention, and he shut us down. He was Senate president, and he shut us down several times. He wasn’t having any of this, messing with people’s civil rights, and the omnibus bill (AB 1800) went nowhere.  We came back with a package of bills — one of which was Laura’s Law – and it was a three-year battle with him. There was overwhelming legislative support for AB 1421, Laura’s Law, in the Assembly, but it was blocked in the Senate.

Did Burton’s views ever change?

No. Most of the Legislature was really good, we had strong support, overwhelming, bipartisan majority votes.  He was obstinate and obstructive. But as we became more powerful, the Chron and the Timeswere both running articles, editorializing, we had hundreds of letters from families, a support list that ran for three pages, from cities, churches, police chiefs, sheriffs, families. We worked it really hard. It was kind of a speeding train that John Burton finally had to take cognizance of, because there is a lot of political muscle in that kind of support.

He did not really come around, as there were various poison pills in Laura’s Law that we only recently took care of. He left his mark on it, and he made it really hard. He did eventually step aside, and let it get to the governor’s desk, but the way it was written, with so many limitations, LA County was the only county to start a very small pilot program in the jail in 2004, which only lasted a couple years. Nevada County adopted it in 2008 only because of a lawsuit by Laura’s parents.

As a result of recent legislation to strengthen it – and data showing significant success, cost savings — Laura’s Law has been widely adopted by the counties. And Gov. Newsom’s current CARE Court plan to expand civil court referrals has received widespread support among legislators. Does this mean major change?

It’s a work in progress, still, but I feel hopeful that CARE Court really puts the onus on counties to step up programs for the most severely mentally ill, people in the streets and in jail. It has the potential to be very effective. It will take good implementation. Counties are going to have to have their noses to the grindstone and be very diligent, or there will be sanctions. The state’s ability to fine counties for non-performance — or even put programs in receivership — is another key feature. SB 1338 (the governor’s CARE Court bill, by Sen. Susan Eggman, D-Stockton, and Sen. Tom Umberg, D-Santa Ana) was passed overwhelmingly by the Legislature, and is expected to be signed by the governor.

$65 million was also recently added in the 2022-23 state budget to help the courts create CARE Court programs, with legal representation for participants, but the actual legal mechanism has been fuzzy from the start. Have those issues been clarified?

The current version engages [local] Legal Aid Societies through the state Bar, which funds them, to provide representation. But there are no clear criteria. It is clear that the governor would prefer that Legal Aid provide representation, or (as a last resort), a public defender.

Very recent amendments to CARE Court legislation require the counties of Glenn, Orange, Riverside, San Diego, Stanislaus, and Tuolumne and the City and County of San Francisco to implement the program beginning Oct. 1, 2023, and the remaining counties to start programs no later than Dec. 1, 2024.  $57 million was also added in the state budget for local implementation.

The bill requires that each participant be assigned a support person, who can be a family member. How will that be implemented?

There are no restrictions for who can be a support person, and the state will provide training in court processes, county services, and the law, but a support person is not required to get training. It’s unclear whether they would be paid, the bill is silent on that, though I believe that is the intent. $65 million in the state budget is linked to the bill for court services.

I think it (the CARE Court bill) has been much improved over the initial version, which lacked specifics. It’s been a difficult needle for the administration to thread. The court procedures have been amended, made much more specific, and there is now explicit authorization for a medication order by a judge, but it’s not really enforceable. If a person is noncompliant, there is no immediate remedy – so, for instance, they can’t be held in contempt of court.

Bureaucracy in mental health policy has always been confusing and duplicative, with limited data, poor accountability. Is this likely to become yet another ineffectual bureaucracy?

There is always the danger of that. The governor is looking for performance. To the extent they can overcome their bureaucratic tendencies, in those counties where performance lags, he’s really put them on notice that there will be consequences. To the extent that they don’t perform, there can be serious consequences. I’m hoping lessons have been learned from performance issues identified in prior programs — Laura’s Law, the Mental Health Services Act  (MHSA, the so-called “millionaire’s tax” passed in 2004 as Proposition 63).

In that respect, it’s a grand experiment.

Yet another bill failed this year to change the definition of “grave disability” in the 1967 LPS law, which severely limits “involuntary” detention, treatment. Why?

There are personalities and people in the Legislature who have the power to obstruct. John Burton was one. Assembly Judiciary Committee chair Mark Stone (D-Monterey Bay), said this year’s bill (by Sen. Eggman,  author of many important mental health bills) was not going to be heard. No rationale. And this is not unusual.

But Stone will not be returning in 2023, and there may be a completely different environment next year, hopefully a chair who will work with us in crafting a bill that will work, rather than just saying no. We’re holding our breath. Legislators have been much more amenable on the Senate side, much more willing to work with us on crafting a bill, not just saying, I don’t like it, you can’t have it.

Why does LPS and the definition of “grave disability” need to be changed?

It’s very tight and restrictive. Some people who are gravely disabled – and who lack the capacity to take care of their medical disorders because of their mental illness — are unable to access the benefits of LPS because of the strict, narrow definition of grave disability.  They need our help. We are unable to step up and do what we would do for other people with medical conditions who are  not mentally ill. Their medical condition may well be a treatable condition in early stages, but can become life-threatening if left unattended, and we see too many tragedies on the streets of mentally ill people who die because of untreated medical illness.

Overall, has there been progress after all these years?

For the first time, we’re making more progress than in past years.  There is so much interest. This is the first year in which we’re actually going to get data from the counties on MHSA. We’re actually going to get accountability, data, get more time for people in inpatient units. That’s going to be very helpful. Strategic planning based on the information that we get is going to be really important.

In terms of the atmosphere in the Legislature, the fact is that there are so many bills. Sixty-nine bills are on my watch list that have to do with mental health: mental health of firefighters, effects of COVID on mental health, sharing data with the state Department of Justice. There is so much interest, so many bills. If half of them get signed, this will be a renaissance. Not all are big global shifts, like CARE Court, but they’re all important.

A community-based Regional Center system for developmentally disabled residents leaving the state hospitals was created decades ago. Is that regional model getting more attention today in mental health care?

Requiring local agencies to do planning on a regional basis would be a departure, and more regional planning – a regional government model — for people with mental illness, would be helpful.  One of our bills would harness the association of local governments into the planning process so you get regional planning. These are local elected officials getting together to talk about shared problems.  People with mental illness don’t always stay in one place, they are wandering from county to county, yet services vary from county to county and are not coordinated.

For example, one can’t access a psychiatrist in some of the smaller, more remote or rural counties. Some more remote counties share a child psychiatrist. Staffing shortages are acute in many areas of the state, as are housing and inpatient treatment. It’s important that we view this through a regional lens, using local governments to set up a mechanism for regional planning.

Can families expect more support in the current atmosphere?

If I’ve learned anything, it’s how much the families are the unspoken, unacknowledged, exploited partners in the care system, often hoping their family member commits a crime so they will be arrested and get treatment in jail.  Families have long been default social workers. The experience of trying to get care in the community can be overwhelming. When things don’t work, the families are there, they have to step in when no one else will. They struggle, and they don’t have resources or support or training.  My son has been in an inpatient psychiatric unit on a conservatorship for 18 months, and is now in a locked facility that provides rehabilitation services. His condition is improving, and I’m not having the same issues.

When my wife and I lived in midtown, roughly 2004-12, sometimes we’d wake up and my son would be sleeping on our front porch. We had options that other families didn’t have. I could call somebody in a treatment program and someone would come over and pick him up. But other families lack this type of support. I remember thinking about the family that contemplated urging their ill family member to throw a brick through a window so he could be arrested and get treatment. In many ways, that’s still where we are.

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 [email protected].

 

Helping mentally ill people: The debate over ‘involuntary treatment’

Lee Davis says flatly that without involuntary treatment for her raging psychosis, she would be dead. “It saved my life.”

A mental health activist, she chairs the Alameda County Mental Health Advisory Board, which advises the board of supervisors and county officials on mental health policy. Davis acknowledges hers is not a popular view among disability rights advocates, who largely oppose any kind of “forced” treatment for mental illness.

Involuntary treatment is at the core of the intense debate over Gov. Gavin Newsom’s proposed California CARE Court plan to help the mentally ill.

“I fundamentally disagree with the notion that everybody is in a position to make a decision voluntarily.” — Lee Davis

“While I was ill, I was a danger to myself,” Davis told a virtual forum sponsored by Disability Rights-California, which strongly opposes involuntary treatment and organized the March 10 “town hall” to air opposition to a far-reaching Newsom administration plan for court-ordered treatment. “I thought I could fly. I almost jumped off a building.”

“I fundamentally disagree with the notion that everybody is in a position to make a decision voluntarily,” Davis added, a distinct outlier in the town hall testimony. “I was absolutely in a different state of consciousness and needed help. I’m so glad I was involuntarily committed and stabilized, and now I’m in a position to speak for people who have had that experience.”

She likens the altered consciousness and delusions that characterize serious mental illness to dementia, and says people in the throes of psychosis deserve the same medical interventions as those with so-called “physical” illnesses – a concept rapidly gaining ground in mental health policy and law.

“You wouldn’t leave an elderly person in a state of mental confusion to just fend for themselves,” she said.

In one of several recent interviews with Capitol Weekly, she said she sometimes feels “like a lone ranger” among disability rights activists, “but I still have to speak to the issue based on my own experiences.”

Davis, 47, is bipolar, and has survived two major psychotic breaks that ultimately landed her in jail, where increasing numbers of mentally ill people are detained, at huge public and human cost.

In 2009, while actively psychotic and refusing treatment, Davis was taken to the notorious Santa Rita Jail in Alameda County following an argument with a friend.

Unlike many others, she lived to tell the tale, and credits the involuntary treatment she received with setting her on a path to long-term recovery. With degrees in anthropology (UC-Santa Barbara) and civil engineering (California State University, Sacramento), she works fulltime as an electrician and has become a prominent activist on mental health issues, openly challenging the prevailing view among civil rights groups that mental health treatment must be entirely voluntary.

She is also a writer and illustrator, and her articles  about her own struggles with bipolar disorder have been widely published.

In 2009, while actively psychotic and refusing treatment, Davis was taken to the notorious Santa Rita Jail in Alameda County following an argument with a friend who was trying to get her into treatment.

“I was belligerent, as is common for people in psychiatric distress,” she wrote in a March 23 letter to the state Health and Human Services Agency, which sought public comment on Newsom’s sweeping CARE Court proposal to overhaul California’s mental health system, requiring court-ordered treatment in all 58 counties.

“I was denied medication, and then was released in the middle of the night, floridly psychotic, with only a bus ticket. It is a miracle I found my way home safely.” Soon after, she was involuntarily detained on a mental health hold, and taken to a psychiatric facility rather than jail.

“I have had the opportunity to recover,” she wrote in a 2019 article, “Being Bipolar” published on Medium, in which she acknowledged the strong support from family, friends and “a deeply compassionate and gifted personal therapist.” And she has long been, “by choice, medication-compliant and, equally important, as a matter of luck, consistently responsive to medication.”

“It was like watching your child slow-walk off a cliff, and not being able to reach them.” — Cheryl Davis

Calling her recovery “more anomaly than standard,” she said too many individuals with serious mood disorders “cycle in and out of hospitals and jail, disproportionately experiencing homelessness and early death. Our systems fail.”

In video testimony for a recent Washington, D.C., conference of the National Alliance on Mental Illness (NAMI), an influential national organization representing families, Davis said opposition to all forms of involuntary treatment is “irresponsible” and ignores the reality of resistance to treatment while deeply psychotic. “I received treatment when I did not want treatment, and it saved my life.”

Her mother, Cheryl Davis, spoke in the video of trying to get her adult daughter into treatment, and instead learning that she had been jailed.

“It was like watching your child slow-walk off a cliff, and not being able to reach them,” she said, her voice breaking. Unlike many others with fewer resources, who end up in jail as a result of their mental illness — often for months or even years without trial, while awaiting sanity evaluations in badly backlogged state mental hospitals — Davis was not charged.

Persistent debate over the legal limits of mental-health treatment is at the heart of Newsom’s Community Assistance, Recovery and Empowerment (CARE) Court  plan, which would create an entirely new system of civil court oversight, combined with intensive treatment, housing and support systems.

Newsom estimates 7,000-12,000 people would be helped annually by a CARE Court system.

Unlike other court-involved mental health programs – Laura’s Law or Assisted Outpatient Treatment (AOT) in civil court, and Mental Health diversion programsin the criminal courts – CARE Court would be mandatory in all 58 counties, with potential court sanctions against counties that fail to provide required care and supervision.

Currently the subject of heated debate in the state Legislature, the plan is designed to help thousands of seriously mentally ill people who are clearly unable to care for themselves, yet refuse help, wandering the streets – and often dying there — or cycling through hospital ER’s and stuck in overcrowded, dangerous county jails ill-equipped to help them.

Newsom estimates 7,000-12,000 people would be helped annually by a CARE Court system, which does not replace existing programs such as Laura’s Law, the 2002 law that gives family members one of the few legal tools to get mentally ill relatives into treatment.

Critics say counties have been slow to adopt effective AOT programs, despite compelling evidence that such programs help stabilize participants, keep them out of hospital ER’s and jails, and save public funds.

Nor does the Newsom plan propose significant change to the 1967 Lanterman-Petris-Short (LPS) law that has dictated mental health policy in California for more than half a century. It was passed in response to abuse and forced treatment of mentally ill and developmentally disabled people in state mental hospitals, which were largely closed in the 1960s and ‘70s. The law has since been widely criticized  – including by its three bipartisan authors — as outdated, overly restrictive, and leading to the current mental health and homelessness crisis in cities throughout California.

“One of the important and early strategic policy decisions the governor made was not to attempt a significant reform of LPS or Laura’s Law.” — Jason Elliott

Several major bills to improve a fractured community mental health care system and reform LPS are currently before the Legislature – including an eight-bill package by Sen. Susan Eggman, D-Stockton, a former social worker and social work professor who has long been at the forefront of mental health policy in California and is also co-author of an administration-backed CARE Court bill currently before the state Senate.

The governor decided early-on not to propose major changes in LPS, historically regarded as the untouchable “third rail” of mental health policy in the Legislature, which has repeatedly failed to enact substantive LPS reform.

“One of the important and early strategic policy decisions the governor made was not to attempt a significant reform of LPS or Laura’s Law,” said Newsom’s senior counselor, Jason Elliott, who has advised the governor on homelessness and mental health issues for many years, starting in 2009 as policy director and later chief of staff to Newsom when he was mayor of San Francisco.

Noting that LPS reform has long generated contentious policy debates over individual rights, Elliott told Capitol Weekly in a May 5 interview, the result has been “many decades of battle scars, hurt feelings and entrenched opinions.”

“Sometimes to make a real policy breakthrough,” he added, “you need to cut a new path.”

The administration-backed CARE Court bill, SB 1338, by Eggman and Sen. Tom Umberg, D-Santa Monica, has overwhelmingly cleared two major committee hurdles.

Confronting a tight timeline for a massive proposal first unveiled in early March,the administration is pursuing the CARE Court plan through intense policy and budgetary debates in the Legislature, aiming for full adoption by the start of the new fiscal year July 1. Statutory adoption of the state budget is required by June 15.

“You take it one step at a time, one committee at a time, and convince as many members as you can that you’ve got a good idea,” Elliott said of the legislative process. “We’ve been through two committees, 19 ayes, zero nays. There has been a lot of ink spilled on the so-called hurdles, and certainly we’re not expecting an easy glide path to the governor’s signature. But I want to push back on this notion that we have this steep, double-black diamond ahead of us.

“No committee in the Legislature is an easy committee. These are people who take their work and their responsibility very seriously. . . .We’re putting all of our efforts into every committee and vote as it comes before us. Step by step, we will get this done.”

The administration-backed CARE Court bill, SB 1338, by Eggman and Sen. Tom Umberg, D-Santa Monica, has overwhelmingly cleared two major committee hurdles — the Senate Judiciary and Health committees —  in the Senate, where it is expected to pass.

But the measure faces an unknown future in the state Assembly, where mental-health reforms have often met with stiff opposition and multiple amendments in the Assembly Judiciary and Health Committees.

Although CARE Court was originally unveiled as part of the governor’s annual budget proposals, Elliott said Assembly Speaker Anthony Rendon called for a “full policy process” in the Legislature, “not just the budget process.”

A companion Assembly bill to the Eggman-Umberg CARE Court bill, by Assemblyman Richard Bloom, D-Santa Monica, was abruptly tabled in Assembly Judiciary last month after the governor’s office and key legislators reportedly rejected extensive proposed amendments. That leaves the Senate bill, which Bloom supports, as the sole policy measure to move through a series of lengthy and often heated committee sessions.  The measure could still be adopted through the budget process alone.

Funding for behavioral health programs is notoriously complex, coming from multiple state, federal and local sources

Regardless of the legislative hurdles, and citing broad support for the proposal from local officials and mental-health advocacy groups, the administration is moving forward with significant funding in the state budget to establish CARE Court in all of California’s 58 counties beginning July 1.

Following release of the governor’s May budget revision on Friday, which included $65 million  in additional funding to create CARE Courts in the counties, even supporters of the plan said it remains short on key details.

Funding for behavioral health programs is notoriously complex, coming from multiple state, federal and local sources. Twelve billion dollars in multi-year state funding was approved last year for homelessness and mental health programs, and $4 billion for improved children’s mental health, with another $2 billion this year in the 2022-23 proposed state budget.

Additional funding is provided by the Mental Health Services Act, the 2004 ballot measure to tax the wealthiest Californians, which has provided billions for mental health care and is expected to add another $3.8 billion this year.

County officials, including judges and public defenders, remain concerned that significantly more funding – and staff — will be necessary to create and maintain the CARE Courts and related support services, particularly for the severely mentally ill people targeted by the proposal.  The governor’s office says it will continue working with state and local officials to implement and fund the program.

In order to achieve even “baseline stability,” some will need “a lot of inpatient time to get better, and medications throughout the process.” — Randall Hagar

Randall Hagar, a veteran mental health policy expert who is legislative advocate for the Psychiatric Physicians Alliance of California, said psychiatrists support the proposal but “are a little skeptical without more details.”

“Some of the people who meet the criteria for CARE Court have been on the streets for so long, it’s hard to imagine them needing less than the complex treatment that is only available in inpatient facilities — and then, once they are discharged, supportive housing. Both are in short supply.”

In order to achieve even “baseline stability,” Hagar added, some will need “a lot of inpatient time to get better, and medications throughout the process.”

He also shares concerns among CARE Court supporters that the proposal does not address deep, systemic failures in existing law, primarily Lanterman-Petris Short.

“We considered everything under the sun,” Elliott said. “And we settled on CARE Court as the path forward. . .We’re certainly engaged in substantive policy discussions with opponents of CARE Court, [but] I don’t anticipate that we’ll earn the support of entrenched activists.” And, despite county indignation about potential sanctions, the administration is not backing down on a plan that could result in stiff penalties against counties that don’t comply.

“Laura’s Law was one of the best tools we had, as an option to conservatorship.” — Karen Larsen

Elliott disputes widespread criticism that the plan entails “forced” treatment. “There is a court-ordered care plan,” he said. “There is not a locked door.

“Those who are opposed will say you’re forcing people into a carceral (incarceration) system that takes away their rights, and I say no, with respect, that’s the system that has existed in California for decades. CARE Court is trying to take people out of that system, to divert people out of the in-custody system and get them the care they need.”

Although often viewed as involuntary court-ordered treatment, the 20-year-old civil-court Laura’s Law program on which CARE Court is based, is usually voluntary.

“We rarely had to go to court,” said Karen Larsen, former director of the Yolo County Health and Human Services Agency, now CEO of the Steinberg Institute, the mental health policy nonprofit founded by Sacramento Mayor and former state Senate President Darrell Steinberg, who was the author of major mental health legislation spanning decades, including the 2004 Mental Health Services Act.

“Laura’s Law was one of the best tools we had, as an option to conservatorship,” she added. “I understand the distrust and fears of coercion [in the CARE Court proposal], but I just don’t see any evidence in this bill, or the potential for it.”

Santa Clara County Superior Court Judge Stephen Manley — whose Mental Health Courts have diverted thousands of defendants from the criminal court system and is widely praised as setting the “gold standard” for such courts in California and throughout the country — strongly supports the governor’s proposal. He joined Newsom on the podium during a March 3 press conference to announce the plan at a mental health facility in San Jose.

Manley is also critical of opposition to the proposal.

“If we don’t try new approaches and keep complaining that things aren’t working, we’re really not moving forward,” he said in one of several recent interviews with Capitol Weekly. “CARE Court will take the most difficult clients with the greatest challenges, who are seriously mentally ill, and give them support and monitoring by the court. It will demonstrate that they can in fact be helped in the community.

“We need to stop trying to fix a failed system. We are rapidly moving back to where we were 100 years ago, where the answer for the mentally ill was simply to incarcerate them in a hospital and keep them there until they die.

“Mental health is a real crisis in our court system, and mental illness is not a crime.”

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 [email protected].

 

A deep dive into Newsom plan to overhaul mental health policy

Santa Clara County Superior Court Judge Stephen Manley started the first Mental Health Court in California – one of the first in the country – in 1998, to divert increasing numbers of mentally ill defendants from the criminal justice system, where jails and prisons are often called “the new asylums.”

Designed to break the tragic pattern for people whose mental illness underlies their crimes — landing them, repeatedly, in jails and prisons ill-equipped to help them – Manley’s courts annually manage the cases of 1,500-2,000 mentally ill defendants (he calls them “clients”). Nearly 70  percent have successfully completed their requirements and many charges were dismissed, saving lives and public funds.

Newsom estimates that it would help 7,000-to-12,000 severely mentally ill people each year, many with chronic physical conditions that are worsened by life on the streets.

So it was not surprising to see Manley speaking at a San Jose press conference March 3 when Gov. Gavin Newsom announced a sweeping proposal to address California’s badly broken system of “care” for the growing numbers of mentally ill Californians wandering the streets, clogging hospital ER’s, jails and prisons. Newsom dubbed the plan “CARE Court,” for Community Assistance, Recovery and Empowerment.

 

If approved by the Legislature, Newsom’s plan would create an entirely new system of civil court supervision, connecting individuals with intensive treatment and, equally important, housing.

By Newsom’s estimate, it would help 7,000-to-12,000 severely mentally ill people each year, many with chronic physical conditions that are worsened by life on the streets, clearly unable to care for themselves. It would not replace existing programs.

“We are taking action to break the pattern,” Newsom said at the March 3 press conference in a mental health facility in San Jose, “that leaves people without hope and cycling repeatedly through homelessness and incarceration. This is a new approach to stabilize people with the hardest-to-treat behavioral health conditions.”

“We are rapidly moving back to where we were 100 years ago, where the answer for the mentally ill was simply to incarcerate them in a hospital and keep them there until they die.” — Stephen Manley

Noting that $12 billion in multi-year state funding was approved last year for homelessness and mental health programs, and $4 billion for improved children’s mental health, he said he is proposing another $2 billion this year in the 2022-23 state budget. Additional funding is provided by the Mental Health Services Act, the 2004 ballot measure to tax the wealthiest Californians, which is expected to add $3.7 billion to state mental health care this year.

Newsom’s proposal requires legislative approval and has drawn criticism from disability rights advocates, who oppose involuntary treatment, and from counties, which dispute the need for potential sanctions against counties. The mayors of major cities, family members and mental health advocacy groups are strongly supportive.

Mental health courts and other forms of intensive mental-health intervention and treatment vary widely throughout California, as counties control local programs — with considerable state funding, vast disparities in quality and little state oversight. Manley’s court is often called the “gold standard” for similar courts around the country, and he sees the successes when care providers and a sympathetic judge join forces to intervene.

Peer support is a key component of the governor’s proposal.

“We need to stop trying to fix a failed system,” Manley said at the governor’s press conference, characteristically blunt, a striking presence with his shock of white hair and black eye patch, the result of a decades-old injury. “We are rapidly moving back to where we were 100 years ago, where the answer for the mentally ill was simply to incarcerate them in a hospital and keep them there until they die. Mental health is a real crisis in our court system, and mental illness is not a crime.”

In a March 7 interview with Capitol Weekly, Manley said treatment facilities and staff must be increased at the local level. “I see these individuals every week, who cannot survive in the community in the condition they’re in, and they’re in jail,” he said. “I have 110 mentally ill individuals sitting in jail whom I’ve ordered released, but there is nowhere for them to go because there are no open beds. I’ve seen this number skyrocket during the pandemic.”

Manley also called for more paid “peer support” workers, who have long been a staple of successful treatment programs a concept that is rapidly gaining support in state and local government. Peer workers are people with “lived experience” in the mental health and criminal justice systems, who may not have clinical degrees.

Major “peer certification” legislation finally passed in California in 2020 after years of failed attempts. It helps expand the use of peers in treatment programs, and peer support is a key component of the governor’s proposal.

Newsom’s plan is a civil court proposal which seeks to intervene before an arrest. It borrows elements from the proven model of Mental Health Court that Manley pioneered in the criminal courts, as well as from Assisted Outpatient Treatment (AOT) programs in civil courts under Laura’s Law.  Approved in California 20 years ago, Laura’s Law programs currently exist in 31 counties, covering about 80 percent of California’s population.

State Sen. Susan Eggman has also introduced eight other mental health bills this year, and has been consulted by the administration on the governor’s proposals.

Both programs have long, documented records of success, and significant cost savings, but are not mandatory under state law. CARE Court would be mandatory, overseen by civil – not criminal – courts.

Plans to put the governor’s proposal into effect were included last week in a state Senate bill  by Sen. Susan Eggman (D-Stockton), a former social worker and Sacramento State professor who has successfully shepherded major mental health legislation into law in recent years. Sen. Tom Umberg (D-Santa Ana), a former federal prosecutor and deputy “drug czar” to President Bill Clinton, is co-author.

Eggman has also introduced eight other mental health bills this year, and has been consulted by the administration on the governor’s proposals.

“We are trying to address a broken mental health system,” she said in an interview, “and the governor’s proposal provides a new entry point – an onramp to a system that for too long has focused on crisis management. We’ve long promised a community mental health system, and we’ve failed.”

“Counties are all in to do our part to solve homelessness and rebuild behavioral health infrastructure … (but) sanctions are not the way to do it.” — Graham Knauss

Unlike local Laura’s Law programs or the Mental Health Courts, Newsom’s CARE Court would be required in all 58 counties, with significant state oversight and possible court sanctions for counties that fail to create, and maintain, viable CARE Court programs.

In “extreme cases,” according to the Newsom proposal, civil courts could “appoint an agent to ensure services are provided.”

Counties immediately balked at the broad range of the proposal, particularly court sanctions against counties, which many mental health experts contend are necessary to provide accountability in a patchwork system long known for inconsistent policy, lax follow-up, poor data collection – and extremely limited state oversight, enforcement or sanctions.

“Counties are all in to do our part to solve homelessness and rebuild behavioral health infrastructure,” said Graham Knauss, executive director of the California State Association of Counties, in a March 3 statement. “Sanctions are not the way to do it.”

Veteran mental health experts sharply disagree.

“I understand they (the counties) don’t like it,” said Randall Hagar, legislative advocate for the Psychiatric Physicians Alliance of California, who has helped write many mental health bills over more than two decades, and has provided input to the Newsom administration on the proposal. “At the end of the day, there has been no accountability and no sanctions that, in my memory, have applied to counties.  Accountability is a really sensitive issue to the counties, but how can they oppose it?”

Echoing the views of other mental health advocates, Hagar, the father of an adult schizophrenic son, said state policy has historically been plagued by clashes among local and state authorities, with county mental health agencies resistant to substantive change, while calling for more funding to deal with a pervasive, statewide housing and mental health crisis.

“There is a tradition of tensions between state and local authorities,” he said. “We need to break up the silos, and it’s not okay to stand on the same policy positions that have been used for so long.”

“CARE Court will serve a different population, but I am hoping the state will run things better [than the counties].” — Brian Stettin

Brian Stettin, policy director for the Treatment Advocacy Center , a national mental health advocacy organization, says counties are too often stumbling blocks for important reforms in California. He cited the slow progress of expanding AOT programs to all counties, which are allowed to “opt out” of Laura’s Law — although all of the larger counties now have AOT programs.

As an assistant state Attorney General in New York in 1999, Stettin wrote Kendra’s Law, named for 32-year-old Kendra Webdale, pushed to her death from a subway platform by a severely mentally ill man who had been repeatedly hospitalized. While AOT has been much more widely utilized in New York than in California, cases still fall through the cracks, Stettin wrote in a recent article about a Jan. 15 subway death that was eerily similar to the Webdale case.

Based on Kendra’s Law, the 2002 California law is named for Laura Wilcox, a 19-year-old college student and Nevada County mental health clinic receptionist who was killed in 2001, along with two others, by a deranged clinic patient, whose family had repeatedly tried to warn clinic officials of his severe deterioration. They refused to listen.

Nevada County became the first county in the state to adopt Laura’s Law, six years after it was passed — a condition for the settlement of a lawsuit against the county by her parents, Amanda and Nick Wilcox, who have advocated for Laura’s Law throughout the state. It remains, by all accounts, one of the most effective AOT programs in 31 of California’s 58 counties.

“Most California counties operate only nominal AOT programs,” Stettin said. “CARE Court will serve a different population, but I am hoping the state will run things better [than the counties]. It is tragic how few AOT participants in California actually go before a judge.”

Some advocates say a ballot measure may be necessary if legislators fail again this year to enact substantive change.

As in California, Stettin said, most AOT cases in other states are initiated with the person’s agreement. But he said California counties tend to reach voluntary settlements that don’t involve the court, whereas other states place all participants under the court’s supervision. “The judge functions as a really positive figure,” he said, “making it a mutual commitment.”

Newsom and supporters of the governor’s proposal – including the mayors of many major California cities — argue that broad statewide reforms are needed to address a deepening crisis, despite billions in funding over decades, and multitudes of failed or flawed policies .

Some advocates say a ballot measure may be necessary if legislators fail again this year to enact substantive change, and Eggman last year created a campaign account for such a measure if legislative efforts fail.

Although supportive of Laura’s Law and recent Eggman legislation to strengthen it, Newsom said it’s not utilized effectively at the county level, citing low statewide figures for Laura’s Law cases — based on incomplete state data about court-ordered treatment, which does not include a larger number of cases that are resolved voluntarily, without court intervention.

Still, getting the law adopted statewide in the 20 years since it was passed has been a long slog.

To be fully funded and approved, through legislation and in the 2022-23 state budget, Newsom’s CARE Court proposal faces huge legislative and administrative hurdles, as well as opposition among disability rights groups staunchly opposed to involuntary treatment. The proposal is strongly backed by state and local officials and mental health advocacy groups. Supporters include family members, who are often the default caregivers for severely mentally ill relatives yet receive hardly any government support or even acknowledgement.

“It’s time we face the painful, but obvious truth: our behavioral health system in California is broken” — Todd Gloria

Newsom has met personally with family members, and has highlighted their struggles to get help for their often adult children. “There but for the grace of God go any of us,” he said. “It’s a system that completely lets them down.”

The proposal is also backed by the mayors of major cities.

“It’s time we face the painful, but obvious truth: our behavioral health system in California is broken,” said San Diego Mayor Todd Gloria at the governor’s press conference, calling the CARE Court proposal “a major step forward, [providing] individuals struggling with behavioral health issues a pathway to the housing and health services they need – and give those who encounter these individuals a real way to get them the help they need.”

Under the CARE Court plan — detailed on a recently created state Health and Human Services Agency website — referrals for services could be made by behavioral health clinicians, family members, law enforcement, first responders and courts. In theory, a “care plan” would be promptly initiated for a range of services, from treatment to housing. Public defenders would be appointed by the courts to represent individuals in the program.

Initial intervention could occur at many key junctures, such as family crises — when people will call 911, generating a law enforcement response which too often ends badly— or after an individual is released from a hospital following a mental health “hold.”

Key elements of Newsom’s CARE Court plan are comprehensive “wraparound” and “continuum of care” services designed to prevent institutionalization…

The most common form of mental health holds in California is a 72-hour “Section 5150” detention under the 1967 Lanterman-Petris-Short (LPS) law that has governed the state’s mental health system for more than 50 years, severely limiting involuntary treatment.

Many people are released well short of 72 hours, frequently returning to the streets.  Last year alone, Newsom said 56,000 LPS 5150 holds were initiated in California.

In the wake of many well-publicized incidents of mental health calls that escalated into arrest, injury and death – and huge legal payouts to families who sue — local governments are already making major shifts in how police respond to those calls, with social workers assigned to work with police to de-escalate such incidents and get people into treatment.

Key elements of Newsom’s CARE Court plan are comprehensive “wraparound” and “continuum of care” services designed to prevent institutionalization, which too often means jail or prison. Both are popular concepts among mental health clinicians and families, but inconsistent and poorly funded at the local level.

At least one-third of inmates in jails and prisons  are believed to be suffering from mental illness. Mentally ill defendants, although not convicted of a crime, are much more likely to stay in jail for long periods while awaiting evaluations of their mental state, to determine whether they are able to understand the charges against them or assist in their defense. The evaluations are largely conducted by state mental hospitals with huge case backlogs.

Although Newsom says the new system won’t replace the state’s antiquated 1967 LPS law, the proposal clearly represents a sea change in state policy.

Mentally ill people are also more likely to be victims of crimes than perpetrators, and charges are often minor, exacerbated or caused by their underlying mental illness and related drug use. But minor charges can easily escalate with multiple arrests, and news articles  abound about people with untreated mental illness committing terrible crimes, frequently after repeated, usually brief hospitalizations, restraining orders, and family pleas for intervention before a crime is committed.

Unlike many earlier proposals, treatment outlined in the governor’s CARE Court plan specifically includes substance-abuse issues, which often accompany – and worsen — severe mental illness, as homeless, untreated people self-medicate with dangerous street drugs.

Although Newsom says the new system won’t replace the state’s antiquated 1967 LPS law, the proposal clearly represents a sea change in state policy. While the Legislature has failed to make broad changes in the law, recent legislation to modify it is regularly passing in the Legislature, and signed by the governor.

In a March 16 interview with KQED Public Radio in San Francisco, Newsom said that substantive mental health reform has been limited by “severely outdated laws and regulations from the 50s and 60s,” a clear reference to the 1967 law. “For decades, we’ve been debating LPS,” he said, ‘which was constructed in a world that no longer exists.”

Lanterman-Petris-Short was introduced more than 50 years ago by three well-meaning, bipartisan legislators in response to decades of institutionalization …

Individuals detained under a “5150” mental health hold (a reference to the section of the state Welfare and Institutions Code that incorporates LPS) would qualify for services under Newsom’s proposal, which includes the possibility of conservatorships for those needing a higher level of care and supervision. Improvements in an underfunded, understaffed public guardian/conservatorship system are also part of the plan, as well as in recently introduced legislation.

Lanterman-Petris-Short was introduced more than 50 years ago by three well-meaning, bipartisan legislators in response to decades of institutionalization, when mentally ill and developmentally disabled people – including many children – were routinely held, often for decades, with little recourse, in a vast system of state mental hospitals where treatment was minimal. Many were injured or died under circumstances state investigators found “highly questionable” in one massive 1970s investigation. Most of the hospitals were closed in the 1960s and ‘70s, with only a few remaining, mainly to house inmates deemed criminally insane by the courts.

But the promised “community care” for thousands of former state hospital residents never materialized, consigning them – and generations to follow – essentially to fend for themselves, often after decades in institutions. Many family members were unwilling or unable to help, while other families became (and remain) default caregivers, with little or no support. Families who do try to help say they are blocked by overly stringent confidentiality laws, and frequently told by authorities that their relatives must be homeless or arrested – or worse — in order to get help. Many caregivers are aging parents of adult children.

“We are at a time when we need to be hopeful — and honest that our current system is not working.” — Le Ondra Clark Harvey

Acknowledging the challenges of implementing a massive proposal with many moving parts – and viewpoints about it – the Newsom administration has been reaching out to disability rights groups, treatment providers, families, community organizations and local governments, among others, with a series of community meetings and webinars.

Disability rights advocates flatly oppose any suggestion of “forced” or “involuntary” treatment (although court-supervised treatment is in reality more nuanced, often voluntary), and county governments remain wary.

The National Alliance on Mental Illness (NAMI), an influential organization that has long represented families, strongly favors the proposal, as do many on-the-ground community treatment organizations. Bipartisan support in the Legislature for mental health reform has often meant unanimous votes on key legislation in recent years.

“We are at a time when we need to be hopeful — and honest that our current system is not working,” says Le Ondra Clark Harvey, a psychologist and former legislative staffer who heads the California Council of Community Behavioral Health Agencies, which represents nonprofits and other agencies that administer many key mental health programs for the counties. “There are many unanswered questions,” she said of the CARE Court proposal, “and I look forward to more detail. But the strategy is good. It’s time to put everything on the table and have an honest conversation.”

“I thought I could fly. I almost jumped off a building. It’s a change in consciousness similar to dementia.” — Lee Davis

During a recent,  virtual “town hall”  organized by Disability Rights California, which has long opposed court-mandated treatment, many participants favored more comprehensive, voluntary services and described negative experiences with involuntary treatment under the current LPS system. But others with “lived experience” in the mental health system, spoke of emerging from the fog of mental illness only because they were involuntarily treated.

“While I was ill, I was a danger to myself,” said Lee Davis,  chair of the Alameda County Mental Health Advisory Board. Davis is stabilized with bipolar disorder and has written extensively on mental illness. “I thought I could fly. I almost jumped off a building. It’s a change in consciousness similar to dementia. You wouldn’t leave an elderly person in a state of mental confusion to just fend for themselves,” Davis told the town hall, although she was not representing the Mental Health Board in her comments.

“I fundamentally disagree with the notion that everybody is in a position to make a decision voluntarily,” she added. “I was absolutely in a different state of consciousness and needed help. I’m so glad I was involuntarily committed and stabilized, and now I’m in a position to speak for people who have had that experience.”

Lawmakers agree: Little change in CA’s mental health care system

In a lengthy, often emotional legislative hearing on California’s badly broken mental health system, lawmakers and dozens of witnesses agreed that very little has changed, despite decades of new laws and huge infusions of public funds.

If there was any consensus on solutions during the grueling, all-day Dec. 15 joint hearing of the Assembly Health and Judiciary Committees, it was that the system urgently needs major overhaul — although legislators have long failed to agree on the details of systemic change.

Testimony from the hearing is expected to serve as a template for yet another round of new bills – and some recycled measures – on one of the most vexing issues facing lawmakers in the coming year.

“We do so much in this state in silence. It’s really frustrating, and inhibits information getting to decision-makers.”– Mark Stone

“We have struggled with this in the Legislature for decades,” said Assemblyman Mark Stone, D-Scotts Valley, chair of the Judiciary Committee. The closure of most state mental hospitals in the 1960s and 70s followed myriad investigations and widespread media coverage of abuse and “highly questionable” deaths in the hospitals. But the “community care” touted to replace them never materialized, leaving counties to create patchwork local systems with little or no state oversight.

Stone called the current system “fractured,” and cited a “disconnect” between local and state mental health agencies, with counties complaining about state licensing delays and state officials saying there are no backlogs.

“We do so much in this state in silence,” he added. “It’s really frustrating, and inhibits information getting to decision-makers.”

As families of severely mentally ill relatives – mostly parents of adult children — demonstrated outside the Capitol, with banners urging “right to treatment before tragedy,” legislators heard wrenching accounts of a system that lacks adequate community treatment facilities, or staff, and is hobbled by laws that block treatment or early intervention, leading to decades of repeat hospitalizations, homelessness, incarceration and early death.

Advocates seeking reform of California’s mental health care system gather at the Capitol. (Photo: Scott Duncan)

“The way that we treat the seriously mentally ill in our state is shameful and unacceptable!” said Teresa Pasquini, the mother of a severely mentally ill adult son who has been bounced around the system for more than two decades — including more than 40 involuntary detentions, frequent hospitalizations, solitary confinement and homelessness.

Pasquini is a longtime Bay Area mental health activist with the influential National Alliance on Mental Illness (NAMI), which represents families, and her testimony was among the most dramatic of the day-long session, as she angrily recounted her family’s tortuous journey to get help for her troubled son.

‘Nothing civil or right’
“There has been nothing civil or right about my son’s care in California,” she said. “We must stop saying that we are progressive protectors of human, civil and disability rights while we are forcing the most vulnerable population into early graves, solitary jail cells or homeless encampments in the name of freedom of choice. There is no choice, no dignity, no freedom under the current system.”

Local and state public agencies charged with their care and treatment work at cross-purposes, uncoordinated, in a vast, dizzying bureaucracy…

Despite billions in public funding — and innumerable reports, studies, task forces, government reorganizations and legislation — increasing numbers of seriously ill mentally ill people continue to suffer and die on the streets, in jails, prisons and overwhelmed hospital emergency rooms ill-equipped to help them. Most are repeatedly returned to the streets, with epidemic proportions of mental illness, substance abuse (often a form of “self-medication” in the absence of treatment) and homelessness in cities throughout California.

Local and state public agencies charged with their care and treatment work at cross-purposes, uncoordinated, in a vast, dizzying bureaucracy with long waitlists for treatment, housing or “beds,” strictly limited legal options for families, little oversight or accountability — and, predictably, frequent tragedy.

Yet a 1967 law — then widely touted as a “landmark” reform measure — has instead become a barrier to significant change in public mental health policy for more than half a century, largely impervious to policy changes or even limited legislative intervention. Efforts to change the law have often failed, mainly over concerns about individual rights, and the Dec. 15 hearing was carefully titled, “Lanterman-Petris-Short: How Can it be Improved?”  Not reformed or replaced, but improved.

One lengthy 1970s state investigation into 1,200 state hospital deaths revealed 140 “highly questionable” deaths in 10 of the 11 state hospitals during one three-year period.

Named for three well-intentioned legislators (two Democrats, one Republican) deeply committed to righting the wrongs of a brutal and archaic system of forced institutionalization, Lanterman-Petris-Short (LPS) relied on an empty promise: that a robust system of community care would be available for the thousands of “residents” who had spent years, decades even, in state mental hospitals, with limited treatment and little recourse. Many died in the hospitals — which housed both mentally ill and developmentally disabled residents.

One lengthy 1970s state investigation into 1,200 state hospital deaths revealed 140 “highly questionable” deaths in 10 of the 11 state hospitals during one three-year period, according to a series of articles in the Sacramento Bee.

Suddenly, as the hospitals were closed, people who had been locked up for years returned to families (if they had any),  who were often unable or unwilling to house or care for them (and many more who tried, at tremendous emotional and financial cost). Case follow-up, treatment or financial support were largely nonexistent. Many died, or became homeless, incarcerated, cycling through hospital ER’s. Families who tried to help them encountered a largely impenetrable bureaucratic wall of legal restrictions under LPS.

State Sen. Susan Eggman has previously said a state ballot measure may be necessary to pass significant reform and has formed a campaign committee for that purpose.

While a state system of 21 regional centers to provide housing and treatment for developmentally disabled residents, was created in 1977 in legislation by then state Assemblyman Frank Lanterman, R-Pasadena (one of the three authors of LPS 10 years earlier), no such system was designed for the mentally ill. Many mental health policy experts point to the current regional center system as a possible model that should be adopted for effective mental health housing and treatment.

‘Lesser than, less ‘worthy’’
“People with developmental disabilities have a right to treatment in the least restrictive environment” under the 1977 Lanterman law, said Sacramento Mayor Darrell Steinberg, a longtime mental health advocate and former state Senate president who was the author of the Mental Health Services Act (MHSA), the so-called “millionaire’s tax” passed by voters as Proposition 63 in 2004.

“The [regional center] system is not perfect,” he added, but it does provide housing and services, while no such services exist for the mentally ill, who are often seen as “lesser than, less ‘worthy’ of our care and treatment.”

State Sen. Susan Eggman, D-Stockton, a former social worker and Sacramento State professor who has been the author of major mental health legislation throughout her nine years in the Legislature (eight in the Assembly), was present on the dais as a “guest” of the two Assembly committees holding the Dec. 15 hearing. She has previously said a state ballot measure may be necessary to pass significant reform and has formed a campaign committee for that purpose.

She also suggested at the hearing that a special session of the Legislature be held to finally address systemic legislative change in a deeply entrenched, conflicting system that clearly isn’t working. And she said the Legislature should consider re-establishing a state Department of Mental Health, which was eliminated by the Brown administration in 2011, its duties absorbed into other departments.

“Nobody in this room is looking to keep more people [detained] against their will.” — Susan Eggman

Major themes in the hearing were the lack of statewide oversight or accountability and notoriously poor or nonexistent data collection on the effectiveness of existing programs. Many cited the lack of a “single point of contact” for state mental health administration, which has long been a complex, often conflicting blizzard of agencies and programs that receive considerable public funding.

Most mental health programs are administered locally by the state’s 58 counties, but there is wide variation in consistency and quality, and only limited state oversight, much less accountability. While the counties report some data to state agencies, there is no consistent enforcement mechanism if they fail to provide adequate data, as many do.

“Nobody in this room is looking to keep more people [detained] against their will,” Eggman said. “We’re not here to expand LPS. Our goal is to help people not reach that level. We are at an inflection point in our society, in our politics, everything. It is incumbent on us to get this right, to use the funds we have to help as many as possible.

“We are all distressed by what we see in the streets. It is apparent that we have a huge breakdown in our system. The counties don’t have enough money, and we’ve given them a lot of money. There is a clear disconnect, with mothers of 40- or 50-year-old adult children struggling to get help. As a society, we have failed.”

‘Funding is a mess’
Funding for LPS comes from a variety of local, state and federal sources, causing further confusion in administering the massive and aging law. “Funding for LPS is a mess,” said Assemblyman Jim Wood, D-Santa Rosa, chair of the Assembly Health Committee, “and shouldn’t there be a single entity to oversee all of the funding? I’m struggling with who is in charge.”

Laura’s Law is one of the few laws to make significant change in LPS, giving family members a legal avenue to get severely mentally ill relatives into intensive care.

“Nobody knows what the hell is going on,” he added, throwing up his hands in frustration.

Witnesses at the hearing included dozens of local and state officials and representatives of mental-health advocacy groups, clinicians, law enforcement, firefighters, social workers and others on the front lines of mental health programs in California.

State Auditor Elaine Howle, who last year released a scathing report  on LPS, remained critical of poor data collection, oversight, and a lack of treatment or follow-up for people leaving care (or recycling through it). “There is a lot of funding,” Howle said at the hearing, “yet no overarching, comprehensive, clear view of mental health services. . .How much are we spending for inpatient vs. outpatient [care], incarceration, repeat holds, suicide rates?”

She praised “Laura’s Law,”  passed in 2002 and recently strengthened in Eggman legislation, as a “very effective type of treatment,” with documented results. It is one of the few laws to make significant change in LPS, giving family members a legal avenue to get severely mentally ill relatives into intensive care.

Randall Hagar, legislative advocate for the Psychiatric Physicians Alliance of California, who has helped write much of the major mental-health legislation in recent years, called the LPS system “crisis-driven and failure-driven,” based on “waiting for danger, which is too late, makes outcomes worse for patients, doesn’t help families,” and is wildly expensive in both human and public costs such as incarceration and hospitalization.

“The financing of the system is crazy.” — Randall Hagar

Concurring with many other experts who testified at the Dec. 15 hearing, he said the system clearly needs “one point of contact” for state oversight, perhaps a new Department of Community Mental Health to provide statewide coordination, data collection and accountability at the local level. And he said multiple funding streams for mental health – including the billions raised by the state Mental Health Services Act – need serious examination.

“The financing of the system is crazy,” he said, echoing the views of legislators and other mental health experts who spoke at the hearing. He said the 1% “millionaire’s tax” is a source of considerable funding but suffers from inconsistent oversight and complex regulations. And it likely will need to be updated, he added, to more accurately reflect the vast sums of wealth acquired in recent years by the “one percent,” either as part of broader legislation or a ballot initiative.  Both approaches are high on legislative agendas in the coming year.

“Mental health and homelessness are at the top of any public opinion poll in California,” Steinberg reminded the committees. “Conventional wisdom says that incremental change is possible in the Legislature, but the fragmentation of the mental health system — and the inability of people to access care – [require] bold and fundamental change.

“The time for that is now.”

Editors 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 [email protected]

 

Real change proves elusive in mental health care system

Important legislation to improve California’s broken mental health system was passed this year, plus billions in new funding in the state budget — all aimed at stemming the tide of a growing crisis on California streets, in hospital ER’s, jails and prisons.

But will it mean real change?

Longtime mental-health advocates and public officials welcome the intense interest in a badly neglected area of government policy.

But some question whether ever-growing infusions of cash and new laws will effectively change a system hobbled by competing bureaucracies, entrenched stigma and a baffling lack of comprehensive statewide data on the effectiveness of old and new programs.

Many say a complete overhaul is needed.

“While it’s amazing to see the magnitude of  interest [and] budget investment, it’s disquieting that there isn’t a better sense of cohesion and coherence in the solutions,” said Randall Hagar, who has written much of the legislation and policy analyses for major bills as a legislative advocate for the Psychiatric Physicians Alliance of California, which represents psychiatrists.

The result, he says, is a “bushel of ideas,” but limited systemic change. “We’ve had two decades of really encouraging sound bites, but we still have the same number of people homeless and mentally ill, the same number in jails and prisons.”

A homeless man lying on the sidewalk in front of a Beverly Hills bank. Experts see clear links between homelessness and mental illness.(Photo: Joseph Sohm, via Shutterstock)

Crippling the efforts for fundamental change is the Legislature’s apparent inability to pass major legislation that significantly alters the 1967 Lanterman-Petris-Short Act (LPS), which has dictated California’s mental health policy for more than 50 years.

One of the few major changes to LPS was passed nearly two decades ago, giving family members a legal avenue to get severely mentally ill relatives into intensive treatment. “Laura’s Law” was strengthened and finally made permanent by state Sen. Susan Talamantes Eggman’s legislation last year, and further enhanced in another bill this year by Eggman (D-Stockton).

The original 2002 law, by then-Assemblywoman Helen Thomson (D-Davis), was named for 19-year-old Laura Wilcox, who was killed in 2001 while working during her winter break from college at a Nevada County mental health clinic. Her killer was a deranged clinic patient whose family had warned authorities about his condition, but were ignored.

Laura Wilcox (Family photo)

While widely praised as a major breakthrough — successfully coaxing more people into voluntary treatment, reducing incarceration, homelessness and hospitalizations, and saving public funds — the law is limited to severely mentally ill people who fit certain criteria. Mental health experts say more needs to be done to treat mental illness before it becomes severe – spurring a major push this year to provide better treatment, and funding, for children and youth.

Suicide 2nd leading cause of death for ages 10-24
Motivated in part by an alarming increase in mental-health crises among young people, especially during the isolation, loneliness and loss of COVID, one of the largest expenditures in the state budget is a five-year, $4.4 billion Children and Youth Behavioral Initiative aimed at better screening, intervention, and treatment for youths up to age 25.

It comes at a time when suicide is the second leading cause of death for young people aged 10-24, according to the Centers for Disease Control — a number that has increased by 60 percent between 2007 and 2018, before the pandemic, escalating even further during COVID.

“Half of all lifetime cases of diagnosable mental illnesses begin by age 14,” and three-fourths by age 25, said Dr. Mark Ghaly, a pediatrician who is Secretary of the state Health and Human Services Agency. He is particularly focused on improved services for kids.

“There’s no universal place to go if a young person is struggling with stress, anxiety, depression — or something more serious,” he wrote in a recent article . “There is too little focus on prevention, too few programs, too few behavioral health professionals, too few emergency services, and too few hospital beds for young people with mental health and substance use issues.”

But getting older teens – or anyone over the legal age of 18 —  into treatment also faces a plethora of barriers under the extremely restrictive provisions of Lanterman-Petris-Short, which established a cumbersome legal system of limited “mental health holds” – the “5150’s” of mental health law, a reference to the state Welfare and Institutions Code, which requires proof of “a danger to themselves or others.” Even then, mental-health holds usually last only 72 hours, hardly time enough for actual treatment, or any treatment at all.

When it was passed in 1967, LPS was regarded as a major “reform” measure, a reaction – many now say an overreaction — to widespread abuse of civil liberties, injuries and deaths in a vast system of state mental hospitals which were largely closed in the 1960s and ‘70s, with stringent limits placed on compelling treatment.

State Sen. Susan Talamantes Eggman (D-Stockton). (Photo: Senate staff)

But the community care designed to take their place never materialized, and the result is legions of mentally ill people — many with drug addictions from “self-medicating” because they aren’t receiving treatment – who are living on the streets, cycling through hospital ER’s, and jails, usually for petty crimes or behavior related to their mental illness.

‘The new asylums’
Jails and prisons have become de facto mental institutions, the “new asylums,” ill-equipped to help or even house mentally ill inmates.  Many are jailed for months, even years, because of a growing backlog of defendants — charged but not tried — awaiting “mental competency” evaluations in the remaining state mental hospitals, which primarily house those deemed criminally insane by the courts.

Legislation to address mental health and related issues like substance abuse, homelessness and incarceration, has been introduced for years, often unsuccessfully, and only recently has the state started to take a hard look – and provide significant funding.

The landmark Mental Health Services Act, the so-called “millionaire’s tax” passed by voters as Proposition 63 in 2004, has provided billions in funding for mental-health programs, but has also been criticized for its complex regulatory structure and lack of state oversight. Counties have also been accused of “hoarding” MHSA funds that should be going to mental-health programs, or using it for other purposes.

In addition to multiple bills enacted this year, hearings are scheduled during the legislative recess to examine possible broad changes to LPS. A Behavioral Health Task Force  appointed by Newsom last year is ramping up its public meeting schedule, and there is talk of a ballot initiative to enact a major overhaul.

A view of a homeless encampment along Central Avenue in downtown Los Angeles. (Photo: Matt Gush, via Shutterstock)

The outlook appears positive.

“I’m excited that the next few years will be transformative,” Eggman, a former social worker and Sacramento State professor who has long been in the forefront of major mental-health legislation, told Capitol Weekly in a recent interview. “We can make a difference and fix a system that we all acknowledge is broken, and help people.

“The governor’s budget includes significant funds for mental health and homelessness. The very wealthy have done very, very well in the stock market. We should use some of that money to lift up the least of us.”

“Maybe we could take these [mental-health] issues to the voters and ask them,” Eggman added. “We cannot ask for changes in the law (Lanterman-Petris-Short) unless we have the infrastructure” – including treatment facilities and housing that are in short supply throughout the state.

Eggman has opened a campaign committee for a possible ballot measure.

Among other bills this year, Eggman’s SB 516 would have redefined “grave disability” (often the standard for mental-health treatment under LPS) by allowing courts to consider a person’s ability to manage a serious physical health condition when determining if they present a danger to themselves under LPS. The measure passed unanimously in the Senate, but was held – along with several other bills involving changes to LPS – in the Assembly Health Committee, which called for more in-depth hearings on the history and future of LPS.

Joint LPS hearing Dec. 15
A joint hearing of the Assembly Health and Judiciary Committees is scheduled Dec. 15, and is expected to guide legislators in crafting comprehensive LPS legislation next year.

Other important bills were also tabled or extended into next year, including Eggman’s  SB 316, which would have enabled clinicians to bill Medi-Cal for more than one medical condition per visit (e.g., treatment for a physical ailment and a mental health disorder). The measure has failed repeatedly over the past 17 years — despite widespread support for coordinated care — but can be revived next year by the author.

A related budget item that failed last year was revived this year. It would provide funding for mental-health training for primary care physicians – who are often the first point of contact for patients experiencing mental-health crises. The state budget includes $9.5 million to fund Primary Care Psychiatry fellowships at the UC-Irvine School of Medicine.

As the lingering COVID pandemic shined a bright light on the stark failures of a cumbersome, outdated system, legislators introduced dozens of bills to strengthen existing laws, and create new programs. Those ranged from measures to target mental health crises among children and teens to a statewide response system for mental-health calls that includes social workers and clinicians, rather than going directly to law enforcement, with often disastrous results.

While local governments are establishing alternative response systems throughout the state, a much-publicized California measure, AB 988, by Assemblywoman Rebecca Bauer-Kahan, D-Orinda, was passed unanimously in the Assembly, but became mired in the legislative process, and was extended into next year for further discussion.

Named for Miles Hall, a 23-year-old mentally ill Black man who was shot and killed by Walnut Creek police officers in 2019 after his family called for help, the measure would implement 2020 federal legislation establishing a national “988” phone line for suicide prevention and mental health crises. Walnut Creek city officials last year announced they had reached a $4 million settlement with Hall’s family.

For his part, Newsom traveled the state, holding press conferences (while also, successfully fighting a recall) to announce major funding for a dizzying array of ambitious programs to tackle one of California’s most persistent and intractable public health emergencies.

In a recent Capitol Weekly conference on “California’s Mental Health Crisis,” Ghaly, who heads the state Health and Human Services Agency, which is leading the charge in the Newsom administration’s plans to address mental health, called the pandemic “the great unmasker of disparities and inequities, and the great accelerant for change.”

Michelle Cabrera, executive director of the influential County Behavioral Health Directors Association of California, said stigma remains, despite growing public support for mental health programs. “We’re on the precipice of change,” she said at the conference, “But stigma is still there, and unconscious bias,” which too often thwart local and state efforts to get mentally ill and homeless people off the streets, into housing and treatment, and keep them out of jail.

A homeless man sits alone in the shadow of a building. (Photo: Followtheflow, Shutterstock).

 

‘A fragmented system’
“We struggle with a fragmented system,” said Dr. Elaine Batchlor, CEO of the MLK Community Health System in Los Angeles, who also spoke at the conference. Despite laws requiring “parity” or equal treatment of mental-health and physical conditions, current insurance and reimbursement requirements – both publicly funded Medi-Cal and private insurers – too often treat mental health and substance abuse separately from physical care.

Batchlor and many other public-health experts say mental-health issues are more effectively (and much less expensively) addressed in a coordinated system of care, so that patients in crisis, who often also have major physical conditions exacerbated by homelessness and poor medical care, are treated under one health-care umbrella.

“We need more acute stabilization units,” she said. “If we can find resources for people in crisis, we can avoid hospitalizations.”

While dozens of bills were introduced this year – Hagar said he was following at least 65 mental-health bills as a legislative advocate for psychiatrists – many failed to gain traction, and some were vetoed by the governor. Others were continued for further hearings into next year. But several major bills were passed, often with unanimous, bipartisan support — plus significant funding in the state budget, federal funds, and Newsom’s well-publicized support for programs to aggressively address mental illness, homelessness and incarceration.

“I’ve really been struck – and pleasantly surprised – by how bipartisan the votes were on so many of these bills,” says Julie Snyder, government relations director for the Steinberg Institute, the mental-health advocacy organization established by former state Senate President, now Sacramento Mayor, Darrell Steinberg, who was the author of the Mental Health Services Act.

“COVID actually accelerated that. Every legislator, lobbyist and staffer has experienced the mental-health impacts of isolation. There is heightened recognition — not that the solutions come more easily,” she said.

Advocates caution, however, that the real work often begins after bills become law — ensuring that the intent of the legislation is actually carried out by state and local government.

“There is tremendous work to be done to ensure that the concepts in the bills and in the governor’s budget are effectively implemented,” says Hagar, pointing to lax, uneven implementation in the 30 counties  that now have some form of “Laura’s Law,” which passed in 2002 and was only recently strengthened and expanded, though still not available in every county. “As we’ve learned with Laura’s Law, implementation can be a bitch.”

Often hampering implementation is a dearth of reliable statewide data collection– to determine how well or how poorly state and local programs succeed in reducing such markers as repeat hospitalizations, homelessness, incarceration. Lack of good data – and followup care for patients released from treatment, or conservatorships – were major criticisms by state Auditor Elaine Howle in a scathing report last yearthat specifically addressed Lanterman-Petris-Short.

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.

Laura’s Law, for example, requires that the state Department of Health Care Services maintain program statistics from the counties, and issue regular reports,but advocates say the data provided is too often confusing and incomplete. 

“There is a lack of statewide data collection, but also a lack of accountability for poor program performance,” says Hagar, who helped write the original Laura’s Law, as well as recent bills to strengthen it, “so we can look at the history, see what patterns emerge.” 

Summary of major 2021 mental health bills
This is by no means a comprehensive list of mental health legislation passed this year. More complete descriptions, and more bills, can be found on several legislative and advocacy websites, including the Steinberg Institute  and the National Alliance on Mental Illness — California. 

Below are the authors and summaries of several major mental health bills passed by the Legislature this year and signed by Gov. Newsom. Many bills have several co-authors.

SB 465, by Eggman, provides for better use of state funds by using “evidence-based outcome measurements” in mental-health care (e.g., measuring the effectiveness of programs in keeping people out of jail, hospitals, homelessness), passed unanimously.

SB 507, by Eggman, further expands Laura’s Law (Assisted Outpatient Treatment, AOT), passed unanimously. It provides for a clinical determination that the person is “unlikely to survive safely in the community without supervision,” that the person’s condition is not only “substantially deteriorating” (the existing standard), but also that assisted outpatient treatment is needed toprevent deterioration” that would likely result in grave disability or serious harm to that person or to others. The bill also authorizes the filing of a petition to obtain assisted outpatient treatment for a person who is about to be released from conservatorship. 

SB 317, by Sen. Henry Stern (D-Los Angeles), expands current law governing treatment options for people accused of crimes who are thought to be mentally ill. If a defendant is found incompetent to stand trial on a misdemeanor charge, the court could refer that defendant to diversion or community treatment programs, consider a referral to a conservatorship proceeding or dismiss the charges. If defendants are confined pending a trial in a state hospital or treatment facility, they would be eligible for partial credit against a subsequent sentence for the time they spent in the facility.

AB 816, by Assemblyman David Chiu (D-San Francisco), appropriates approximately $130 million annually to build apartments for homeless people living with severe mental illness, including “wrap-around” support services.

SB 14 and SB 224, by Sen. Anthony Portantino (D-La Canada-Flintridge), to address a growing mental-health crisis among children and youth in California schools by implementing procedures to educate students and staff about mental health, and ensure that school absences for mental health issues are excused in the same way as absences for physical illness.

SB 428, by Sen. Melissa Hurtado (D-Sanger), requires private health insurers to cover screening for Adverse Childhood Experiences (ACEs) — traumatic events in a child’s life (such as violence, abuse and neglect) which are increasingly known to cause or exacerbate mental illness in children, who can be helped with early identification and treatment.

SB 221, by Sen. Scott Wiener (D-San Francisco), requires health providers and insurers to schedule follow-up appointments with psychotherapists or other non-physician specialists within 10 days of an initial appointment for a non-urgent mental health or substance use disorder.

Providers are now required to schedule an initial appointment with a clinician within 10 days of a person seeking help, but it is often weeks before people can get a follow-up appointment.

AB 118, by Assemblywoman Sydney Kamlager (D-Los Angeles), enacts the Community Response Initiative to Strengthen Emergency Systems Act (C.R.I.S.E.S.), to provide grants for community-based pilot programs that reduce reliance on law enforcement agencies as first responders in crisis situations that are unrelated to a fire department or emergency medical service response.

Editor’s Note: 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 [email protected].

Capitol Weekly Interview: Susan Talamantes Eggman

Susan Talamantes Eggman was raised in Turlock, where her family owned a small almond orchard and apiary (bee-keeping), and her first job that wasn’t on the family farm started her on a path to working in health care and mental health throughout her life.

Toward the end of her senior year at Turlock High School, in 1979, she got a job at a psychiatric facility, Crestwood Manor, where her title was  “milieu manager,” a fancy way of saying she tried to keep the severely mentally ill patients safe, mediate disputes, help them with daily tasks and medication.

“There were fights, and falls, and people could still smoke,” she recalled in an Aug. 26 interview with Capitol Weekly. “We would go outside, and I was the lighter of people’s cigarettes.” And she remembers “very clearly, the first time I was laid out in the hallway during [dispensing of] meds.”

A male patient “punched me right in the stomach so hard that it knocked the wind out of me, put me on the floor. I remember being surrounded by people looking down on me. That’s something you don’t forget.”

She worked at Crestwood for about six months, graduated from high school and, at 18, from a family of veterans, joined the U.S. Army as a medic. After four years in the Army, she returned to Turlock and completed a Bachelor’s degree in Psychology and a Master’s in Social Work at California State University, Stanislaus, later earning a PhD in Social Work at Portland State University.

State Sen. Susan Eggman.

She started her PhD program in 1997, when Oregon’s ground-breaking end-of-life law — known as the Death with Dignity Act — had just taken effect, and she worked as a medical social worker with patients in hospice care at the University of Oregon Hospital (now Oregon Health and Science University, a trauma center and teaching hospital).

Her mother, who was Latina, served as Eggman’s research assistant for her doctoral dissertation, and they traveled throughout the Valley, interviewing families for a research project on the challenges of end-of-life care for Latinos.

Long-shot run for City Council
A licensed clinical social worker (LCSW) with long experience in medical social work in myriad settings — from hospitals and hospices to locked psychiatric facilities, jails and addiction treatment centers – Eggman, now 60, was a Social Work professor at California State University, Sacramento, when she decided to run for the Stockton City Council in 2006. It was a long shot, and her surprise upset victory made her the first Latina and the first lesbian ever elected to the council.

During the campaign, she regularly confronted rank homophobia. The opposing candidate referred to herself as “God’s candidate,” and introduced her “soul mate” husband at campaign events.  In one televised debate organized by the NAACP, Eggman turned pointedly away from the camera and addressed her opponent directly: “Injustice is injustice, no matter how you wrap it up.”

It was typically direct, no-frills Eggman, cutting through the political noise to expose the core of the issue.

She was an unlikely politician – a social worker and teacher with a passion for community organizing — but has rapidly risen in local and state government, earning a reputation for successfully working across the aisle to pass, often unanimously, some of the most significant mental health legislation in decades.

State Sen. Susan Eggman, D-Stockton, at a Capitol committee hearing. 

In 2012, she made a similar grassroots run for the state Assembly, was easily re-elected and last year won a state Senate seat representing San Joaquin County, a wide swath of Stanislaus County and Galt in Sacramento County. She has successfully shepherded multiple, complex mental-health bills into law, including a major Assembly measure last year, AB 1976, which significantly strengthened “Laura’s Law” to give families one of the few legal avenues to get seriously mentally ill relatives into treatment.

Passed nearly two decades ago, Laura’s Law (Assisted Outpatient Treatment, or AOT) has been successfully implemented in many California counties — reducing hospitalizations, incarceration, homelessness and saving public funds. But it was not made permanent until Eggman’s legislation, nor did it require counties to hold public hearings and explain why they did not have such programs, as AB 1976 did. It was passed unanimously last year, and has since been adopted in 30 of California’s 58 counties, including all of the larger ones.

Eggman introduced six mental-health reform measures in the Legislature this year. Two of the most significant bills were unanimously approved and sent to the governor before the Legislature adjourned on Sept. 10, and one was extended into next year:

–SB 507,  further expanding Laura’s Law, passed unanimously and sent to the governor.

SB 316, enabling clinicians to bill Medi-Cal for more than one medical condition per visit (e.g., treatment for a physical ailment and a mental health disorder). The measure has failed repeatedly over the past 17 years — despite growing support — and this year  was tabled in the Assembly, but can be revived next year by the author.

SB 465, providing for better use of state funds by using “evidence-based outcome measurements” in mental-health care (e.g., measuring the effectiveness of programs in keeping people out of jail, hospitals, homelessness), passed unanimously and sent to the governor.

SB 621, providing more housing and treatment for the huge numbers of people who are homeless and mentally ill, stalled in the Senate.

SB 516, redefining “grave disability” (often the standard for mental-health treatment) by allowing courts to consider a person’s ability to manage a serious physical health condition when determining if they present a danger to themselves. The measure was extended into next year for further hearings.

SB 749  (with Sen. Steve Glazer, D-Orinda), creating better statewide data collection on mental health expenditures and programs, opposed by county mental health directors concerned about costs, died in the Assembly.

End-of-Life Law
In addition to her mental-health legislation, she is perhaps most widely known for the 2015 landmark End of Life Option Act, which for the first time provided terminally ill Californians the option to end their lives. And she is true to her three-generation family roots in agriculture and natural resources, serving on the Senate committees on Agriculture, Natural Resources and Energy, and sponsoring a bill providing funding for solar energy in multi-family housing units in disadvantaged communities.

State Sen. Susan Eggman and her daughter Eme.

She also serves on the Senate Committees on Health; Business, Professions and Economic Development; Budget and Fiscal Review; Energy, Utilities and Communications, and Military and Veteran’s Affairs. She is a member of the legislative Latino Caucus, the Women’s Caucus and is vice-chair of the LGBTQ Caucus.

Eggman lives in Stockton with her partner of more than 30 years, Renee Hall (they were married in 2014), and their daughter Eme.

Randall Hagar, who has long represented the state’s psychiatrists and helped write multiple bills on mental-health issues, many authored by Eggman, says she is laser-focused and thoroughly prepared in long, legislative hearings, cutting through the bureaucratic morass with incisive questions, moving key bills through the circuitous, time-consuming legislative process.

“She’s a woman of the people,” he says. “She relates to farmworkers, comes from a small farming family, very down-home, nothing fancy. And she’s not a calculated person, nor a self-promoter. She’s a master bread-maker, and when she tweets, it’s likely to be about bread.”

“Bread is life,” Eggman, who bakes bread for her legislative colleagues, told the LGBTQ publication, the Bay Area Reporter for a recent profile.

“I love to feed people,” she added. “It is the ultimate act of nurturing.”

Editor’s Note: Eggman was interviewed by Sacramento journalist Sigrid Bathen for Capitol Weekly on Aug. 26. The following interview has been lightly edited.

CW: During your eight years in the state Assembly, and this first year of a four-year term in the Senate, you have become known as the preeminent legislator for significant mental-health legislation. As a licensed clinical social worker and Sac State social-work professor, you have vast experience in mental-health issues. What originally drew you to focus on mental health, first as a social worker and later as a state legislator?

Eggman: I knew from a pretty young age that I wanted to work with people, impact people’s lives — going back to my first job that was not on my family’s farm, working in a locked psychiatric facility in Turlock for about six months. I started there during my senior year in high school. After graduation, I joined the Army, was a medic for four years, a general medic and urology tech. There I got medical training that has served me well, and I’ve often been a first responder at various events. While I was getting my Bachelor’s (at Cal State-Stanislaus), I worked at a drug and alcohol program. While I was getting my MSW, I worked in a locked psychiatric facility for eating disorders, and at a dual-diagnosis center (mental illness and chemical dependency). I’ve worked in hospice care, mental health, crisis intervention, in jails and hospitals. I have a lot of direct field experience.

CW: Many people in the forefront of mental-health policy reform are family members who have lived with the realities of mental illness while also battling the vagaries of the mental-health bureaucracy and a patchwork system of care. What is your experience as a family member, and how did those experiences help to shape your views?

Eggman: My aunt, who had severe bipolar disorder and eventually died. She was raped in the Tenderloin [in San Francisco], contracted HIV-AIDS. She wasn’t sick enough to be hospitalized, but sick enough to be raped. How is that dignity for anybody?

And now, watching my cousin, who was her mother’s primary caregiver and is not doing well today. You see the long-lasting impact of mental health issues on a family. Families can try their very best, and are not able to make the system work.

CW: You came to public office later in life, having been a medical social worker and professor at California State University, Sacramento, for many years. What prompted you to run for your first public office, on the Stockton City Council in 2006?

Eggman: Because somebody had to, and I’m a social worker. It was the day after [George W.] Bush was elected to his second term, and there had been “welfare reform” at the federal level, which was an attack on the most vulnerable among us. I went to a faculty meeting, and it was like walking into a funeral. I looked around and banged my fist on the table and said somebody gets elected, why don’t we run for office? We’re trained in organizing, problem-solving. It was one of those life-defining moments.

But this was 2006, and people said, ‘You’re a Latina and a lesbian – you can’t tell anybody you’re a lesbian!’ And I said, ‘So I’m gonna tell people my partner is my cousin? People don’t have to vote for me, and I’m running, as a lesbian and a Latina.’ It was a big upset, big surprise (an open seat soon to be vacated by a term-limited member). It was all grassroots, no developer money. We talked about obesity, literacy, cleaning up parks. Two of my second-year MSW (Master’s in Social Work) graduate students worked in the campaign, and I’ve always had MSW’s working in my office, five currently. I’m passionate about my profession, and it’s a great fit for policy. At the end of the day, I see it as a continuation of my work.

CW: That first Stockton campaign was ugly at times, with homophobic threats and slurs. But you raised more than $100,000, mostly in small-dollar contributions, and won by a significant margin. How did you deal with the threats, insults?

Eggman: Yes, there were threats, and I was kicked out of churches. Reporters followed me around.  That’s a whole different conversation. There were very few “out” [elected officials] at the time. But things got better, and there’s hope.

CW: Laura’s Law  (California’s version of Assisted Outpatient Treatment or AOT) by then state Assemblywoman Helen Thomson (D-Davis) was passed in 2002. Last year, your AB 1976 to strengthen Laura’s Law and finally make it permanent, was unanimously passed in the Legislature, [and] quickly signed by the governor. Since its passage, increasing numbers of California counties which previously were able to quietly “opt out” of Laura’s Law — as many did – have enthusiastically embraced AOT programs, pointing to the significant success in previous Laura’s Law counties, which have seen major reductions in incarceration, hospitalization and homelessness, and resulting cost savings.

That support is a far cry from insistent opposition, often from political progressives and disability rights activists fearful of involuntary treatment, when the law was first passed. Why do you think that opposition has faded, and evolved? Are public attitudes changing? And what does that mean for future mental-health policy and programs?

Eggman: It is the right time. The public is willing to look at things differently. We had a system that didn’t work. And we changed it, but we didn’t fix it, and now we have another set of problems. Homelessness and the very real, visible mental health issues in front of people every day, have prompted us to examine our feelings. The best place for [mentally ill] people is in the community. But there are times when treatment is necessary, and people no longer have an option when they can no longer care for themselves. . .It is when our values collide with some of our freedoms. . .The consequences of that are middle-class people seeing homeless people on the streets. . .It’s right at their doorway. It has crept into living rooms across America as it hasn’t before, especially in California where we pride ourselves on how we treat people with dignity and respect.

As I’m going into the end (Eggman is term-limited at the end of her current term), I want to focus on mental health. That is where I started my career as a young person. And we can make a difference and fix the system that we all acknowledge is broken, and help people. The governor’s budget includes significant funds for mental health and homelessness. The very wealthy have done very, very well in the stock market. We should use some of that money to lift up the least of us.  I’ve always been focused on improving people’s lives. And in the end, my focus will be on mental health, not exclusively, but that will be my primary focus.

I’m excited that the next few years will be transformative.

CW: You’ve always worked across the aisle. AB 1976 – to strengthen Laura’s Law — was remarkably bipartisan, which is also true of other mental-health bills. Mental health has never really been a traditionally partisan issue, but more disability rights and “progressives” vs. “involuntary treatment,” which was always an oversimplification.

Eggman: Totally.

CW: The state Auditor released a blistering report on California’s mental-health care system last year, lambasting the lack of statewide data collection and follow-up care for people detained under very limited Lanterman-Petris-Short (LPS) mental-health “holds,” usually no more than 72 hours, often much less. The auditor’s very specific critique has been addressed in several of your current bills on better data collection and measurements based on actual patient outcomes. But the Auditor has been criticized for concluding that LPS, the 1967 “reform” measure that has governed mental health care in California for decades, should not be changed. Should legislators revisit that issue in a broader sense?

Eggman:   That’s a conversation many people are having.

CW: Local officials – especially judges – express growing concern about the number of severely mentally ill people kept for months, sometimes years, in local jails without trial, awaiting mental competency evaluations, in large part because of a huge backlog in the remaining state mental hospitals (which now primarily house those deemed criminally insane). Some defendants are diverted to Mental Health Courts, but many others languish in jail.  It’s a dire situation exacerbated by COVID. It’s been suggested that more of those evaluations could be done at the local level.  Legislative solutions?

Eggman: There was a proposal by the governor to move people back to the counties. Dr. [Mark] Ghaly (who heads the state Health and Human Services Agency) is really good, determined to make this better. The Senate Mental Health Caucus (an informal caucus on mental health issues chaired by Eggman and state Sen. Scott Wiener, D-San Francisco)  met recently about how that money will be spent. There is money coming, in infrastructure spending, but how will it be utilized?  Buildings could be rehabbed (for housing, treatment). We need beds. We need to have the full continuum of care.

Counties are responsible [for care]. But we need the infrastructure. We would have the beds right now if the state hospitals [were repurposed). I hope the pandemic ends before I’m termed out, because I want to visit all of the state hospitals, so I can get a better sense of how they could be [utilized] for care. They could be used to help a lot of folks, but they’re full, and the counties are responsible for these folks but don’t have anywhere to put them.

CW: You have long worked to get a CSU in Stockton, and $54 million was appropriated in the governor’s 2021-22 budget for major building improvements at the Stockton campus of CSU-Stanislaus. Not a complete campus, but a major improvement. How do you plan to pursue this in the next few years?

Eggman: We didn’t get the campus, but we did get a pretty good down payment. And it’s becoming a major health-care center, for dialysis, prostheses, an ACE program (to address Adverse Childhood Experiences). There is a real health-care focus, partnering with local hospitals. And it’s located on the grounds of the old Stockton State Hospital.

CW: You’ll be termed out in less than four years. You’re often mentioned as a very viable candidate for statewide office, or Congress, after that. It’s early, but what are your future plans?

Eggman: I do not have [a campaign] account open for anything else. I do have an account for a ballot initiative, but no specific proposal at this time. Maybe we could take these [mental-health] issues to the voters and ask them. I don’t know. We cannot ask for changes in the law (Lanterman-Petris-Short) unless we have the infrastructure.

I taught at Sac State for 12 years. My exit strategy is to return to teaching. I have no interest in Congress.

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