Two decisions last week -- the Supreme Court's ruling that California must reduce its prison population and the state Legislature's move to beef up security at state mental hospitals -- are related to a larger, longstanding problem of chronic underfunding for mental health care in California, according to veterans of the system.
Mental health experts argue that part of the overcrowding problem in California's prisons and security problems at mental hospitals are a result of too little attention and money spent on mental health care.
"That's absolutely the case and it's nothing new, unfortunately," said Larry Poaster, chair of the state Mental Health Services Oversight and Accountability Commission.
"Because of the inadequacy of mental health funding over the years, there's little doubt that many people who end up in our criminal justice system -- either in prisons or in mental hospitals -- could have been steered in other directions with early intervention and treatment," said Poaster, who worked 30 years at the county level of the state's mental health system, most recently as director of the Stanislaus County Mental Health Department.
But that's not how the state's approach to mental health has evolved, according to many advocates. Instead of diagnosing and treating mental health problems early on, California tends to react once mental health problems rise to the level of the criminal justice system. "There's an old saying that the largest psychiatric hospital in California -- and maybe the world -- is the Los Angeles County Jail," Poaster said.
Legislature Struggling With Mental Health
The state Legislature is grappling with the mental health system on two levels -- the immediate need for increased security at state mental hospitals and the long-range plan to dismantle the state Department of Mental Health, part of a longstanding plan to shift toward community-based delivery of mental health care.
The immediate need to beef up security compelled otherwise tight-fisted legislators to approve spending $9.5 million in general fund money this year to improve safety and security at three state mental hospitals.
Last week, at a budget subcommittee hearing, Department of Mental Health officials outlined a pilot project to make state mental hospitals safer. The effort has been advanced partially in reaction to the killing last fall of a mental health care worker at Napa State Hospital.
The plan is to issue personal alarms to staff members at Napa State Hospital, and to expand the program to other facilities if it goes well.
Budget Subcommittee Chair Sen. Mark DeSaulnier (D-Concord) was emphatic that the pilot program start as quickly as possible.
"We cannot minimize the danger of not getting this right," DeSaulnier said. "There are people's lives at risk, obviously."
The number of violent incidents at state mental hospitals has been gradually increasing, according to Cindy Radavsky of the Department of Mental Health.
"We've been noticing an increase in the number of those [violent] patients," Radavsky said. "And we'd like to refine the transfer of those patients ... to make sure it's a good evidence-based process, so we're not violating patients' rights."
The department refers 12 to 15 patients a year to the Department of Corrections, Radavsky said. In effect, these referrals are often part of a growing cycle of the criminal justice system referring convicts or people deemed unfit for prosecution to psychiatric facilities, ... who in turn are referred back to the Department of Corrections if they become violent.
About 90% of the patients in state mental hospitals arrive there through the criminal justice system, according to state estimates.
Long-Range Shift Toward Community Care
As part of California's efforts to shift oversight and responsibility of many governmental programs from state to counties, legislators are considering dismantling the state Department of Mental Health.
Many mental health advocates welcome the shift, but they worry that new responsibilities will arrive without enough money to do the job right.
"I'm a fan of realigning programs to the lowest governmental level because they usually work better," said Poaster, who added that it is important to distinguish that his comments in this story reflect his own thoughts, not the position of the commission he chairs. The state Mental Health Services Oversight and Accountability Commission, created when voters approved Proposition 63 in 2004, will issue its stance on realignment and other issues after meetings later this year.
"Whether realignment is good or not boils down to the dollars and cents," Poaster said.
Patricia Ryan, executive director of the California Mental Health Directors Association, agreed.
"We have a pretty good idea about what works to keep people out of jails and out of mental health hospitals, but we don't have enough money to do those things," Ryan said.
She said she and many of her colleagues in the profession believe that the public understands the situation but that policymakers may not.
"The passage of Prop. 63 is a good indication," Ryan said. "People understand that there are consequences of not treating people's mental illness. The public is there, but the political system isn't exactly clear on it yet."
Hospitals Will Stay With State
Even if the Department of Mental Health is dismantled, state government will still retain oversight of state-run psychiatric hospitals. Exactly how and where that oversight may fall is yet to be determined.
Diana Dooley -- secretary of the California Health and Human Services Agency, who last month lifted a hiring freeze at state psychiatric hospitals -- said her agency is committed to improving the way the state deals with mental health.
"The key issue is most significantly with the state hospitals," Dooley said. "We're moving substance abuse programs to the county level. So what is left (in the state's purview) is the state hospitals. We decided that we're not going to let the tail wag the dog and leave the state hospitals as the thing left over. We're going to commit to improving them."
Legislators and CHHS officials are working on improving the financial workings of the institutions as well as addressing security and safety. Some legislators contend that centralizing financing will help improve the state mental hospital system. Currently, the five hospitals operated by the Department of Mental Health individually do their own purchasing. An effort is under way to create centralized purchasing for the entire system. Staff overtime hours are also targeted for reduction. State Sen. Elaine Alquist (D-Santa Clara) said the Legislature should consider a cap on spending at each of the hospitals.