Mental Illness Among Us: Private Suffering, Public Shortcomings
California has remarkably transformed the delivery of treatment and services to persons with mental illness, but significant obstacles remain. While funding for mental health services has increased in recent years, many persons still slip through the cracks. In addition, our collective failure to adequately fund mental health services has overburdened our criminal justice system and costs Californians more in the long run.
First the good news. Instead of isolating patients in institutions, mental health treatment now stresses recovery, with greater integration into the com-munity where family members and support networks are available. In 1957, the State housed over 36,000 patients in eight state hospitals. Today, community-based treatment is preferred, and the State operates only five hospitals, with a total population of 4,255.
Criminalizing Mental Illness
Now the bad news. While today's community-based treatment emphasizes recovery and rehabilitation, it is woefully under-funded, despite evidence that comprehensive, community-based treatment substantially reduces incarceration and homelessness. As a result, counties ration care toward the most severely afflicted. Where mental health service providers must often turn away patients due to insufficient resources, the criminal justice system cannot. Unfortunately, many Californians with a serious mental illness (about 5 percent of the population) will encounter the criminal justice system, usually because they have displayed symptoms of untreated mental illness in public.
Today 80 percent of the commitments to the state hospital system are penal commitments. On any given day, the Los Angeles County Jail treats more people with mental illness than any other facility in the country. About 15 percent (24,000) of California's prison population suffers from mental illness. The Department of Corrections spends over $1 billion to incarcerate and treat prisoners with mental illness. When the costs to the criminal justice system and local corrections are included, the total approaches $3 billion.
Ironically, the criminal justice system has become the "safety net" for persons with mental illness. But a jail sentence or prison term (felony conviction required) may reduce their chances for recovery. In his book Prison Madness, Terry Kupers notes that prisoners with mental illness are more vulnerable to being victimized by other prisoners. As a result, some withdraw into their cells, worsening their symptoms and their prognoses for recovery.
Obstacles to Treatment
In 1967, the Lanterman-Petris-Short Act (LPS) removed the "need for treatment" from the criteria under which people could be involuntarily committed and replaced it with "gravely disabled" or a "danger to self or others." As a result of LPS, thousands of persons with mental illness were released from state hospitals with the expectation of receiving community-based treatment. In 1991, the realignment of most mental health services to the local level created a financial incentive for counties to develop community-based treatment options to be overseen by the state Department of Mental Health. Unfortunately, community-based treatment has never been adequately funded and many persons with mental illness fend for themselves.
Despite progress in recent years, people with severe mental illnesses are often victimized by misunderstanding and discrimination. While media reports emphasize the most egregious incidents involving persons with mental illness, most of their encounters with law enforcement are of the public nuisance variety. Lacking adequate mental health services in the community, police officers repeatedly answer calls for assistance with a person with mental illness. Prosecutors charge the same person repeatedly for committing a public nuisance. Typically, the defendant is released after pleading guilty to time served and, lacking available treatment, the pattern is repeated. Possessing a criminal record may make one ineligible for some treatment programs, which reduces opportunities for recovery.
About half of all persons with mental illness also have problems with substance abuse. While some use drugs for recreational purposes, most are "self-medicating" in order to treat the symptoms of their mental illness. Substance abuse makes detection difficult and makes it harder to engage patients in treatment.
While community-based treatment offers the best hope for recovery, it also presents special challenges. Patients in state hospitals have shelter and receive medical care and treatment at the institution. However, outpatients in community-based
treatment programs may require housing assistance and transportation to and from medical appointments, therapy sessions, school and employment. It is estimated that between 20 to 40 percent of California's homeless population have a serious mental illness. Thus, providing comprehensive services requires extensive coordination between numerous agencies and service providers.
Towards a Reasonable Solution
In 1999, Governor Davis signed AB 34 (Darrell Steinberg, D., Sacramento) which appropriated $10 million for the establishment of local pilot programs in three counties to provide comprehensive treatment and services to persons with mental illness. In 2000, this program was expanded to 32 county and city programs. In a May 2002 report to the Legislature, the Department of Mental Health concluded that these programs "enable the target population to reduce symptoms that impaired their ability to live independently, work, maintain community supports, care for their children, remain healthy, and avoid crime." (See Resources, page 9.) The report also showed that for an annual expenditure of $14 million, the state saved $7 million from reduced hospital stays and reduced incarcerations in just one year.
Looking Ahead
A report by the Little Hoover Commission notes that "while mental health advocates have many champions, they have been unable to make their voices heard in the public policy arena." Many share this frustration. A coalition of mental health providers and Assemblyman Darrell Stein-berg are sponsoring the Mental Health Services Act for the November 2004 ballot. The ballot proposition would provide $600 million per year to expand local mental health programs by assessing a surcharge on incomes over $1 million per year.
In this issue, you will read several remarkable stories written by FCL supporters who have firsthand experiences in dealing with mental illness. Their stories contain a recurring theme: treatment works, and people with severe mental illness can lead meaningful lives in their communities, especially when patients and their loved ones are involved in their recovery. FCL believes that providing adequate resources for the treatment, care, and rehabilitation of individuals who suffer from mental illnesses is a primary responsibility of a just society. Thanks to the efforts of many dedicated mental health providers, we know what works. The time for correcting this public travesty is long overdue.
- Jim Lindburg
WHAT YOU CAN DO
Let your state representatives and fellow citizens know that treatment works and is humane and cost effective. Study the Mental Health Services Act at http://www.campaignformentalhealth.org/
Understanding Mental Illness
All Mental Illnesses: Disorders characterized by cognitive, emotional or behavioral anomalies. An estimated 21 percent of the adult population has a mental illness each year, or 5,225,368 Californians.
Severe Mental Illnesses (SMI): Of those with mental illness, some have symptoms that significantly interfere with their major life activities. An estimated 5.4 percent of the adult population has a severe mental illness, or 1,343,666 Californians.
Severe and Persistent Mental Illnesses (SPMI): Of those with a severe mental illness, a significant proportion experiences symptoms that persist for an extended period of time. An estimated 2.6 percent of adults have SPMI, or 646,950 Californians.
Sources: Department of Finance. 2000. "Population Projections." U.S. Department of Health and Human Services. 1999. Mental Health: A Report of the U.S. Surgeon General. Pages 45-49. Reprinted from: Being There: Making a Commitment to Mental Health. Little Hoover Commission, November 2000
Common Mental Illnesses
Schizophrenia: The most disabling mental illness. Often characterized by hallucinations and delusions, disorganized speech and behavior, and restric-tions in the range and intensity of emotional expression, in the fluency and productivity of thought and the initiation of goal-directed behavior.
Panic Disorder: Panic disorder is characterized by recurrent and unexpected panic attacks. Symptoms include trembling and shaking, heart palpitations, chest pain, nausea and fear of losing control.
Obsessive-compulsive Disorder: Obsessions are recurrent and persistent thoughts, impulses or images. Compulsions are repetitive behaviors or mental acts that the person feels driven to perform. The compulsive behavior is aimed at preventing some dreaded event or outcome.
Clinical Depression: The most common psychiatric disorder. Episodes can be continuous or separated by years without reoccurrence. Symptoms include: depressed mood, little or no interest or pleasure in daily activities, significant change in weight and appetite, insomnia, fatigue, feelings of worthlessness, excessive or inappropriate guilt, diminished ability to concentrate, recurrent thoughts of death or suicide.
Bipolar Disorder - Manic Depression: Bipolar disorder is characterized by extreme changes in mood, from severe depression to severe mania, or elevated mood. During both extremes the person may be unable to make rational decisions. Mania may be characterized by several days without sleep, loss of touch with reality, and feelings of having special powers.
Source: National Institute of Mental Health (www.nimh.nih.gov).Reprinted from: Being There: Making a Commitment to Mental Health. Little Hoover Commission, November 2000.
Involuntary or Voluntary Treatment?
FCL recognizes that compulsory treatment may be needed for some individuals with mental disorders when they are gravely disabled, or present a danger to themselves or others. Last year, AB 1421 (Helen Thomson, D., Davis) was signed into law by Governor Davis. Known as "Laura's Law," in memory of the late Laura Wilcox (see the FCL Newsletter, June 2003), the legislation provides that a person may be ordered by a court to receive outpatient treatment if the court determines that the person is likely to become dangerous or gravely disabled without the treatment.
A Rand Corporation study presented to the state Legislature in 2001 found that over 16,000 Californians experienced more than one 72-hour custodial hold in fiscal year 1997-98. Of those, 7,400 suffered from schizophrenia or other psychotic disorders, of which more than 2,700 had received no outpatient treatment in the previous year. The Rand study could not determine whether they lacked outpatient treatment because of non-compliance or because of problems in accessing community-based services.
Despite this ambiguity, the Rand study makes it clear that a significant percentage of people with severe, recurring mental illnesses are not receiving treatment. In all likelihood, if mental health service providers had the resources to perform outreach to persons with mental illness and develop their trust, compulsory treatment would be largely unnecessary except in rare cases.
- Jim Lindburg
How My Family and I Were Changed by Mental Illness
by Pat Williams (with Ira Saletan)
Mental illness has affected my family in profound ways. I have lost two sons. We have had our lives changed and disrupted in many ways by what happened with them. I have come to understand the challenges facing those with mental illness and those who love and care for them. With my husband and others, I have dedicated much of my life to becoming a service provider and advocate for those who need help and support, starting with our understanding.
At the age of 30 and a new mother, I knew almost nothing about mental illness. We had a very happy family, moving with three young children (David, Kathy and Andy) to Davis, where my husband Bill took a faculty position at UC Davis. We were thrilled to be in sunny California.
One of the first signs that something wasn't right occurred when David was 10, on our way home by boat from Australia. As we crossed the equator, he wore his wool clothing and didn't notice it was hot. His behavior began to change. Through junior high and high school, he pulled away from his old friends and got involved in some negative activity.
We later learned he was suicidal during that time.
I had not been aware of any family history of mental illness. Later I found a letter about an aunt who had attacked her mother, was hospitalized and then apparently committed suicide.
In 1965, there was no psychiatrist and no formal mental health services in Yolo County. We finally persuaded David to see a psychiatrist in Sacramento and to become involved in group therapy. He benefited greatly. Because of the stigma about mental illness at that time, we felt safer going to Sacramento so that our neighbors and friends would not know what was going on.
Like many others, we figured we should be quiet, act as "normal" as possible, and hope whatever was happening would just go away or pass off. I worried that others would blame me and my family, that this would negatively affect my children's future.
So I didn't say much; I didn't want others to hear and talk.
David was diagnosed with schizophrenia and depression, attended California State University, Sacramento and graduated. He saw his psychiatrist occasionally but would not take medication. He committed suicide
at 33.
David's younger brother Andy got into trouble as a teenager when his behavior became more extreme. A school psychologist referred him to a psychiatrist in Sacramento but he resisted treatment. While at a Quaker work camp in Michigan, Andy disclosed that he was suicidal. When he came home, we went to his psychiatrist who gave him medication for his depression. Andy was accepted at UC Santa Cruz. The doctor supported his attending, provided he take his medications for depression and schizophrenia.
Depressed and manic, Andy began to fall apart at UC Santa Cruz. A professor called to say, "If we were in
England, he would be in the hospital." Bill brought him home and he was hospitalized. The doctors tried to persuade Andy to take Lithium but he refused. He escaped from the hospital and returned to Santa Cruz, but was soon back in Davis.
Then Andy took our station wagon and disappeared for two months. We received a call from the hospital in Redding that he had driven the car over an embankment. Andy was alive and no bones were broken. A miracle. We asked Andy if he would like to change to David's psychiatrist and he agreed.
Andy took off again and flew to Washington D.C. He tried to see President Nixon. Andy was put in jail, became terrified and called Bill's mother who called us. We reached a lawyer in Washington who advised us to fly immediately to the Maryland jail with an armed guard and be at Andy's hearing. We were there.
The judge let Andy go with us and then to Kings View Hospital in Fresno. It was known as the best hospital for young people with serious mental illness in California. The doctor at the hospital told us Andy was too manic and would have to go home. We were shocked but agreed.
When we got home, Andy and I were sitting at the kitchen table talking about what to do. I suggested that he consider going to Napa State Hospital. He said, "Take me there now, before I change my mind." Napa State Hospital was just what Andy needed. It was 1972, and he was 22 yrs. old. They locked the door so he could not run away and so that he received good treatment and medication. Andy stayed there for nine months. After three months of coaxing him to try Lithium carbonate, he took it and it worked well. Thanks to the medication and a good structured program, he became our Andy again - a loving and intelligent son.
There was no residential care facility then in Davis or Woodland for a person recovering from mental illness, so Napa sent him to a group home in San Mateo County. San Mateo Mental Health Services had a well developed system that included many board and care homes, work activity programs and day programs.
Lithium carbonate was hard on Andy's kidneys, but it helped him to stay out of the hospital. Electroshock therapy can erase some people's memory. The choices were difficult. We met a psychiatrist at the World-Wide Affective Disorder Day Dinner (an event I founded, which continues to this day) and invited him to our home. He spoke about the effectiveness of electroshock therapy on depression. We wanted our sons to try it but they refused.
I urge all parents or guardians in this kind of situation to get professional help early, when you have more legal rights over the person in your care. When s/he turns 18, you have few rights and are almost helpless.
I became active in the local Mental Health Association, the Statewide Legislative Advisory Board, and the Yolo County Mental Health Advisory Board. I heard about support groups for people caring for those with mental illness. I began the Yolo County affiliate of the newly organized California Alliance for the Mentally Ill (CAMI).
I knew of eleven families in my community who were hiding the problem of mental illness behind closed doors. They had no one to share the pain with and needed a support group. I phoned them and we met. We united as an affiliate of CAMI and are still going strong. It was an exciting time. We meet monthly for a potluck and program with a speaker.
My family liked the Friends Meeting and we became active. I cried I was so happy. David was 16. I was still cautious about reaching out and speaking out about mental illness. But I began to work on related issues at the Davis Meeting, Quarterly Meeting, and Yearly Meeting.
In the mid-80s, with support from other Friends, a Minute was passed by Pacific Yearly Meeting on "The Meetings and the Mentally Ill," about inclusion and worship. I was thrilled with this. We developed a booklet each year and provided educational materials at Yearly Meeting. I carried this for ten years, but was unable to find a successor and this group was laid down along with the Minute that helped to create it. We need more leadership on this issue.
Many opportunities presented themselves. I have testified at the Capitol more than 50 times. I've also spoken many times at city council and other local meetings to raise awareness and seek support for needed projects and services. I could always speak about mental health issues because I saw and understood the need.
Assemblywoman Helen Thomson from Davis and other legislators have been very supportive of measures to improve and more adequately fund our mental health system. We have seen some important steps forward, including the recognition at the national level that mental health treatment should be supported on parity with other health care services.
In 1979, Assemblyman Tom Bates carried a bill, signed by Governor Jerry Brown, which appropriated $3 million to fill in the gaps in mental health programs. We received funds for a halfway house, three socialization centers, a transitional living farmhouse, a crisis house, employment program, and the Yolo Community Care Continuum that I helped
organize.
This accomplishment was one of the highlights of my life. Bill and I acquired more property and managed more facilities to provide services for those with mental illness.
We established an employment program in Davis, which was a great success. Work is important in healing and living with mental illness. Even one day per week for two hours is helpful. The last big push Bill and I made was starting Pine Tree Gardens, a residential care home for mentally ill adults, with the support of the Yolo County Mental Health Services staff. Our son Andy was one of the residents. It was so successful we opened another one, Pine Tree Gardens East, in 1990. These two homes fill a great need. We need more in every county.
Andy died from pneumonia in 1999. Bill died this year. My daughter Kathy and her husband now live near me. I am now 80.
CAMI now has 14,000 members in California. The stigma of mental illness has declined somewhat. Medication, services and facilities are generally better and more accessible than what I remember from when my family experienced our difficulties. More people understand the problems and are speaking openly about their experience. This has helped counter the "not in my back yard" opposition to community treatment facilities and services. Sensitive but important
issues such as authority to require involuntary medication of the mentally ill are being addressed. The limitations of our overall health care system and the economics and politics of budget cuts make delivery of adequate mental health services a continuing challenge.
- Pat Williams is a member of the Davis Friends Meeting and an FCL supporter. She lives in Davis, California. Pat is currently focusing her legislative efforts on supporting SB 921, sponsored by Senator Sheila Kuehl, which would establish a universal, single-payer health care system in California (see Newsletter, February 2003). She can be reached at (530) 747-6177.
- Ira Saletan, Development and Outreach Coordinator with FCL, has grown in significant ways through his experience with mental illness and recovery, thanks to medication, therapy, and the support of others. He can be reached at <outreach@fclca.org>.
Dual Diagnosis: What my clients want you to understand
by Carole Lutness
"People think we are leeches on society. They think we are deviant. Yet they use alcohol, prescription drugs and illegal substances themselves." "It's just that their brains are different. Or maybe they can hide it better than we can." These are some of the comments my clients in our Dual Diagnosis Support Group said when I asked them what they would like our state representatives and government officials to understand about people who have the co-occurring bio-chemical brain disorders of mental illness and substance abuse. I am a Psychiatric Social Worker (LCSW) and also a CADC (Certified Alcohol and Drug Counselor), and I serve as a Dual Diagnosis Coordinator for the Los Angeles Department of Mental Health. As a Quaker I seek to "find the light of God in every person" and apply this in my work. People with mental illness that have become mired in the morass of substance abuse did not start out with the intention of becoming addicted. They are generally people with a genetic predisposition for both mental illness and addiction. Moralistic shaming is not the way to help someone with two very serious chronic illnesses.
"People don't look at someone with cancer and condemn them, but I always feel judged as less than by others," said "Jack" (names of patients have been changed), a husky, baby-faced 38-year-old with long red hair and many tattoos. Jack began hearing frightening voices in his late teens and found that drinking and using drugs helped him not hear them and made him less anxious around others. He hid his mental illness, worked as a musician, married and had children. The stress of job and family led him to heavier and heavier drug use until he finally suffered a complete psychotic breakdown and was hospitalized. His wife took his children north and he has been living with his parents for the last three years. Now clean, he has been attending Alcoholics Anonymous and support groups in our agency for more than two years. Jack is complying with his medication regime, and though he still hears voices he is now well enough to go back to school. His goal is to become a physical therapist.
Rebecca, a perky 40-year-old blonde who talks rapidly and is either way up or way down, recounts that in her "look-good" family she always felt odd and lost. Raised in affluence, she remembers coming home from school in the afternoon and finding her mother lying on the sofa watching TV. "There was never anyone there to pay attention to me. I started being depressed when I was seven. No one noticed. I put on a 'happy face,' excelled in school and never felt like it was ever good enough." She discovered her father's codeine pills when she was about 10. "I would open the capsule, take half of the codeine out and replace them. No one ever suspected. I discovered it helped me feel less sad and lonely." She began using alcohol and drugs heavily in high school but was able to obtain a master's degree and maintain a successful professional career. As her mood swings became more severe, her attempts to self-medicate with drugs went out of control. She became suicidal after she began hearing persecutory voices and was hospitalized seven times in one year before coming to our clinic. Bright and motivated, she has abstained from drug use, but will probably continue to hear voices and fight severe mood swings. Because she has been unable to work for more than two years, she has no health insurance and has exhausted her savings. At risk for homelessness because her family is not a resource for her, she has nonetheless successfully managed financial setbacks, such as her car breaking down. Thankfully she is now receiving SSI and Medi-Cal and should become self reliant.
"People are afraid of us. They don't understand. We want to be productive and have good family lives," Rebecca says. "Being mentally ill means we just can't handle stress and pressure yet that is all we have because we live from hand to mouth, are always at the brink of eviction, or the car breaks down so we can't get to Mental Health for our doctor's appointment, or our roommates start using [drugs] again." Rebecca used to live in a nice home in a middle class neighborhood. "Now I'm living in 'the projects' and I am really scared to go out sometimes. There are drug deals going on all the time and I hear gun shots frequently."
Many persons with mental illness and substance abuse problems do not have Rebecca's advanced social and problem-solving skills. Carrie, an African-American woman with schizophrenia whom I met when I was a supervisor of Day Treatment at a hospital in South Central Los Angeles, is continually responding to her voices and her visions. Since childhood she has been tormented by them. She began drinking in late adolescence and has been the victim of frequent sexual exploitation by men who take advantage of her and then abandon her. Cloziril, a wonderful anti-psychotic drug, was the only medication that helped her with the voices and helped her connect with others. Taking Cloziril enabled her to stop drinking; her grooming improved and she began talking to other clients in the day treatment program and engaging in some productive activities. Unfortunately, tests revealed that Cloziril was causing a blood disorder so it was discontinued. Seeing her deteriorate again was very painful. Within a few months she was back to wandering around the back of the day treatment room, responding to her voices and visions. She started drinking again.
Getting to know people who struggle with two very serious brain diseases, whose senses lie to them continually, who are tormented by paranoia and fear and who want desperately what everyone else wants, I cannot help but respect and admire them. I believe that no matter how ill someone becomes, there remains that "still small voice," that "light of God," that core of health inside. It takes patience, faith, unconditional positive regard and the knowledge that they can and want to grow to engage people with these illnesses. They are often self-loathing and have built high walls to defend themselves from what they believe others will do to their already abysmal self-esteem by judging and shaming them and making them feel more inferior than they already do.
Policymakers need to understand that these are medical, biologically based illnesses. People with co-occurring illnesses need the basic necessities of life: food, clothing and shelter. When their illnesses are raging, they can no more work than you could if you had two debilitating illnesses. This means that barriers should be removed from health care, housing and cash assistance. We really need a universal health care system that does not differentiate between the "worthy" and "unworthy." Emergency rooms are usually the only clinic our clients without Medi-Cal have, which means they often wait 12-13 hours to be seen. Usually there is no one providing medical case-management for them. It is very short sighted to believe that closing medical facilities and eliminating social service programs represents any real and lasting saving of our precious public dollars. Lacking basic services, persons with mental illness deteriorate and become more difficult and more expensive to treat. Instead of spending money for relatively inexpensive treatment programs, we squander billions on warehousing them in our jails and prisons. Furthermore, caseloads must be reduced. With 80-plus cases, three intakes a week and three groups to run, I work in a "country club" agency compared to other Los Angeles County mental health agencies. There is never enough time to give these clients what they need. Only the most motivated make it. I have little time to do outreach to those who are in desperate need of treatment. Yet, when I am able to make a few phone calls to encourage them to come in to see me, they can develop the hope and trust necessary to proceed with treatment.
These people, some of the most in need in our society, are expected to access services that are full of bureaucratic road-blocks. There is no inpatient detoxication facility in Los Angeles. Medi-Cal does not pay for detoxication, and there is no medical detoxication for the indigent. The county treatment beds are scarce and it is almost impossible to admit a person with a dual diagnosis. There are almost no psychiatric hospital beds available when our Psychiatric Mobile Response Team determines someone is "a danger to self or others or is gravely disabled" and needs to be admitted. We need easier access to HUD housing when patients do come out of treatment, and we need more transitional living programs. There is still a 7-10 year wait for Section 8 (federally subsidized) housing, and most sober-living programs will not admit someone using psychotropic medications. It is vital that the public be educated about co-occurring illnesses, the workings of the mentally-ill brain, and addiction. Finally, we need to grant easier access to SSI, and revamp it to include a gradual reduction of benefits, which would encourage participants to move back into productive work.
Society needs to recognize that not everyone can "pull themselves up by their bootstraps." For some, the bootstraps are broken and society must help repair them. Many years ago I was appalled by a local official who indicated that he was unwilling to have the county pay for the residential treatment of a seriously mentally ill boy. "Just wait a few years," he said, "we have jails for people like him." I hope we are further along in our thinking now than we were back then.
- Carole Lutness, LCSW, CADC, is a Psychiatric Social Worker II for the L.A. County Department of Mental Health. Carole is a member of Orange Grove Friends Meeting and co-clerks the FCL Development & Outreach Committee.
Funding SOLUTIONS
by Dianne Marshall
Approximately twelve years ago, then-Dade County District Attorney Janet Reno and Dade County Judge Stanley Goldstein decided that the judiciary should play a different role in the lives of drug-addicted defendants. Their decision gave rise to what is now known as the practice of therapeutic jurisprudence. This practice established a commitment to treatment services integrated with criminal justice case processing to be shared by the courts, treatment providers, social workers and law enforcement personnel. Popularly known as "drug courts," today there are more than 900 in operation throughout the country, with more planned.
The drug court model allows offenders to be sentenced to treatment rather than jail or state prison. Most of these programs utilize a multiple-phase approach with treatment sessions, court appearances and drug testing. Successful completion is honored with a graduation ceremony shared with friends and family, while unsuccessful termination may result in incarceration.
The drug court model has been adapted to serve juveniles, parents whose children have been taken from them by Child Protective Services, and mentally ill offenders. Jails are now the most frequent provider of mental health services in many jurisdictions throughout California.
According to the state Department of Mental Health, the number of local jail inmates receiving mental health treatment has more than doubled in the last ten years.
The Mentally Ill Offender Crime Reduction Grant (MIOCRG) Program, administered by the California Board of Corrections, provides funding to implement and evaluate the effectiveness of several Mental Health Courts throughout the state. The Mendocino County Mentally Ill Offender Court Program, known formally as SOLUTIONS, has been in operation since July 1, 2001. Since then, 49 individuals have participated in the treatment program.
MIOCRG funding makes it possible for SOLUTIONS to employ a team consisting of a forensic mental health clinician, a forensic case manager, two probation officers, a substance abuse therapist and a research evaluator. Working closely with a judge, this team assists individuals with a mental health diagnosis who have committed non-violent crimes.
SOLUTIONS is a 3-phase program. Participants advance from Phase I to Phase II to Phase III and then into aftercare. Advancing means less intensive treatment services and an increased emphasis on independent living skills, including living on one's own, more free time, fewer court appearances and becoming employed.
Services provided include mental health and substance abuse counseling, medications management, obtaining benefits such as Medi-Cal and Supplemental Security Income, vocational rehabilitation, assistance in finding housing, food, clothing, nutrition, leisure activities and assistance with outstanding matters before the court. The team approach makes it possible for the mentally ill person to become stabilized on medications, shelter, employment and therapy for addressing the underlying issues that led to substance abuse and/or a mental illness diagnosis.
In Mendocino County, SOLUTIONS participants appear in court on Friday. Last Friday was a tense, anxious day for our team. Once again, a 21-year old client I'll call "W" was hearing voices. He insisted that the FBI implanted a microphone in his ear and was speaking to him through the voice of a juvenile probation officer.
W contends that his time in jail is responsible for his mental illness. Though W's mental illness precedes his contact with the criminal justice system, jail is a tremendously negative experience for him. The voices of the FBI agent and the probation officer he hears all manifest within W in ways that you and I can only imagine. Continued placement in jail would not help W cope with his mental illness, as he experiences paranoia, which jail would only reinforce. That is why we all worked so hard last Friday to be sure that he did not have to return to jail.
W came to us with a preoccupation with guns and having told his family that they might end up like a family killed by their own son eight years earlier. He dislikes taking his medication because of the side effects he must endure before the medication can generate any sense of well-being. W's parents were awash with mixed feelings. They knew W needed to be stabilized and that their lives could be at stake. Yet, their desire to prevent their son from returning to jail was greater than their desire for personal safety.
Our SOLUTIONS team was faced with a need both to help W understand that he had to take his medication to assure his and his family's safety, and to avoid using the jail as the safest place available for W's care.
We did it! The forensic clinician prepared a report for the psychiatrist that explained why a particular medication needed to be injected. I found the psychiatrist in the women's section of the county jail and secured his cooperation, despite his overwhelming schedule. The clinician, the deputy public defender assigned to SOLUTIONS, the probation case manager, W's father and the judge all met with W. He was able to trust the people speaking with him, as he was treated with respect and not herded through a system that reacts only negatively to undesirable behaviors. W agreed to take his medication and to continue cooperating with SOLUTIONS. By the end of the day W had received his injection and a medication to combat the side effects. He was able to go home safely with his family.
Let there be no doubt in anyone's mind. Without SOLUTIONS, W would have had an involuntary and unsuccessful commitment to jail for three days. Three days is hardly long enough to get him on a medication regimen that he would have likely quit upon release, either for "feeling better" or for seeking to prevent dreaded side effects. The time in jail would have reinforced his paranoia and the voices that reminded him of the neighbor family that had been killed. Neither W nor his family would have been any safer upon his release from jail.
The cost of the SOLUTIONS Program for W is $66.74 per day, compared to the cost of a state hospital stay of $301.36 per day. The county bears the cost of the SOLUTIONS program, unless W is convicted of a felony and is committed to a state hospital.
What happens next for W and the others receiving services through grant-funded mental health courts?
W does not know this program is grant funded. Neither do the other participants. Funding for the program is expected to run out by June 30, 2004. Since it takes 18 months for a patient to progress through the program, no more participants should be admitted, as we will not be able to provide them with the minimum level of services and treatment. Even with funding, an 18-month treatment program may not resolve a lifetime of mental illness. Success means living without the support, medications management and therapeutic intervention that being in the program provides.
If it takes a village to raise a child, it most certainly takes concerted, orchestrated, compassionate cooperation among many key players to address the needs of the mentally ill. Those of us working on the SOLUTIONS Program continue to seek any possible funds to continue this work. We hope that additional funding will be made available to assure not only that the core services provided by SOLUTIONS and other mental health courts be continued, but also that comprehensive case management be available for these individuals for the rest of their lives. Our participants must be able to look forward to success, knowing they will not be abandoned.
- Dianne Marshall is Therapeutic Courts Administrator for Mendocino County Superior Court and a member of the State College, Pennsylvania Friends Meeting.
For Further Reading on Mental Health
Being There: Making a Commitment to Mental Health, Little Hoover Commission, November 2000.
Little Hoover Commission, 925 L St., Suite 805, Sacramento, CA 95814; (916) 445-2125, www.lhc.ca.gov.
The Campaign for Mental Health, 1127 11th St., #925, Sacramento, CA 95814; (916) 557-1156; http://www.campaignformentalhealth.org/
Criminal Justice/Mental Health Consensus Project, Council of State Governments, PO Box 11910, Lexington, KY 40578; (859) 244-8000; www.csg.org.
Effectiveness of Integrated Services for Homeless Adults With Serious Mental Illness (Report to the California State Legislature, May 2002); California Department of Mental Health, 1600 9th St., Room 151, Sacramento, CA 95814; (916) 354-6565; http://www.dmh.cahwnet.gov/.
Kupers, Terry M.D. Prison Madness: The Mental Health Crisis Behind Bars and What We Must Do About It, Jossey-Bass Publishers, 1999.
Mentally Ill Offender Crime Reduction Grant, California Board of Corrections, 600 Bercut Dr., Sacramento, CA 95814; (916) 445-5073; http://www.bdcorr.ca.gov/cppd/miocrg/miocrg.htm.
President's New Freedom Commission on Mental Health, 5600 Fishers Lane, Room 13C-26, Rockville, MD 20857; Phone: (301) 443-1545; http://www.mentalhealthcommission.gov/.
Shavelson, Lonny. Hooked: Five Addicts Challenge Our Misguided Drug Rehab System,
The New Press, 2001.
Upcoming Events
October 18: Universal Health Care Interest Group at College Park Quarterly Meeting (Nevada City)
An interest group in consideration of the minute passed by the Pacific Yearly Meeting concerning universal health care will be held at the College Park Quarterly Meeting. Sara Rogers, Legislative Aide to Senator Sheila Kuehl, will discuss Senate Bill 921 and how Friends can support this effort. The interest group will be held Saturday afternoon from 2:30 p.m. until 4:00 p.m. For more information, contact Russ Jorgensen at (530) 265-4166.
December 5-6: La Jolla
"Working Together to Make a Difference with Compassion and Justice"
Announcing the FCL 2003 Statewide Gathering
Citizen Advocacy Forum, December 6, San Diego
The FCL Administrative Committee will meet Friday evening. After a public Citizen Advocacy Forum Saturday morning in San Diego, the statewide Executive Committee meeting of FCL representatives (and others who are interested) will convene Saturday afternoon at the La Jolla Friends Meeting House. Topics to be addressed are expected to include legislative advocacy, ways of reorganizing and strengthening FCL, and finances and fundraising. For information about the Forum, contact George Gastil at (619) 465-9176. For information about the Administrative and Statewide Meetings, contact the FCL office at (916) 443-3734, or Statewide Clerk George Millikan at (510) 486-1391.
Subscribe to the FCL Newsletter
You can have each issue of the FCL Newsletter mailed to your home or place of business, simply by mailing a request to our office, together with a check for $35 ($12 low-income). Bundle subscriptions to a meeting, congregation, or other group may also be arranged at a cost of $75.
Friends Committee on Legislation
717 K St., Suite 500-B,
Sacramento, CA 95814-3408
(916) 443-3734
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