Capitol Weekly Interview: Randall Hagar and mental health care

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

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

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

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

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

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

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

When did you become interested in mental health advocacy?

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

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

How did your mother’s illness affect the family?

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

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

How did you and your brothers cope?

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

Describe your time as a student at UC-Davis.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Did Burton’s views ever change?

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

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

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

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

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

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

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

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

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

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

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

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

In that respect, it’s a grand experiment.

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

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

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

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

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

Overall, has there been progress after all these years?

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

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

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

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

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

Can families expect more support in the current atmosphere?

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

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

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