Why It’s So Hard to Get Mentally Ill Californians Into Treatment

Tent of homeless person on 6th Street Bridge with Los Angeles skyline in the background. California, USA. (Photo By: Education Images/UIG via Getty Images)

(CALMATTERS.org) — For years, Diane Shinstock watched her adult son deteriorate on the streets.  Suffering from severe schizophrenia, he slept under stairwells and bushes, screamed at passersby and was arrested for throwing rocks at cars.

Sometimes he refused the housing options he was offered. Sometimes he got kicked out of places for bad behavior.  Shinstock, who lives in Roseville and works on disability issues for the state of California, begged mental health officials to place him under conservatorship—essentially, depriving him of his personal liberty because he was so sick that he couldn’t provide for his most basic personal needs of food, clothing and shelter.

But county officials told her, she said, that under state law, her son could not be conserved; because he chose to live on the streets, he did not fit the criteria for “gravely disabled.”

“I was devastated,” she said. “I cried for days.”

So Shinstock—along with her husband Joe, a policy consultant who works for Republican leadership in the Assembly—set out to change state law. Their uphill battle illustrates the complex philosophical, legal and ethical questions that surround conservatorship in California.

What responsibility does government have to protect people with serious mental illnesses who refuse treatment?  How should it balance the right to liberty with the need for care?

At the heart of the long effort to answer these questions is a law signed in 1967 by then-Gov. Ronald Reagan. Aimed at safeguarding the civil rights of one of society’s most vulnerable populations, the Lanterman-Petris-Short Act put an end to the inappropriate and often indefinite institutionalization of people with mental illnesses and developmental disabilities.

It also provided them with legal protections, such as the now-familiar rules in California limiting involuntary holds on people deemed a danger to themselves or others to 72 hours, better known as a 5150 hold.

Those who want to change the law, like Shinstock, believe Lanterman-Petris-Short’s protections too often prevent very sick people from accessing the help they need. Others say people who suffer from mental illness need better care and support from society, not intrusions on their civil liberties. If the state wants to help those with serious mental health issues, they say, it should address the housing crisis and the under-resourced community mental health systems.

It’s an argument that has repeatedly stymied bills to force seriously mentally ill people to get care. This year, several were proposed. At the moment, only one—Senate Bill 1045—is left.

SB 1045 would create a 5-year, opt-in pilot program for San Francisco, Los Angeles and San Diego Counties, making it easier to conserve individuals with serious mental illness and substance abuse disorders who refuse treatment and have been detained frequently by police. Counties would have to prove that they could provide housing and wraparound services before they could participate.

Diane Shinstock and her husband worked on a second bill with Assemblyman Phillip Chen, a Republican from Brea. That bill, Assembly Bill 2156, would have expanded the definition of “gravely disabled” to include a person’s capacity to make informed decisions about food, clothing, shelter and medical care. (Current laws don’t speak to decision-making capacity, and their criteria don’t include medical care.)

Meanwhile, The Steinberg Institute, a nonprofit focusing on mental health policy, co-sponsored a third bill. Assembly Bill 1971 didn’t address decision-making, but also would have made it easier to conserve people with mental illnesses who refused medical treatment.

The volume of proposals demonstrated the hunger for solutions, said Adriana Ruelas, the institute’s government affairs director. “We have to do something,” she said.

But opponents of the various bills say it does no good, and perhaps does harm, to force people into care that is insufficient.

Without enough long-term services and housing in place, people who are conserved could easily just end up back on the streets with even worse mental health and substance abuse disorders, said Jennifer Friedenbach, executive director of the Coalition on Homelessness in San Francisco.

“Instead of correcting the system, it’s expanding the part of the system that works the least,” she said. “If we want increased resources, let’s just fund them. Why are we wasting a bunch of money on a court process when we can just give them the care they need?”

Jen Flory, a policy advocate with the Western Center on Law & Poverty, agrees.

“We understand it’s a crisis,” she said. But without better services and housing that is accessible to people with criminal backgrounds, making it easier to conserve mentally ill people is just another false promise.

“Until we solve that problem about where someone will actually live, we are concerned about taking their rights away,” she said.

Sen. Scott Wiener, a San Francisco Democrat and author of SB 1045, argues that rights already are being taken away from people with serious mental illnesses—by the criminal justice system.

“We do have a very large conservatorship program in California—it’s called jail,” he said.

Wiener said the idea for his bill originated with San Francisco’s Department of Public Health, which would see chronically homeless, severely mentally ill and drug addicted people come in again and again on 72-hour involuntary holds. By the time these holds were up, many individuals would be coherent enough that a judge would let them go. Before long, the same people would be picked up again.

Under Wiener’s bill, judges could consider individuals’ histories of involuntary holds when deciding whether to conserve them. To participate, a county would need to prove that it has enough housing and resources to fully support the conserved individuals.

Wiener estimates the bill will impact between 50 and 100 people in San Francisco who are already well-known to the department. “This is not about broadly conserving large numbers of homeless people,” he said.

Besides the philosophical debate about civil liberties and housing, the various bills were pushed and pulled by the practicalities of lawmaking. Shinstock’s bill redefining “gravely disabled,” for instance, was folded into AB 1971, the similar bill being pushed by The Steinberg Institute.

But then AB 1971, which initially would have made conservatorship easier statewide, was scaled back to be just a pilot project in Los Angeles. That created a new legal concern: How could “gravely disabled” be defined differently in Los Angeles County than everywhere else?

That and other amendments prompted Shinstock to formally withdraw as a supporter. Then AB 1971 also ran into opposition from the California Hospital Association.

Sheree Lowe, the association’s vice president of behavioral health, said she worried the measure would increase the number of individuals being brought in on involuntary holds, without changing legal requirements that hospitals obtain consent before providing treatment to individuals. Last week, the bill was pulled back by its authors.

That left SB 1045, the Wiener proposal to change the process by which mentally ill people can be conserved. It passed the Senate and Assembly and was sent to the governor for a signature or veto this week.

The Hospital Association’s Lowe said her association supports SB 1045, since it focuses on individuals who are already frequent users of the system, and because the county Boards of Supervisors would be involved in conservatorships.

Concerns have been raised, though, about funding for public guardians’ offices. Scarlet Hughes, executive director of the California Association of Public Administrators, Public Guardians and Public Conservators says her group isn’t opposing SB 1045, since it’s a pilot impacting only a few counties. But she doesn’t want “another unfunded mandate” either.

She also said she worries that there are not enough community placements for conserved individuals, meaning that increasing numbers of people would be stuck in locked facilities waiting for a spot. In recent years, many board and care homes have closed, she said.

“This is a 50-year-old problem that has just gotten worse every year,” she said. “Now we’re at a crisis point.”

When her son was a child, Diane Shinstock said, he was a sweet and kind little boy who loved his younger sisters and was good with the family pets. He played Little League baseball, joined the Boy Scouts and loved to make pancakes. If Diane was sick, he was the one who came to check on her.

But, early on, he would go into out-of-control rages. He was diagnosed with depression at 8, bipolar disorder at 9. At 10, he was enrolled in a day treatment program. At 21, he was hospitalized with his first psychotic break.

In the 12 years since, Shinstock said, she has watched her son, now 33, cycle among hospitals, the streets and jails. For several years he was conserved. The locked facilities and board and care homes where he stayed were often depressing, and sometimes disgusting. She understands why people wouldn’t want to live there.

“I had a hard time being there for an hour,” she said.

After the county determined that he didn’t need to be conserved anymore, her son ended up homeless in 2013. In 2016, after a series of charges for disturbing the peace and disorderly conduct, he cut off an ankle monitor and landed in jail.

He spent the better part of 15 months in solitary confinement, ostensibly for his own protection, and because he was unmedicated, his mental health “deteriorated to an extreme degree,” said Shinstock. By this past January, he was so emaciated that he was unrecognizable, she said.

Only then did the county agree to conserve him again. She doesn’t know how long it will last this time.

“Regardless of what we call it,” she said, “he needs help.”

This article was originally published by CalMatters.org

SF Disability Discrimination Case Could Hobble Law Enforcement Nationwide

adaThe Americans with Disabilities Act, passed by Congress in 1990, was the product of good intentions. Its proponents — President George H.W. Bush chief among them — wanted to eliminate arbitrary barriers to the physically disabled. “Let the shameful wall of exclusion finally come tumbling down,” Bush solemnly declared at the legislation’s signing ceremony. The ADA sailed through Congress with little resistance. Unfortunately, as is so often the case with federal do-goodery, those good intentions produced a poorly drafted statute full of vague definitions, ambiguous obligations, and complicated enforcement schemes, made even worse by byzantine enabling regulations and far-fetched judicial interpretations.

Twenty-five years later, the true consequences of the ADA are still unfolding. Hijacked by trial lawyers, government bureaucrats, and activist judges, the noble goals of the ADA have brought instead a host of other absurdities: costly and ubiquitous (and largely unused) curb cuts and ramps in public areas; Braille buttons on drive-through ATMs; alcoholic pilots and truck drivers, deaf lifeguards, and one-legged firefighters; drug-addicted employees who can’t be fired, lest employers “discriminate” against a “protected class”; and serial litigants — some of whom have filed thousands of lawsuits — who make a cottage industry out of fly-specking small businesses’ compliance with arcane and prolix structural requirements for bathrooms and parking lots. Much to the likely chagrin of the ADA’s proponents, the definition of “disabled” is not limited to people in wheelchairs — it includes those suffering from morbid obesity, drug addiction, phobias, allergies, narcolepsy, sleep apnea, and dyslexia. Of the estimated 43 million “disabled” Americans protected by the ADA, fewer than 2 percent are in wheelchairs, the vast majority of whom reside in nursing homes.

Employers must “reasonably accommodate” this thicket of disabilities by restructuring job duties, granting leaves, providing technological support, hiring assistants, granting reassignments, making “individualized determinations,” and entering into “interactive dialogues,” all while ignoring “discriminatory customer preferences” and, of course, “traditional stereotypes” (no matter how well-founded). The ADA essentially requires employers to function as social workers and ignore the economic burden unless it constitutes an “undue hardship.” In short, the ADA has short-circuited common sense.

Alas, critics have railed against the asininity — and astronomical compliance costs — of the ADA, to no avail. Despite their most dire predictions about the law’s nonsensical potential those critics had no inkling of the ridiculous extremes that were yet to come, thanks to an inventive ruling of the San Francisco-based U.S. Ninth Circuit Court of Appeals.

Last year, in Sheehan v. San Francisco, the Ninth Circuit held that the ADA applies to law-enforcement officers, and requires them to “accommodate” armed, violent suspects if they are “mentally ill” (and therefore “disabled”). The case arose from an incident in 2008 involving two female police officers who were responding to a call for assistance by a social worker at a group home for the mentally ill. The social worker had been threatened with a knife by one of the residents under his care, a middle-aged woman with schizophrenia named Teresa Sheehan (whose condition had deteriorated because she refused to take her medication). The social worker wanted to have Sheehan involuntarily committed for 72 hours for evaluation and treatment, and requested that the police transport her to the mental health facility for that purpose. When the officers arrived, Sheehan became violent, grabbed a knife, and threatened to kill the officers. The officers drew their weapons and unsuccessfully attempted to subdue Sheehan with pepper spray. In the course of trying to arrest Sheehan (who was still brandishing the knife), the officers shot her several times. Sheehan survived, and sued the officers (and the City of San Francisco) in federal court for various claims, including violation of the ADA. Sheehan did not dispute that she was armed and violent. She alleged, however, that “the officers should have respected her comfort zone, engaged in non-threatening communications and used the passage of time to defuse the situation.” The federal district judge, Charles Breyer (younger brother of U.S. Supreme Court Justice Stephen Breyer), dismissed the case before trial on summary judgment. Sheehan appealed.

The Ninth Circuit ruled, as a matter of first impression, that the ADA applies to all arrests, even those involving violent confrontations, and that a jury should decide whether the officers “reasonably accommodated” the violent, knife-wielding suspect “by employing generally accepted police practices for peaceably resolving a confrontation with a person with mental illness.” The city appealed to the U.S. Supreme Court, which heard the case on March 23. The city contends that the ADA should not apply to police conduct when public safety is at risk. According to the FBI, about 400 people are killed each year by police—as justifiable homicides in the exercise of deadly force. Sadly, at least half the people killed by the police have mental health problems of some sort, according to a 2013 report from the Treatment Advocacy Center and the National Sheriffs’ Association.

Do we want juries second-guessing hundreds of police encounters each year to determine if armed, violent suspects were mentally ill and if the police “reasonably accommodated” the suspects? Police officers are not psychiatrists. They cannot be expected to diagnose whether a violent suspect is mentally ill or merely mean and aggressive. People who threaten to kill the police are by definition unreasonable and even irrational. Some social scientists believe that all criminals are emotionally disturbed; should this entitle them to special treatment by law enforcement? Hamstringing the police endangers public safety. Split-second decisions made in violent confrontations with armed suspects are not suitable for Monday morning quarterbacking. If the Supreme Court does not reverse the Ninth Circuit’s ludicrous decision in Sheehan v. San Francisco, the errant intentions of the ADA will have succeeded in disabling the police.