Sigrid Bathen

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Tag: mental health

Out of the Snakepit, Parts 1 & 2

by Sigrid Bathen posted September 9, 2005


Rose King has seen it all.

A widely recognized expert on mental health issues, she has served in the trenches of the mental health wars for more than 30 years–even before the 1969 suicide of her husband, who suffered from what was then called manic depression. Years later, her son also committed suicide—after suffering from the same illness, known now as bipolar disorder.

She saw the emptying of the state hospitals during the 1960s–ultimately, some 87 percent of 36,000 patients were “deinstitutionalized”–that began under Gov. Ronald Reagan and continued through the 1970s by Gov. Jerry Brown. She saw the legions of homeless mentally ill roaming the streets, passing through temporary shelters and jails, victims of the state’s failure to pay for community mental health care as promised when the state hospitals were shuttered.

Today, only 4,700 mental patients remain in state hospitals.

She saw families struggling with health insurers and public mental health programs to get help from a failed system plagued by lack of money, understaffing and disorganized services. The hard lesson learned: Care is often available to the mentally ill only when they are in a state of severe crisis.

“It hasn’t really changed since my husband became ill,” says King, who lives in East Sacramento. “It remains crisis-driven, crisis-perpetuating and fragmented.”

“We turn mental health clients away and tell them to return when their symptoms are so severe and persistent that they cannot meet their own needs, and may no longer even recognize that they need care,” the Little Hoover Commission noted in a 2000 report.

But last year, voters approved Proposition 63, the landmark mental-health initiative that taxes the wealthy at 1 percent of all income over $1 million. That means Californians will now see the first major infusion of money into mental health care in decades—an estimated $1 billion a year, specifically for community mental health care.

King and other activists hope that the money will transform the wretched conditions that blight urban streets and consign millions of afflicted Californians and their families to lives of poverty and desperation.

But the story of Rose King and her family is not just a story of the struggle for mental health care. It is the story of a system so flawed that it harms the very people it is supposed to protect.

Rose and Joseph King first sought help from their health insurer–Kaiser–as Joseph began to experience frightening symptoms of depression and paranoia in 1968. Joseph “saw the doctor who had treated him for asthma, and was told there was no psychiatrist on staff in Sacramento,” Rose recalled. An urban planner who worked for regional planning agencies in California and Alaska, Joseph soon became so disturbed that he could no longer work.

Desperate, they drove to DeWitt State Hospital in Auburn–which was in the process of closing.

“They wouldn’t accept him at DeWitt,” she said. “He didn’t look ill, and they said he ‘didn’t meet their criteria.’ We had no idea where to go.” He was finally admitted “for a couple of weeks” to a mental health clinic run by Sacramento County, where his wife said he was seen by a psychiatrist twice, and sent home on a weekend pass. That night in 1969, at age 36, Joseph King killed himself.

Grief-stricken and now a single mother to 8-year-old twins and their 6-year-old sister, King, who had been a homemaker and volunteer political activist, went back to college, earning a Bachelor’s in government-journalism at California State University, Sacramento, and a Master’s in journalism at the University of California-Berkeley.

She interned in the Capitol for Democratic Sens. George Moscone and Mervyn Dymally, and worked for $25 a week in the unsuccessful 1970 gubernatorial campaign of Assembly Speaker Jess Unruh. She later worked in paid jobs for a succession of powerful Democratic legislators–including Assembly Speaker and Lt. Gov. Leo McCarthy, Senate Leader David Roberti and Assembly Speaker Antonio Villaraigosa.

But her first introduction to mental health issues had been in 1967, the year before her husband became ill, when she ran an unsuccessful but well-publicized campaign to recall Reagan, in which many of the core activists were medical and psychiatric workers infuriated by conditions for the mentally ill.

As she became more involved in the issue, she pressed politicians, pollsters and the media to lift the heavy curtain of ignorance and stigma that has long surrounded mental health policy. She helped staff a statewide task force on mental health issues under McCarthy when she was his chief of staff in the lieutenant governor’s office.

“Nobody even asked what public opinion was on the subject,” she says. “I asked Mervin Field to start putting [questions about mental health] in his surveys, and there were two statewide polls done for the [Senate] Rules Committee when I was working for Roberti in the 1980s. The importance of the subject of mental health to citizens was first in one poll, second in the other.”

In 1984, her 23-year-old son Michael was diagnosed with bipolar disorder, which is often hereditary and can surface with frightening symptoms in late adolescence or early adulthood. Years later, after battling the disease for nearly two decades, Michael committee suicde. He was 42 years old.

In 1990, King worked on an initiative to raise the alcohol tax to fund mental health care.

“It was unsuccessful, but not because people didn’t think something should be done about mental health,” she says. She was chief consultant to the Joint Legislative Committee on Mental Health Reform convened by Senate Leader John Burton in 2000 and co-chaired by former Assemblywoman Helen Thomson, author of numerous mental health measures over the years and a former psychiatric nurse who is now a Yolo County Supervisor. Thomson was termed-out of the Legislature in 2002, and King, who was principal consultant to the Assembly Health Committee that Thomson chaired, retired the same year.

King’s oldest daughter, Michael’s twin sister, does not have the condition, says King, but her youngest daughter was diagnosed with bipolar disorder at age 30, following childbirth, which can be a “trigger” for emergence of the disease. King’s youngest daughter, now 43, a college graduate with two degrees earned before the onset of the disease, “manages her condition quite well and works in her profession,” her mother says.

Recently, a teen-age grandchild has shown symptoms of the disease, and the 66-year-old King once again finds herself in the mental health trenches, seeking help from a still-fragmented system of mental health care that has bedeviled California families like the Kings for decades.

As California gears up to put Proposition 63 into effect, former Assemblyman Darrell Steinberg, who authored the measure, King and other supporters are carefully following its progress.

“I’m hopeful,” King says of the flawed, crowded mental health care system. “It’s not like we don’t know what works or what needs to be done…It’s not unusual for a case manager to have a caseload of 120, all people in crisis.”

She adds: “The system today is really no better than it was in the late 60s when my husband became ill.”

Next week: The devil is in the details: putting the voters’ will into effect.


Sigrid Bathen teaches journalism and communications at California State University, Sacramento. She has covered mental health issues for 30 years, winning several California and National Mental Health Association awards–and a Pulitzer nomination–for her mental health coverage in the Sacramento Bee and the California Journal.


New money for mental health care; Families hopes rise

by SIGRID BATHEN posted 09.08.2005


 

Darrell Steinberg, whose crusade to help California’s mentally ill culminated in the passage of the landmark Proposition 63, got an early education in the power of grass-roots advocacy.

As a law student at the University of California at Davis in 1984, he led a successful student campaign to improve access for the handicapped at the law school. Two of Steinberg’s closest friends were quadriplegics who could not access the mock courtroom in their wheelchairs, and the students successfully forced the university to install a lift.

Steinberg, a Sacramento lawyer and Democrat who is running next year for a local state Senate seat, learned a lesson that he would remember years later when he successfully pushed for Proposition 63: Get organized, then get the money.

“We organized, involved the press and found the money, which supposedly was not available,” Steinberg recalled when, as a state Assemblyman, he returned to his former law school 20 years later to deliver the commencement speech.

Now, the money for community-based mental health care will finally become available.

Approved in November and still in its planning stages, Proposition 63 represents the most important changes to California’s mental health system in decades. The changes are desperately needed: More than half of those surveyed in public opinion surveys say they have a relative or close friend with serious mental problems. For the first time, the families of the mentally ill will be directly involved in deciding how to spend the mental health funds.

Proposition 63 will provide an estimated $1 billion annually through a 1 percent tax on all annual income above $1 million. The money will go to community-based mental health care programs, which can apply for grants following Proposition 63’s strict criteria. The money can be used only for local mental health care — including housing, training, therapy and counseling — and cannot be diverted to state correctional or parole programs. So far, $24 million has been allocated for the initial planning and review of local project proposals. By the end of the current fiscal year in June 2006, some $700 million is expected to be set aside for community mental health services.

The money has been a long time coming.

“We have a once-in-a-lifetime opportunity to demonstrate to the state and the country that people with mental illness can lead productive lives, be part of our communities, live independently–and that with a decent system of supports and services, people do not have to be relegated to lives of hopelessness,” Steinberg said.

Steinberg, a former Sacramento City Council member, made mental health care one of his principal campaign platforms when he ran for state Assembly in 1998.

Shortly after he took office, Steinberg introduced AB34, which initially provided $10 million to fund pilot projects for community services to the mentally ill. The bill was the direct progenitor of Proposition 63 and marked the first significant investment in mental health in decades.

One year after the pilot projects were funded in 1999, Steinberg said, “we found that the 1,000 people helped under AB34 were showing the beginnings of real success, with decreased hospitalizations and reduced homelessness.” He points to impressive statistics from the AB34 projects: Participants had a 56 percent reduction in hospital stays, a 72 percent reduction in jail stays and a 65 percent increase in full-time jobs. The success of the pilot projects prompted Steinberg to push for more funding, and to take the matter directly to the voters during his final year in the Assembly, where he was termed-out in 2004.

Thus, Proposition 63 was born.

Steinberg and Rusty Selix, the longtime executive director of the Mental Health Association of California, led the Proposition 63 campaign, organizing a coalition of supporters who included the mentally ill and their families – people who historically were excluded from mental health policy-making. The coalition raised $5 million to place Proposition 63 on the ballot and secure its passage.

Officially called the Mental Health Services Act, it was approved with 53.4 percent of the vote. The mentally ill and their families are specifically included in the planning, implementation and staffing of the new law. Steinberg, meanwhile, chairs the 16-member Oversight and Accountability Commmission for Implementation of Proposition 63, which will be administered by the state Department of Mental Health.

Polling for the measure showed that a majority of people had a relative or friend with severe mental health problems, although the stigma against seeking care remained. “Public acceptance has been proven,” says Selix. “But the willingness to talk openly about it among average people is another matter. Not every school, nor every employer, understands.”

Clearly, after decades of neglect, the available funds will be stretched thin.

“The law was pretty specific,” says Dr. Stephen Mayberg, a psychologist who has been director of the state Department of Mental Health for 12 years. “They wanted to make sure to expand services, not to duplicate or backfill services, and specific populations are targeted.” Funding cannot be used for jail and prison or parole populations, and must avoid what Mayberg calls “the fail-first system” of previous years.

“The first time they have contact is when they are institutionalized or arrested–that is probably not a good introduction,” Mayberg says.

Mayberg’s department employs more than 10,000 people, many working in the remaining state hospitals which house some 4,700 people–mostly individuals who have been judged criminally insane or incompetent to stand trial. It is a much different population than was housed in 1961, when 36,0000 mentally ill were kept in state hospitals throughout California, before the “deinstitutionalization” of the hospitals under Govs. Ronald Reagan and Jerry Brown.

Those hospitals were plagued by scandals ranging from unexplained patient deaths to persistent reports of neglect, abuse, misdiagnosis and over-medication. But when they were closed, little was left in their place. Mental health care activists say the promise of community care has been little more than a cruel hoax on the mentally ill and their families, leaving increasing numbers of homeless mentally ill on the streets or in jail.

Proposition 63 backers hope that community care, at least, will markedly improve with significant money and staffing under the new law. The state Department of Mental Health recently added more than 80 employees specifically to work on improving and expanding community programs under the new law.

Experts say housing is the most urgent need – and the initial funding priority — for the chronically mentally ill (who often avoid shelters), as well as for families of the mentally ill and former foster kids who are kicked out of the foster care system.

“It’s very hard to provide services if people don’t have stable housing,” says Tim Brown, longtime executive director of Sacramento’s Loaves & Fishes, which does not accept government funding but has been actively involved in local planning for use of the new money. “But people need a lot of support in housing. It’s certainly preferable to their going in and out of jail.”


Sigrid Bathen teaches journalism and communications at California State University, Sacramento. She has covered mental health issues for 30 years, winning several California and National Mental Health Association awards–and a Pulitzer nomination–for her mental health coverage in the Sacramento Bee and the California Journal.

Changes in mental health care system spur new optimism

capweeklyaug2011

Changes in mental health care system spur new optimism

by SIGRID BATHEN posted 08.18.11


Massive changes in how mental health care is delivered to Californians – including abolishing or restructuring the two state departments responsible for mental health and substance-abuse programs – are being closely watched by care providers and advocacy groups.

They say they are “cautiously optimistic” that Gov. Brown’s plan will result in a coordinated, community-based system of care for the thousands of people who historically have faced a dizzying patchwork of care, or no care at all.

But advocates emphasize that mental-health care must have a prominent position in the state bureaucracy.

“We need somewhere to go to at a very high senior policy level,” said Mark Gale, chairman of the public policy committee for the California arm of the National Alliance for the Mentally Ill and the father of a mentally ill son. “We need someone at the highest level who understands core mental health policy, law and regulations, someone who has lived it. If we don’t get this right, the system will become extremely dysfunctional. If we get it right, there is great opportunity.”

Financed in part through a one-year appropriation of $861 million in the 2011-12 budget from the so-called “millionaire’s tax” approved by voters in 2004 as Proposition 63 to fund new mental health programs, the reorganization aims for a coordinated approach to mental health – and a major shift from the state to the counties for funding and managing mental-health programs, with state oversight.

Some services are being moved to the huge state Department of Health Care Services. There is talk of two new departments – one under the rubric of “Behavioral Health” or “Mental Health and Substance Abuse,” and another for “Institutions” or “State Hospitals” to administer the remaining state hospitals, which primarily house the criminally insane.  A recent spate of assaults, including the strangulation death of a psychiatric technician at Napa State Hospital last October, has prompted a series of state and federal crackdowns at those facilities, which currently house nearly 6,000 patients.

A major concern is abolishing the Department of Mental Health.

“There is tremendous fear in the mental health community about eliminating the Department of Mental Health,” said Rusty Selix, longtime executive director of the Mental Health Association in California. Selix is the co-author, with state Senate President Pro Tempore Darrell Steinberg, D-Sacramento, of the landmark Mental Health Services Act, passed by voters in 2004 as Proposition 63.

“Where are we left if the next administration doesn’t have the same level of interest?” Selix added.

Representatives of advocacy and professional groups are vocal participants in public hearings held throughout the state in August and September by the state Health and Human Services Agency and the soon-to-be defunct Department of Mental Health. The hearings solicit comments for the complex reorganization plan taking shape at the state and local level.

“There are a lot of pieces to this puzzle, and we need to look at it as a whole – courts, prisons, police, state hospitals, community programs – and re-engineer a system that works better,” said Randall Hagar, government affairs director for the California Psychiatric Association, who has followed mental health issues for decades and is the father of a schizophrenic son. He says the Brown administration’s reorganization proposals come at a critical juncture for both providers and families. “Some of the tools are there already, but we have a system that has evolved piecemeal for nearly five decades.”

Rose King, a legislative and state policy expert on mental-health issues (who is the widow, mother and grandmother of mentally ill family members), has regularly attended the ongoing “stakeholder” meetings and expresses increasing concern that the vague outlines of a new system still fail to address historic discrimination against the mentally ill, despite state and federal laws requiring parity in treatment for mental as well as “physical” health.

But she says the reorganization “has great potential” and “creates an opportunity for the integration of mental illness and substance abuse disorders” – and to close the disparities in treatment of mental  and physical health care.

Pat Ryan, executive director of the California Mental Health Directors Association, which represents county mental health directors, said the goal of the reorganization “is to get people help sooner rather than later, to avoid both incarceration and institutionalization. If you starve the system and don’t have money specifically intended for prevention and early intervention, you’re never going to get there, because you’re always going to be dealing with crises.” Like other advocates and providers, Ryan said “leadership is critical” in any new system – in which the counties will play an increasingly larger role under the Brown administration proposals and federal health care reform.

“The idea is to get the money flowing directly to counties with fewer strings and less bureaucracy,” said  Farah McDaid Ting, senior legislative analyst for the California State Association of Counties.  “It’s an opportunity for counties to take an integrated approach and offer a continuum of services. We haven’t had that opportunity before.”

Central to the reorganization are lessons learned from the tortuous implementation of Proposition 63, which levied a 1 percent tax on millionaires and provided $900 million to $1.5 billion annually in additional revenue for local mental health programs.

Hailed as the first significant infusion of state funding for mental health since the closures of decrepit, understaffed and overcrowded state mental hospitals nearly four decades earlier – dumping huge numbers of mentally ill people on communities ill-equipped to handle them – Prop. 63 became both an important harbinger of change and a bureaucratic nightmare.

Critics of its implementation – including some of those who helped write the law – say the process was plagued by red tape, glacially slow state Medi-Cal payments to counties, high consultant fees, accusations of cronyism,  and only a trickle of funds for actual programs.

While success stories emerged from communities where homeless mentally ill for the first time found coordinated housing and treatment with Prop. 63 funding, thousands more received little or no treatment, continuing on a tragic downward spiral of homelessness, institutionalization and incarceration, worsened by the severe economic downturn and draconian budget cuts.

The state required counties to jump through an array of bureaucratic hoops and “pre-approvals,” infuriating local officials.  At the same time, there were broad state and local cuts to social programs, with some Prop. 63 funds used in recent years to help balance the precarious California budget.

“The planning process went on and on,” says former Yolo County Supervisor and state Assemblywoman Helen Thomson, D-Davis, who chaired the Joint Legislative Committee on Mental Health and the Assembly Health Committee and is a former psychiatric nurse married to a psychiatrist.

“Every county hired a different kind of consultant. A lot of money was going into the Prop. 63 fund, and it was bureaucratized.” While some new Prop.-63-funded programs provided services, she said, “clinics were closing, beds eliminated.” Intended to supplement existing services and create new programs, Prop. 63 funds were used by cash-strapped counties to finance dwindling mental-health services.

Hagar says the language of the law included “something for everybody, to get everybody on board,” in order to ensure its passage. “Unfortunately, it was so diffuse that we had a lot of exemplary projects developed, doing a wide range of things – suicide prevention, school-based services – while heavy-duty services, core services for those who were homeless or not ‘engaged’ in the system,  did not receive the same level of support.”

Steinberg remains one of its most passionate proponents, and is clearly stung by what some say is the scapegoating of a landmark law.

“You can’t blame [Prop. 63] for the problems of a mental health system that has been decades in the making,” he said.  Quick to criticize the cumbersome implementation process, he is hopeful the current reorganization will address flaws in the process. “The process has been faulty, and it has gone too slowly at times. It’s been way too slow off the mark in reporting data.” Still, he added that despite setbacks, the 2004 law “remains a monumental accomplishment,” and, when fully implemented, will help provide coordinated care and keep the mentally ill out of jails and prisons.

“The fact is that we’re living through the worst recession in 50 years, and we’ve cut budgets in ways I abhor,” he added. “Prop. 63 was never intended to be the solution for all of the system’s problems. It was intended to provide comprehensive care for people with severe mental illness, with the main goal of keeping people out of the system. ”

The law included specific requirements that funds be used only for “new” services (not existing programs), and not for jails or prisons. The complex approval process that evolved, administered by the state Department of Mental Health, will likely be scrapped by 2012-13, along with the department – “reorganized” or “redirected” in state budgetary parlance – as will the state Department of Alcohol and Drug Abuse.

While state administrators are deep in a widely publicized “Public Safety Realignment,” less has been said publicly about the administration’s lower-key efforts to coordinate mental-health and substance-abuse programs with the state’s vast and costly correctional system, which faces massive court-ordered population reductions and mandated improvements to all aspects of prison health care.

Since many prisoners are also mentally ill and vast numbers are serving time for drug-related crimes, advocates say coordination of mental-health and substance-abuse services at the local level is critical to any reorganization plan, and could help avert much more expensive, sometimes deadly, arrests and incarceration.

Local officials express relief that some of the bureaucratic hoops, especially the much-maligned “pre-approval” process for Prop. 63 funding, will be eliminated, and that Medi-Cal reimbursement backlogs – which often stacked up for months, leaving counties holding the bag – will be reined in.

Newly appointed Health and Human Services Agency Undersecretary David Maxwell-Jolly, the former state Health Care Services Department director who is overseeing the reorganization with Agency Secretary Diana Dooley, said technological improvements have dramatically reduced the paperwork blizzard and Medi-Cal backlogs. He noted that state officials were “less responsive and perhaps less efficient than we could be.”

But officials are adamant that state oversight and especially “evaluation of outcomes” will be a high priority under the reorganization, and that mental health will remain high on the administration agenda regardless of its placement in the state bureaucracy.

Among those assigned to this daunting and often thankless task is a career state administrator, Cliff Allenby, recently appointed by Gov. Brown as interim director of the Mental Health Department. A veteran state Finance Department administrator who has headed several state agencies, including the Department of Developmental Services, Allenby has no illusions about the challenges inherent in reshaping a flawed and broken mental health system.

“We don’t have all the answers,” Allenby said. “We really don’t. The stakeholder process is very important – what should remain, and how that should be [reorganized].  I’m not here to prejudge, and we really will listen carefully at the stakeholder meetings to what they have to say, then prepare a proposal for the 2012-13 budget.”

“I’ve been around a long time, and Sacramento is just not the place to establish policies that work in all 58 counties,” he added, borrowing an oft-repeated anecdote from the governor’s proposals. “What works in L.A. isn’t necessarily what works in Redding.”

Many aspects of the proposed reorganization are unknown, including the specifics of long-term funding sources and state oversight of local programs. “Somehow we must have a very high-level policy visibility that is not buried in some bureaucracy somewhere,” says the Psychiatric Association’s Hagar. “The track record hasn’t been great.”  But despite sometimes heated disagreements among the various “stakeholders,” there is widespread consensus that the administration push toward coordination of mental-health services is long overdue.

Advocates and providers are hopeful that much-touted plans for “integration of services” will carry more weight than the hollow promises of decades past.  They point to the badly fragmented system  that resulted, in which the streets, jails, prisons and state mental hospitals for the criminally insane have become both the first and last resort for the severely mentally ill, who might have been helped with earlier intervention.

“The jails are full of people who are mentally ill, and hospitals are ringed with barbed wire and security guards,” says veteran mental-health advocate and former Assemblywoman Thomson.  “It’s the ‘trans-institutionalization’ of mental illness, and it’s tragic.”


Sigrid Bathen teaches journalism and communications at California State University, Sacramento. She is a former Sacramento Bee and California Journal reporter and editor who has covered mental health issues for more than 30 years.

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