Get Out of Jail Card: a Ticket to Treatment

Sacramento Assemblyman Darrel Steinberg discusses his new demonstration program to get mentally ill homeless people out of jails and prisons and into treatment.

Assemblyman Steinberg: About 50,000 people in California are homeless and severely mentally ill-20 to 40 percent are military veterans. Many could benefit from modern psychiatric treatment if they had the economic means to house and support themselves, and the social and logistical supports that encourage and sustain their initial and continued treatment.

Without services, the homeless mentally ill frequently wind up in jails or prisons, primarily for committing "crimes of survival." The estimated criminal justice and law enforcement cost to deal with people with mental illness is $1.2-$1.5 billion annually.

It is unfathomable to me that in a state boasting the seventh largest economy in the world, our biggest-and sadly sometimes our best-mental health services lie in our jails and prisons.

We cannot continue to allow mental illness to be a crime. The way to prevent this is to adequately fund community programs that successfully treat the mentally ill and provide the support they need.

It is often difficult for the mentally ill to gain access to and continue in mental health services when they lack adequate food, shelter, transportation and psychosocial and economic support. Their mental illness interferes with their basic living and treatment, and their substandard living worsens their mental illness. AB 34 intends to interrupt this cycle. We expect to see reduced jail and prison time served and more productive living by the targeted population.

What this takes is a comprehensive system of wrap-around services including community-based outreach, early intervention and treatment, case management, housing, drug treatment, and interagency coordination. Law enforcement, employment, housing, public welfare, health, and mental health agencies must all be involved.

Our goal is for the clients to have the highest possible independence in housing, employment, education and training, and income; to develop the ability to control their daily lives and long-term decisions-including the ability to manage their mental and other health needs; and to avoid antisocial and criminal behavior as well as dependence on addictive substances.

Q: That's an ambitious goal, especially with a tired, beaten and despairing population. About 40 years ago, as Deputy Director of Community Services in the California Department of Mental Hygiene, I oversaw the new Short-Doyle Act. It intended to help local governments operate broad-based community mental health services, offering outpatient, inpatient, day hospitalization, night care, rehabilitation (e.g., support, training, job finding, sheltered living) and mental health consultation and rehabilitation.

Our target was voluntary patients of all ages, without regard to income or severity of illness. Several counties, like San Mateo and Santa Clara, developed far-reaching programs. Sacramento County didn't beef up its skimpy Short-Doyle program until a decade later, when federal funds underwrote a wide range of services. By the time Sacramento saw homelessness and untreated severe mental illness as serious problems, the broader array of coordinated services was gone. What happened and what is different now?

A: Sacramento was not alone in having inadequate programs in place. When the state first emptied the state hospitals it did not provide for the whole array of wrap-around services patients needed to help them live on their own. This included housing assistance, life skills and vocational training, substance abuse treatment and peer support.

The counties began to develop programs built around the broader model, but, even in the innovative and well-funded Bay Area counties, state and federal funds were never enough and Proposition 13 eliminated the ability to tap local funds to go beyond state and federal support.

As state and federal funding was cut back throughout the 1980s and as housing costs skyrocketed, the numbers of people left untreated and in the streets rose dramatically.

AB 34 focuses on this population with objective performance measures for awarding and evaluating contracts. The state advisory committee developing the criteria for awarding and evaluating grants includes representatives from state, county, and community veterans' services; housing and housing assistance programs; law enforcement; county private sector and public mental health service providers; state corrections; rehabilitation and alcohol and drug programs; and citizen advocates for mentally ill patients.

We have already seen success. The three programs funded under AB 34 have brought more than 600 people off the street and into housing and services as of January 1.

Every indication is that these comprehensive, voluntary programs work to stabilize severely mentally ill clients at risk of homelessness and incarceration.

Q: Despite tremendous advances in medications, patients still respond very differently and unforeseen stresses alter drug effectiveness and reactions. This is hard for anyone to take, let alone severely mentally ill patients barely surviving in a harsh environment. Will local programs have the resources to keep patients voluntarily participating?

A: I believe that these programs will be more accountable and will be able to leverage both federal and private foundation dollars to make them even more cost effective and comprehensive.

Q: Was there opposition to AB 34 that might surface in Sacramento County?

A: There was no opposition. Counties, law enforcement, the business community, individuals and agencies serving the seriously mentally ill, family members, and the clients themselves supported this bill. Everyone sees this as an issue whose time has come.

Our biggest challenge was the county's capacity to build the needed system of care quickly enough.

The result is a $10 million investment in expanding successful programs in three counties-Sacramento, Stanislaus and Los Angeles-as a demonstration program. There will be a report to the legislature on May 1st indicating the success of the program.

We have every indication that this approach works. Law enforcement, local businesses, clients and families, and mental health professionals all agree that supportive services provided in the community are cost effective and break the jail-street-hospital cycle and result in stabilizing the severely mentally ill.

Ed_Rudin@macnexus.org