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.

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.

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