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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Manley is also critical of opposition to the proposal.

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

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

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

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

 

A deep dive into Newsom plan to overhaul mental health policy

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Veteran mental health experts sharply disagree.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“The time for that is now.”

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

Editor:

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

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

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

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

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

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

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

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

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

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

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

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

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

But she supports it now.

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

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

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

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

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

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

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

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

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

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

Joe Simitian, member, Santa Clara County Board of Supervisors

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Johnson

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“I now get it.”

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

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

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

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

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

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

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

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

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

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

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

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

Lloyd Connelly

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

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

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

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

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

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

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

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

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

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

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

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

Nevada County Judge Tom Anderson

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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