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.”
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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 [email protected]