FCL NEWSLETTER ? June, 1998
Cell Therapy -- Ken Larsen &Steve Birdlebough
- Action Items
Mental Illness and the Homeless -- Nina Salomon
Resources on Mentally Ill Offenders
What Ever Happened To?
Articles in Prior Newsletters
[FCL N/L 6/98]
California fails to look after its mentally ill. This failure sometimes carries tragic consequences; reports of mass and serial killings by severely disturbed individuals are staple fare for the media. However, the real tragedy may reside in the fact that proper and timely treatment can materially cut the likelihood that such horrors will happen.
Mentally ill patients, under treatment, are unlikely to commit crimes. A 1997 study by the California Department of Mental Health of 3,000 seriously mentally ill persons found that less than two percent of those persons receiving regular treatment had been arrested in the previous six months.
If mental illness goes untreated, a different story emerges. Of 85 persons with serious mental illness held in the Los Angeles County jail, only three were under conservatorship at the time of their arrest, and only two had ever received intensive treatment. Four hundred and fifty out of 500 mentally ill persons charged with crimes in San Francisco were not receiving mental health treatment at the time they committed the crimes for which they were held.
California has been running away from taking responsibility for the care of all of its residents with mental illnesses for thirty years. While this neglect harms everyone, the brunt of the impact has fallen on the poor. The downward spiral began with passage of the Lanterman-Petris- Short Act in 1969. This well-intentioned bill brought about the wholesale discharge of patients who, prior to the legislation, would have been confined to state hospitals. While civil liberties violations, neglect, and mistreatment in these institutions were rampant and scandalous, the lack of alternatives available to patients once they hit the streets was equally deplorable.
In 1969 Dr. Jerome Lackner was state health director under Governor Jerry Brown and a leading advocate of community care. He now admits, "What little there was of a community mental health system when we let everybody out has progressively diminished. In the last three or four years, the diminution has been absolutely wrenching: closed clinics, closed services, laid-off caregivers. There was an inadequate system to begin with, and it's become more inadequate....The only long-term treatment for the mentally ill is when they finally break a law and do something really terrible."
The legislature's attempts to improve the system mostly add up to tinkering with the maze of rules and financing arrangements that burden the state's mental health care system. Their main preoccupations have been to make available to Medi-Cal patients the more promising, potent, newer medications that have been developed in recent years coupled with an effort to make the managed care industry pay for mental health treatment as it does for so-called "physical" ailments. The fruits of these efforts, however, still lie in the future. While the 1997-98 Medi-Cal budget included $19 million for more effective and less debilitating drugs, this is only a drop in the bucket in the face of the tens if not hundreds of thousands of homeless and uninsured mentally ill in the state. Legislation (AB 1100, authored by Helen Thomson, D., Davis and Don Perata, D., Alameda) to get insurers to cover mental illness is stalled in the Senate under the threat of a governor's veto.
One California prison psychiatrist told Dr. E. Fuller Torrey, a National Institute of Mental Health researcher, "We are literally drowning in patients, running around trying to put our fingers in the bursting dikes, while hundreds of men continue to deteriorate psychiatrically before our eyes into serious psychoses." And a Los Angeles police captain disclosed to Torrey that the police engage in a large number of mercy bookings of mentally ill homeless women, who are often the victims of sexual predators.
Sheriffs and Police Chiefs would prefer not to have mentally ill people in their jails and prisons. It is more costly to keep them there than in other settings. Yet, ironically, the California Department of Corrections is the largest provider of mental health services in the state, treating over 13,000 inmates with severe mental problems. An untold additional number of state inmates have undiagnosed mental illnesses that run the gamut of psychiatric ills. At the local level, according to a recent Department of Justice study, the Los Angeles County Jail provides mental health treatment to some 1,700 of its 18,500 inmates, and should be treating many more. That, in itself, is bad enough. Worse, most correctional staff are not adequately or explicitly trained to deal with this population, and the mentally ill are often targeted for abuse or exploitation by other prisoners.
Imprisoning people with mental disorders is an expensive mistake. The conservative Pacific Research Institute estimates that the cost is between $1.2 and $1.8 billion per year. The hidden costs of the present high levels of incarceration of the mentally ill are even higher than the visible costs. Few people with mental illness are made better by incarceration; all too often incarceration exacerbates their condition. Fragile individuals emerge from even short periods of imprisonment with their social and job skills gravely impaired. This keeps them from realizing their potential as contributing and tax-paying citizens. Meanwhile, their families are traumatized, and prison staff struggle with the added stresses presented by these difficult inmates.
There is no single answer to the problem of mental illness. But California, which ranks 48th among the 50 states in per-capita expenditures for mental health, has nowhere to go but up. Hawaii, for example, has demonstrated the value of reducing medical costs through focused mental health treatment that combined brief, targeted counseling, rapid alleviation of symptoms, and other therapeutic measures taken according to individual patient need. (See accompanying chart.)
"Clearly, we need to build more capacity at the community level," says state mental health director Stephen Mayberg. "The new research seems to indicate that, for those with the most serious impairment, the broader array of interventions we can offer, the better they get - better housing, more jobs and job training, more support groups, more socialization. When you get a job, you have to get up and take your medication, take care of your hygiene."
[FCL N/L 6/98]
AB 1100 (Helen Thomson, D., Davis and Don Perata, D., Alameda) requires insurers to cover medications for severe mental illness. FCL SUPPORTS. Write to your state senator and the governor.
AB 2059 (Dion Aroner, D., Berkeley) creates 100,000 public service jobs. FCL SUPPORTS. Write to your state senator and assembly member.
AB 2737 (Dion Aroner, D., Berkeley) provides matching funds to local governments for supportive housing for homeless and extremely low-income persons. FCL SUPPORTS. Write to your assembly member.
SB 256 (Barbara Lee, D., Oakland) provides $200 million in bonds for low-income and homeless housing. FCL SUPPORTS. Write to your assembly member.
SB 1485 (Herschel Rosenthal, D., Los Angeles) proposes to allocate $30 million to fund pilot programs for four years to establish the most effective ways of diverting mentally ill people from courts, jails, and prisons. It is expected that these programs would obtain solid information about the number of mentally ill people in the criminal justice system and the associated costs, point to ways to get homeless people with mental illness back into treatment, provide supported housing for the mentally ill, follow up on those who fail to keep appointments for treatment, provide follow-up for mentally ill persons who show up in emergency rooms, and provide for individuals who need treatment for both mental and addiction problems. The Board of Corrections would award Mentally Ill Offender Crime Reduction Grants on a competitive basis to counties. FCL SUPPORTS. Write to your assembly member.
SB 1950 (Byron Sher,D., Palo Alto) appropriates $5 million to the Emergency Housing and Assistance Fund at the Department of Housing. Write to your state senator. FCL SUPPORTS.
SB 2123 (Barbara Lee, D., Oakland and Diane Watson, D., Los Angeles) directs the Legislative Analyst to study and report to the Legislature on methods to achieve universal health care, including a government-run single payer system. FCL SUPPORTS. Write to your state senator.
CalWORKS Mental Health Services: FCL supports the governor's proposed $36.1 million for this program that provides treatment of mental and emotional disabilities that limit or impair welfare recipients' abilities to obtain or retain employment. FCL SUPPORTS. Write to your state senator and assembly member. Thank the Governor for increasing this item by over 300% in his revised budget.
-Ken Larsen &Steve Birdlebough
Sources: California Journal, Pacific Research Institute, Assembly Budget Committee, and Senate Public Safety Committee.
[FCL N/L 6/98]
A Resource Manual for Local Systems Change (1997) has been produced by the Human Interaction Research Institute, to guide persons working to improve mental health services in local criminal justice systems. It is available from the Institute, 1849 Sawtelle Blvd., Ste. 102, Los Angeles, CA 90025 (310) 479-3028.
The California Alliance for the Mentally Ill has produced three videotape presentations intended to stimulate dialogue between mental health professionals and law enforcement personnel, and to enhance the training of individuals who deal with persons who have mental illnesses. They may be obtained from the Alliance, 1111 Howe Ave, Ste. 475, Sacramento, CA 95825 (916) 567-0163.
Each Quaker Meeting in California has also received a collection of materials on coping with mental illness, provided by the Pacific Yearly Meeting's Committee on Mental Illness.
[FCL N/L 6/98]
The incidence of severe mental illness among the homeless is much higher than it is in the general population -- between one- quarter and one-third of the adult homeless population in the U.S. suffers from some form of severe and chronic mental illness, such as schizophrenia, bipolar disorder, or major depression. By way of comparison, about one person in 10 in the general population will present these symptoms at some point during a lifetime.
The connection between mental illness and homelessness is complex but clear. People delay treatment for mental problems, partly out of ignorance, partly due to the stigma that many still attach to psychiatic disorders. This delay may contribute to the deterioration of the condition, making landing or holding a job difficult. Frequently mental illness is aggravated by excessive drinking or use of drugs, and the person may become alcohol dependent or addicted, resulting in alienation from family and friends. These factors, singly or in concert, often lead to homelessness.
Even if a mentally ill person is appropriately diagnosed and supported by family members, the restrictions on private and public medical coverage can cause economic hardship that leads to homelessness. Most private health insurance policies either do not cover mental health care at all, or sharply limit its coverage to a few counseling sessions or a brief hospital stay for inpatient treatment. Visits to psychiatrists or prescriptions for expensive psychoactive drugs can quickly eat up a family's resources. And, to qualify for Medi-Cal, impoverishment is de rigeur. AB 1100 (Helen Thomson, D., Davis and Don Perata, D., Alameda) seeks to rectify this situation. It would require insurers and HMO's to cover biologically-based severe mental illnesses at the same level as other physical illnesses. The bill would help the insured mentally ill and their families to maintain a normal life, thus reducing the risk of the mentally ill becoming homeless.
Until recently, mentally ill patients were not supplied with the most effective and costly medications until older and cheaper drugs -- often ones that carried disagreeable side effects -- had been tried and failed. Because of prior experience with outdated drugs that had debilitating side effects, many patients came to resist pharmaceutical treatment for their mental illness or rejected it altogether. (The 1997/98 state budget bill may signal an end to this problem; it includes a provision to enable Medi-Cal to use newer, more effective medications as the first line of treatment. A bipartisan majority of the legislature supported this provision.)
Once a mentally ill person becomes homeless the situation gets much more complicated. Even with adequate diagnoses, effective treatment is often not practicable. Because of their transient lifestyles, coherent, continuous treatment cannot be delivered. Moreover, not all homeless individuals who suffer from a mentally disabling condition are affected by a clear-cut mental illness such as schizophrenia. Addictions and disorders of mood that grow out of their life situation are especially prevalent among the homeless.
While effective treatments are available, they are in short supply -- notably so when it comes to treating the homeless mentally ill. As a result, many end up with the most inappropriate form of care; they are taken to jail, usually charged with misdemeanors. It is estimated that up to one-third of the country's jail population is mentally ill; nationwide, almost 700,000 persons diagnosed as mentally ill are imprisoned annually. Yet, a step back towards reliance on mental hospitals would not be an appropriate solution.
A huge majority of the imprisoned mentally ill, although they are disturbed and unable to manage their affairs, would not represent a threat if they were placed in an appropriate sheltered and supervised housing arrangement in the community. Of the homeless mentally ill, only five to seven percent would need to be institutionalized, according to the 1994 Federal Task Force on Homelessness and Severe Mental Illness.
Instead of a return to a system of state-run psychiatric hospitals, several studies suggest that the most effective way to help mentally ill homeless people is to employ an integrated approach entailing proper diagnosis, appropriate treatment, community housing supervised by trained staff, job training, and work placement. Although this comprehensive approach to service might seem costly, in the long run it is certainly more cost-effective than the in-and-out-of-jail cycle in which many mentally ill homeless currently move. To help homeless mentally ill persons it is essential to keep in mind that nothing will work without first seeing to it that they have safe, affordable housing.
-Nina Salomon
(Nina Salomon is a student from the Free University of Berlin, who studied in 1997/1998 at CSU Sacramento, and served as an intern at FCL during the spring, 1998 term.)
Sources: Fact Sheets published by the National Coalition for the Homeless, October, 1997; California Journal, October, 1997; Public Welfare, Spring, 1993; Psychiatric Quarterly, Winter, 1994; Psychosocial Rehabilitation Journal, January, 1991; The Sacramento Bee, October 5, 1997.