The growing push for major action on mental health and homelessness

Brian Bloom was an Alameda County public defender for nearly three decades, part of a specialized mental health unit whose clients suffered from severe mental illness, many unable to understand – or even acknowledge – that they were sick, becoming mired in an overwhelmed criminal justice system ill-equipped to help them.

Often deemed “incompetent to stand trial” by the courts, they stayed in jail, because there was nowhere for them to go, despite judges’ orders that they be released to treatment. The vast network of state mental hospitals, widely criticized as inhumane and abusive – were mostly closed in the 1960s and ‘70s – and those that remain primarily house defendants judged criminally insane, leaving little room for inmates stuck in jails and prisons, awaiting evaluation and treatment.

The “community care” touted to replace the hospitals in landmark 1967 “reform” legislation never materialized, and seriously mentally ill patients suddenly discharged after decades in state hospitals, ended up on the streets in a rapidly spiraling homelessness crisis.

This may be the year that changes, as the Newsom administration, state legislators and local officials – pushed by escalating homelessness and the increasing clout of family members – propose major reforms in a broken system of care that many say is no care at all.

A growing chorus of critics say well-intentioned but archaic laws – designed to protect individual rights, with stiff restrictions on what constitutes “grave disability” – prevent desperate families from getting severely mentally ill relatives into treatment, leaving them to suffer and die on the street.

This may be the year that changes, as the Newsom administration, state legislators and local officials – pushed by escalating homelessness and the increasing clout of family members – propose major reforms in a broken system of care that many say is no care at all.

Bloom has long advocated for a “collaborative, coordinated approach” to divert mentally ill defendants to mental health courts, which are among the many “alternative courts” responsible for cases involving mentally ill defendants, often self-medicating with street drugs. And he is a strong supporter of a growing body of state law that encourages – even requires – local intervention and treatment before someone is arrested.

“It requires collaboration among systems that don’t ordinarily have much coordination – prosecutors, public defenders, county mental health, law enforcement – for that to work,” he said, “so that cases are sent directly to mental health court, determining at the outset what level of treatment a person needs, instead of [mentally ill defendants] descending into the criminal justice labyrinth for months, even years.”

In such a model – increasingly supported by public opinion, policy and law – that intervention would be early, swift and coordinated, sometimes facilitated by a civil (not criminal) court judge. “Many people are already in the county system,” Bloom added. “They’ve been arrested before, or hospitalized. It’s not that the counties don’t have experience. Collaborative courts shouldn’t be some kind of fringy thing on the side. They should be the norm.”

Now retired from the public defender’s office, Bloom chairs the Alameda County Mental Health Advisory Board, which advises county officials on how to address a growing crisis in homelessness and mental illness, starkly visible in the mental and physical disintegration of thousands on the streets of Oakland, where the population of homeless residents has mushroomed in the past five years.

It’s one of the worst local crises in a state with the largest concentration of homeless people in the nation, exacerbated by huge disparities between great wealth and grinding poverty. In a 2022 report on homelessness in the U.S., the Department of Housing and Urban Development estimated that 172,000 people were homeless in California in January 2022, a nearly 13% increase since 2019.

Reports on income inequality paint an equally grim picture. “The gap between high- and low-income families in California is among the largest in the nation – exceeding all but four other states in 2020,” the Public Policy of Institute of California said in a recent report. The income gap worsened during the pandemic, and exorbitant housing prices pushed increasing numbers of Californians into homelessness.

Statistics on the percentages of mentally ill people who are homeless – and those in jail – are notoriously unreliable, from one-fourth to one-half, particularly if common “co-occurring” substance abuse is also involved. In many cities, law enforcement is joining with social workers and other mental health clinicians to help de-escalate mental health calls, which too often end in incarceration, injury and death.

As jails and prisons have become the primary source of mental health “treatment” in a broken care system – and homelessness continues to expand despite huge public expenditures – policy-makers struggle with solutions. One of the most far-reaching is Gov. Gavin Newsom’s CARE (Community Assistance, Recovery and Empowerment) Act being rolled out in eight California counties this year, becoming statewide in 2024.

Central to any significant LPS reform is expanding the definition of “grave disability” – the highly restrictive standard for even limited involuntary mental health holds.

Although Newsom did not propose substantive changes to the 1967 Lanterman-Petris-Short (LPS) law that has governed – many say hamstrung – mental health policy for more than five decades, the administration is working with key legislators to address elements of the law that severely restrict interventions to get people off the streets, into treatment, and keep them out of jail.

Central to any significant LPS reform is expanding the definition of “grave disability” – the highly restrictive standard for even limited involuntary mental health holds.

Modest legislation to expand the standard to include physical as well as mental health – and the ability to care for basic health needs – has repeatedly stalled in the Legislature despite broad, often unanimous, bipartisan support among legislators.

Sen. Susan Talamantes Eggman, D-Stockton, a former social worker and college professor who chairs the Senate Health Committee and is widely acknowledged as the state’s legislative leader on mental health legislation, almost succeeded in expanding the grave disability standard in legislation last year. Her SB 1416 sailed through the state Senate with bipartisan support, and was unanimously passed by the Assembly Health Committee. But it died without being heard in Assembly Judiciary, then chaired by Assemblyman Mark Stone, D-Santa Cruz.

Long opposed to involuntary treatment, Stone, who has since retired, reportedly utilized an Assembly rule that allows committee chairs to determine whether or not a bill is heard in committee. “No such rule exists in the state Senate, they have to hear it,” says veteran legislative advocate Randall Hagar, who represents psychiatrists and has helped write many mental health bills, spanning decades.

LPS reform supporters are optimistic that new members and leadership changes in the Assembly – including a new Judiciary Committee chair, Assemblyman Brian Maienschein, D-San Diego – will mean more support for reforming the grave disability standard, as well as other related mental-health measures. Maienschein strongly supported Eggman’s bill last year, calling it a “hugely important tool” in reducing homelessness, getting people into treatment.

He pointed to his many years as a San Diego city councilman and as the city-county Homelessness Commissioner, who saw firsthand the human devastation caused by untreated mental illness, substance abuse and homelessness.

“The ability to provide food and shelter (the existing LPS standard for determining whether someone is “gravely disabled”) doesn’t amount to much if you’re dying of lung disease,” he said in an Assembly Health Committee hearing last year, noting increasing deaths “from hypothermia, cardiac arrest, respiratory issues, starvation – all of which are treatable.”

Under current law, local jurisdictions interpret the vague, outdated “grave disability” standard in wildly different ways, either placing people in limited LPS “5150” mental-health holds – a reference to the state Welfare and Institutions Code governing involuntary, 72-hour holds in overcrowded hospital ER’s – or, more often, leaving them to fend for themselves on the streets.

Speaking “as someone who spent much of my professional career walking into these canyons  [where homeless encampments have proliferated in his district], to try to talk somebody into coming in for treatment who is schizophrenic,” Maienschein said, “they believe they’re making decisions in a logical way. It’s not humane to have these individuals on the street where they aren’t getting medical treatment, and are more likely to be victims of crime.

Under current law, local jurisdictions interpret the vague, outdated “grave disability” standard in wildly different ways, either placing people in limited LPS “5150” mental-health holds….or, more often, leaving them to fend for themselves on the streets.

“And I think we would all like to see law enforcement working on different issues than someone urinating in public.”

Eggman is preparing to announce a package of bills in early March, with her major focus on expanding the grave disability standard. Reflecting the distinctly bipartisan push for mental health reform, newly elected state Sen. Roger Niello, R-Sacramento, a former state assemblyman and Sacramento County supervisor, has also introduced a bill, SB 232, to expand the standard. He said he is working with Eggman to craft a bipartisan measure, calling homelessness and mental illness “a very high priority.”

Early in his Senate term, Niello reached out to a longtime colleague, former state Assemblywoman Helen Thomson, D-Davis, also a former Yolo County Supervisor, who championed major mental health legislation during a contentious time in the late ‘90s and early 2000s. She was vilified by other legislators who said her legislation infringed on the civil rights of mentally ill people and by activists who demonstrated loudly on the Capitol lawn, calling her “Nurse Ratched” (the abusive nurse in “One Flew Over the Cuckoo’s Nest”).

The protests nearly derailed Thomson’s most important bill, Laura’s Law, passed in 2002, named for 19-year-old Laura Wilcox, a college student working in a Nevada County mental health clinic when a deranged patient, Scott Thorpe, killed her and two others, seriously injuring three more. Thorpe’s family, including a brother who was a Sacramento police sergeant, had repeatedly attempted to warn local mental health officials about his deterioration, but they refused to listen, much less intervene.

A model for the more expansive CARE Act, Laura’s Law (Assisted Outpatient Treatment or AOT) created a civil-court process for getting seriously mentally people into treatment, ultimately adopted by 31 California counties.

Thomson, a former psychiatric nurse married to a psychiatrist, said expanding the grave disability standard “is the foundation of LPS reform,” noting that public sentiment has significantly shifted over the years as California’s homelessness crisis has escalated. She praised Niello for “stepping out of this terrible ‘we vs. them’ mentality’” in partisan politics.

“I remember observing her attempts to reform LPS,” Niello recalled in an interview with Capitol Weekly. “She was treated very badly. People weren’t ready.”

Niello, who was vice-chair of the Budget Committee when he was in the state Assembly, said homelessness and mental health must be given high priority. “I am not sure the state is facing a greater priority now than homelessness,” he said. “Even though there is a deficit, there is room to fund these programs. We still have a sizable general fund.”

Eggman is preparing to announce a package of bills in early March, with her major focus on expanding the grave disability standard.

While Newsom’s office does not “typically comment on pending legislation,” spokesman Daniel Lopez said in a statement that Eggman, a co-author of the CARE Act, has been “a key partner as the Administration works to implement this paradigm shift in mental health services.” He said the governor “is confident that Senator Eggman’s leadership on this critical issue will continue to deliver thoughtful, empathetic measures that uphold the dignity and rights of those suffering from the most severe forms of mental illness and substance use.”

Managing the complex implementation of the CARE Act is the task of the state Health and Human Services Agency, headed by agency Secretary Dr. Mark Ghaly. The plan – if it’s not blocked by the courts – involves a dizzying array of sometimes resistant state and county agencies, as well as health plans and non-profits that actually implement many local treatment and housing programs. At the first meeting of the 26-member CARE Act Working Group Feb. 14, demonstrators filled the room – mainly family members frustrated by decades of dealing with a patchwork system to get help for severely mentally ill relatives.

The large, peaceful group held a rally at the Capitol before the meeting, and marched to the nearby state offices of Disability Rights California, which is the lead organization attempting to block the CARE Act by filing a lawsuit in the California Supreme Court. A Capitol Weekly reporter arrived a few minutes before the protestors, and the doors were locked. She rang the doorbell, and a receptionist emerged briefly from the darkened offices.

She said nobody would be available to speak with reporters or, presumably, with protestors, who say they have been ignored despite frequent attempts to establish a dialogue. The doors remained locked as the group stood quietly holding signs demanding better care and featuring family members who had died of untreated mental illness and physical decline.

DRC legal director Christian Abasto said in a later phone interview with Capitol Weekly that DRC “listens to all people. We’re glad to meet with any group.”

At the working group meeting, a long line of CARE Act supporters from the demonstrations waited to speak during a “public comment” period at the end of the meeting. They told horrific, deeply personal stories of their attempts, largely unsuccessful, to get help for their severely mentally ill relatives, often adult children. Many strongly objected to the lack of family representation on the working group, and to the inclusion of a DRC representative when DRC is attempting to block the law in court.

Sacramento activist Elizabeth Kaino Hopper, an organizer of the demonstration, spoke about her severely mentally ill daughter, Christine – who had graduated at the top of her class in high school, was about to graduate from UC Davis when her symptoms worsened. She was present with her parents at the Capitol rally.

Christine, 33, was released in January after nine months in jail, declared “incompetent to stand trial,” following years in and out of hospitals, homeless on the streets. Her family struggled to get help, as authorities repeatedly insisted Christine was not “gravely disabled” under the rigid requirements of an outdated law. Her assault case is now in Mental Health Court, and she is receiving intensive treatment in a local program. Charges will be dropped if she completes the program.

“All of this could have been avoided,” her mother said, “had the laws been changed, and the CARE Act in place.”

“Being out is really nice,” Christine told a San Francisco Chronicle reporter at the Capitol rally. “I can see the stars at night. … I’m really happy to be out and lucky to have my mom.”

Editor’s Note: Sigrid Bathen is an award-winning journalist who taught journalism at Sacramento State for 32 years. She is a former Sacramento Bee reporter who has covered mental-health issues for several publications and 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].