Capitol Weekly, a publication of Open California, periodically holds webinars on topics that are at the top of policymakers’ minds. This week, they held a virtual roundtable for their annual look at health care in the Golden State, focusing on California’s escalating mental health crisis. You may view SYASL staff notes (they should not be considered verbatim) from the event dialogue below.
Panel One – Origins of California’s Mental Health Crisis and Long-Term Solutions
Janet Coffman, Healthforce Center at UC San Francisco
- We have a behavioral health workforce that does not fully reflect who we serve, particularly therapists and psychiatrists
- We do not have a great career ladder for people to move up to a bachelor’s degree or other degrees
- We know our community colleges are working to build ladders, but it is going to be critical if we really want the career workforce where we need them to be
Michelle Cabrera, County Behavioral Health Directors Association of California
- It can take months and sometimes years to build rapport with people, and it is necessary; often much of what needs to be done falls outside of health insurance
Elaine Batchlor, MLK Community Healthcare
- We see a lot of homeless individuals who are not getting the care they need on a daily basis. They are only receiving care when they are in a crisis and then they are being sent back out into the conditions that led to that crisis
- We are trying to meet them where they are and address those crisis issues
- These people are not getting any medical care until they are in crisis, and this is a failure on our part, there is no funding for street medicine, and that needs to change
Jim Beall, Former State Senator
- A lot of people besides Darrell Steinberg haven’t wanted to spend (their time in the legislature) on mental health, we built a committee when I was in the legislature
- People tend to look at mental health as a budget issue rather than a human being issue and this was and probably still is one of the biggest barriers in the State Capitol building
- When I was a Santa Clara Supervisor, we started wrap-around services
- Housing was the big bottle back then and still is now, as well as more staffing for programs
- We need to incentivize people going into the profession and create opportunities for people, particularly people of color
- Need to look at closing more prisons, saving money, and making it a full mental health services system
- Realign the budget priorities
- My whole 40 years in office I have been on budget committees
- The Governor started by saying he was going to close some prisons, but we need to do a lot more on getting people treated
- Once people are out of prison and don’t have a therapeutic environment when they get out – this needs to be provided
Elaine Batchlor
- People of color are disproportionately represented, we need to allocate resources to the workforce, we need a workforce that looks like the people they are serving to reduce the barriers
Jim Beall
- The bottleneck has always been the housing issue
- People need to be in the communities and close to their families
- Being in jail or prison also causes its own trauma
Janet Coffman
- We have a meth crisis, and it has not gotten the airtime it deserves
- We don’t have as good of evidence with meth of what works and what doesn’t compared to MAT with opioids
- There is some evidence that paying people to stay clean works for some people
Michelle Cabrera
- I agree with Janet; we do not have MAT for meth
- Recovery is possible for meth users too
- We have some counties that have experience in different methods
- I think it requires more attention, especially with fentanyl crossing into the picture
- There is inadequate access around behavioral health
- It leads to people falling out of employment and into the State’s safety net
- We need to demand more accountability as a community and hold entities responsible for doing their part, early psychosis works, our focus on early prevention really needs to be there, and people need to know if their health insurance isn’t there for them, that the state will help so they can get the help they need before it affects their jobs, life, etc., and they end up completely reliant on the state’s safety net to meet all needs due to job loss
Jim Beall
- I don’t think the barriers are too strong, the state can use its licensing process to enforce standards of care on private health insurance companies
- There is plenty of ways the state can make the private insurance industry make the standards of mental health treatment better
Janet Coffman
- The workforce piece is relatively small. What we have in the budget this year is a good down payment toward improving our workforce, but it is a drop in the bucket
Michelle Cabrera
- It won’t matter if we can’t increase salaries, no one will be willing to stick it out if they can get a better work-life balance and pay somewhere else
- If the state conservatorship laws change, one of the hopes people have is that they really want to get people help, for us, our public guardians are not funded by the state, they are completely county-funded at this point, a lot are not reimbursed through Medi-Cal, any thought we are going to somehow fix this needs to be very clear that this assumes you have the resources to provide
- Long-term, we want to help people out before they even need to go there
- We need to start paying now rather than later
Panel 2: Compelling Treatment – Balancing Individual Rights and ‘Grave Disability’
Judge Stephen Manley
- My job as I view it is to get you interested in participating in treatment
- I will do all I can to get you interested in getting help
- For a judge to order for someone to be involuntarily medicated – this is just words out of a judge’s mouth and a piece of paper – it doesn’t really get you anywhere; people go right back to the behavior they were in before
- I am not criticizing the state hospitals, they do a great job given their resources, but we need to rethink and change the entire system and realize that mental health is a relapsing condition, and it never stays where you think it should
- We need to meet people where they are every day and encourage them
Al Rowlett, Turning Point Community Programs
- This approach is different than conservatorship, which is a much more intrusive process
- We engaged an individual 38 times, and it was on the 38th time they accepted help and told us that they would accept help so we should stop asking – later he told us it was our constant engagement that helped him
- Turning Point operates two locations, one in Nevada County and one in Placer County, 24/7 support in the community so people can get the support they need and not be dependent on specialty mental health services for the rest of their lives
Brian Stettin, Treatment Advocacy Center
- We are a national nonprofit group
- AOT is the practice of providing outpatient treatment under a civil court order
- California Laura’s Law is a great example of this and why we really shifted our focus in recent years
- Most counties have AOT programs in place, but there are still frustrations
- We are now much more engaged with local mental health systems helping with technical assistance to get AOT programs off the ground and running
- I was asked to develop a system/program from the incident of the lady who was pushed in front of a train in New York, and it has now served as a model in many other states since
- I would like to see more in CA to see AOT live up to its promise
Al Rowlett
- We do not have an array of housing options available for people once the crisis has been mitigated
- In Sacramento County we operate at the only urgent care available in Sacramento
- Board and care facilities are going away in CA at an alarming rate due to funding and it mirrors the housing crisis we are having
- We need the resources in the communities where people want to live – when they are motivated to live in a community without a stigma and have a supportive environment that includes mitigation of all the risk factors, people can be successful in managing their psychiatric illness
Stephen Manley
- There are 1,700 people sitting in jails waiting to be transported to a state hospital
- We need to place people in the communities they came from in hospitals for treatment
- What is needed is to invest funding in community treatment resources at the higher levels of care that may be needed
- It is inexcusable that we permit this to go on year after year with people sitting in jails waiting for help
- When all is said and done, they come back to their community and are homeless and at square one
- All the resources are at the local level, and unless they are built out, you are simply spinning people from the county, back to the state and back to the county again
- There are hundreds if not thousands of people who can be placed in the communities
- The Governor has on his desk SB 317, this would change the statutes in terms of misdemeanors for ISTs
Brian Stettin
- There is an intersection here with Laura’s Law
- It is important to keep in mind that we really perverted the purpose of what the state hospital is there for
- People need the bed for a civil commitment not because they are in trouble with the state
- Beds can be done in smaller facilities closer to home, those beds can be used for people that are getting out of the hospital too soon and need time to become stable
Stephen Manley
- We have people in jail cells that are so sick, sitting with feces on the wall, and my question is always, where are we going to place them? We cannot just let them sit there and ignore them week after week, month after month, year after year, because we don’t know where to place them
- There are no conservatorships granted for individuals in the criminal justice system
Al Rowlett
- We are using data to inform people about AOT so they better understand the programs and the commitments made to make them successful so they do not have to live a life dependent on programs and we are showing them how they can become ambassadors for others
Keynote Speaker
Senator Susan Eggman
- I have a long history of being around mental health issues with family and friends
- My first love, her name was Kris, I went to the military right out of high school, she exhibited some signs when we were teens, and I watched her struggle with her mental health needs and watched her family struggle to get help for her. When we were 30, I invited her to an event, and she said she couldn’t come because she needed to get a haircut. Well, she was found in the bathtub, she attempted to take her life with a gun to the forehead and was not successful and was life support for a month before they harvested her organs took her off life support
- I always knew I wanted to help people and got a job at Crestview Manor – it was not a good model of care, but people were safe in a facility
- When I got out of the military, I got my bachelor’s degree in psychology and worked with substance abuse disorders, and got into mental health work
- I started working more in healthcare and hospice, and I was a kid who barely graduated high school, I had a smart mouth, and the military changed that and helped me develop self-control and learn how to be effective
- I went on to be a professor in Portland and worked in emergency rooms and social work
- After getting my Ph.D. at Sacramento State, I landed in Stockton
- When my mom died, I couldn’t do end-of-life care anymore; it was too hard. She was my research assistant
- I couldn’t understand why people who were doing the work weren’t being taught to run for office to create change, so I decided to run
- I was the first Latina, first lesbian, and I went for it, I was successful in getting the seat
- I had two MSW students with me my entire time in City Hall working to lift communities
- 2008 came, and we ended up going into bankruptcy as a city
- If we hadn’t done that, Stockton would still be trying to dig itself out of a hole
- It was a hard decision, but I had to do what was right for the people of the city that I served
- Many were angry with me, including labor, but I went ahead and ran for State Assembly anyway and am now in the Senate and in my final term
- I have served in a lot of areas but hadn’t served on budget, and this year I am chairing the budget subcommittee on health and human services, and wow, what a year to serve
- I have always had MSWs with me on my staff and we are very focused on expanding care
- In my last time here, I really want to focus on mental health professionally
- People living on the streets encounter more trauma which then leads to long-standing issues in their lives
- I would like to see more mental health resources in schools and a lot on the mobile side
- What I am really excited about is the over $1 billion for infrastructure – we do not have enough capacity to take care of all the people who need to be cared for
- I was on a call today with Catholic Bishops who are wanting to help, and they are currently offering a convent that will house pregnant women currently on the streets in Los Angeles County, so we are working to transition that building
- The prison in Susanville, part of our fairgrounds, there is a lot of excitement around properties that can be repurposed to house people
- I would encourage everyone to start looking at abandoned buildings in their communities
- Some people may never be able to live fully independently, but they can certainly live productive lives
- I want to offer myself and my staff – if anyone runs into barriers accessing funding, please let us know, we are good at kicking down doors
- It is unconscionable that we have pregnant women and others living on the streets
- One of the things we identified is the mental health oversight accountability didn’t have the teeth needed to see where the money was really going
- So, the Governor just signed SB 465 which requires that they get the data, it gets reported to us and we can make decisions on how it can be more data-driven, see where the gaps are and how we can use it most effectively
- SB 516 didn’t make it, but we will circle back in 2022 to it for LPS
- Anyone can call themselves a social worker now, we think everyone at the supervisor level should be a licensed mental health therapist, we are going to work on this
- We are gathering data and seeing where the holes are, polling people to see what the appetite is for a ballot initiative
- We need to do a better job at early intervention, which is key
- We know the pandemic has been hard and there is a stigma asking for help, we think covid has helped reduce the stigma some
- Workforce development is going to be a big component
- A lot of people leave the field because they need to be able to pay the bills
- Please encourage all the young people you know or the people looking to go back into the workforce to go into human services
- We all have a role in looking out for each other, taking care of our mental health and looking out for one another is what keeps the world turning on its axis
- If you can make the system work, it is so much better for families
- CalAIM must be a major component for removing the MS exclusion to pay for IMD and long term residential
Panel 3: Mental Health in the COVID Era
Jessica Cruz, National Association on Mental Illness
- Covid brought to light what has been a struggle for years, leaving people to fend for themselves
- Covid has opened the door for some great opportunities but also brought other challenges
- Covid brought some in recovery back into crisis, that was a time when families needed more intervention
Mark Ghaly, Secretary of the California Health and Human Services Agency
- We haven’t spent enough time talking about how those with severe mental issues are at higher risk with covid
- The data is staggering
- How the conditions have shifted, how conditions have led to increased risk of bad outcomes, and the impact of dealing with that has on an entire family
- How do we begin to address at younger ages, with large scale intervention and augment with other attributes in connection with schools, the formal clinical delivery system, and the relationship wealth we know is important to bend the curve
Tom Sopp, Long Beach Unified School District
- We received the most referrals in the first month of school, I am proud of our staff and administrators who are able to identify students in need dealing with sadness and depression
- I see an increase in services, a lot of innovation in terms of providing programs, groups, individual services
- Sadly, it isn’t enough; we see more aggression this school year
- There are not enough licensed providers to go around
- There are staff shortages as well
Jessica Cruz
- There is the education piece around the resources around mental health services for students and parents
- I saw firsthand how the pandemic impacted teachers with their own mental health
- There has been a tremendous turnover in early retirement and a huge gap in educators for people needing to step away and take care of their own mental health
Paul Marcille, California Psychological Association
- One of the things that were amazing was the pivot toward telehealth
- Telehealth has allowed many to access care who weren’t able to before
- There was an added level of intimacy to it, especially for adults with people being able to attend in their own home environment, they are less defensive and more open
Dan Morain, Moderator
- I worry about older people and people without internet who do not have access, how do you reach these folks in times of covid?
Mark Ghaly
- We had to go almost exclusively to telehealth visits, and we are now asking the questions of what the impact was, it is not a one-size-fits-all
- I think we will be learning over time and where the mix of different usage of technology will fit in
- I think the access has helped to scale access in congregate and locked facilities
- We still need to meet those on the streets and institutions where they are, which brings up our workforce crisis
- It is not just going to take brick and mortar but a great deal of investment in the workforce
- We want to see that every single referral has a place to go
- SUDs have the greatest gains to make
Jessica Cruz
- We are seeing people have a hard time finding places to go when needing mental health services
- Emergency rooms are having people stay longer because there is nowhere to go
- People need services when they need them and where they need them along their journey
- Peers and family members are a huge component, it is often families trying to navigate the system
- NAMI is often getting calls from families asking where to go and who to call
Mark Ghaly
- We can no longer look at this as a Monday-Friday, 8-5 practice, and getting a workforce that can wrap around the needs is what will be most impactful
Paul Marcille
- People are leaving school with massive amounts of school debt and need jobs that can support paying school loans, and this is a major problem
Jessica Cruz
- There is no one-size-fits-all
- There needs to be accessibility no matter where people are on the spectrum
- There should be services and supports, while we need to flip the triangle, we also cannot turn our backs on those who are living severe mental illness
- We can’t wait for a crisis to take place, we need to prevent it, it might mean beds, housing, or other supports
- We want to make sure we are creating a better future for those to come, and we want to make sure families are not left behind in the process
- We must recognize this is not just moms, dads, brothers, sisters but their community supports as well
Mark Ghaly
- We need to build a system people can rely on, so they don’t have to wait so long and end up on the streets or incarcerated
- It is going to take all of us, schools, insurance companies, homeless service providers, higher ed; everyone needs to come together
- At HHS we will continue to convene these roundtables to deliver on a promise we have not been able to deliver on in a really long time
Tim Foster, Capitol Weekly
- Videos from all of today’s panels will be posted on Capitol Weekly’s website in the coming days
- Thank you to all our panelists
