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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 sigridbathen@gmail.com


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 sigridbathen@gmail.com.

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.

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

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

That’s 10 more than had previously adopted “Laura’s Law” in the 19 years since it was originally enacted, inspired by the Nevada County murder of a young woman by a mentally ill gunman.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

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

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

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


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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

Disability rights activists testified vehemently against the law, saying it violated the right to refuse treatment. They held noisy demonstrations on the Capitol lawn and in hearings on the original bill, many wearing yellow t-shirts with the triangular symbol for concentration-camp inmates deemed “mentally defective.”

Then-state Assemblywoman Helen Thomson, D-Davis,  a former psychiatric nurse and Yolo County supervisor who is the author of the original law, was heckled and called “Nurse Ratched,” after the abusive nurse in Ken Kesey’s “One Flew over the Cuckoo’s Nest,” about a fictional psychiatric hospital.

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

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

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

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

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

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

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

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

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

“The human rights and public-health crisis is not fair to families, and I think it has become a stark reality for everybody. Now is a good time. We are passing things we’ve never passed before.”

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

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

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

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

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

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

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

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

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

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

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

Santa Clara County Supervisor Joe Simitian.

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

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

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

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

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

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

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

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

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

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

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

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

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

Christine Hopper (Family photo)

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

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

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

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

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

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

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

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

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

Christianne McCrea. (Family photo)

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

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

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

Letter to the Editor: Mental health care


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

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

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

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

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

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

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

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

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

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

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

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

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

But she supports it now.

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

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

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

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

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

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

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

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

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

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

Joe Simitian, member, Santa Clara County Board of Supervisors

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Johnson

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“I now get it.”

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

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

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

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

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

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

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

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

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

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

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

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

Lloyd Connelly

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

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

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

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

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

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

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

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

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

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

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

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

Nevada County Judge Tom Anderson

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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





Published on 9/16/20

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

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

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


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

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

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

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

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

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

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

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

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

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

CW: Do you think the governor will sign it? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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