THE ROCK REPORT: SLO County Health Leaders Focus on Housing to Treat Chronic Homelessness, Mental Illness

By ED OCHS

As undeniably complex as the issue of homelessness is nationally, what is needed to provide better homeless and mental health services in SLO County is clear: More of everything.

According to a February survey on homelessness and mental illness treatment in SLO County conducted by The ROCK, SLO County officials and professionals working to find pathways to solutions on a daily basis agree: More funding, more affordable housing and more treatment are badly needed to begin to make a serious dent in chronic homelessness shadowing the county.

They also unanimously concur that the Affordable Care Act will offer a huge boost for the chronically homeless in the county as more people become eligible and more services are offered, including mental health, under an expanded Medi-Cal program. (See separate article. Click here.)

More permanent housing for disabled

Last year’s Point-in-Time Count, conducted by the Homeless Services Oversight Council (HSOC), logged 2,186 homeless people in San Luis County in one 24-hour period in January 2013, and an estimated 3.497 people homeless over the course of a year. Of those, 29% were chronically homeless, with many more at risk, while 49% reported experiencing some form of mental illness, according to the count. Significantly, missing from the data, according to Homeless Services, are persons who do not access shelter, case management, or transitional or permanent housing assistance.

“These statistics demonstrate the need for more permanent, supportive housing for persons with disabilities as well as more treatment services,” responded Laurel Weir, Homeless Services Coordinator, Department of Social Services.

According to Weir, approximately 25 homeless patients per month are admitted to the County’s Psychiatric Health Facility (PHF), a short-term-stay, crisis facility for adults and youth who are admitted because they are a danger to themselves or others, have been found incompetent to stand trial, or who have been conserved. Over the past year, homeless persons constituted the overwhelming majority of persons admitted to the PHF under California Penal Code 1370 (incarcerated persons who have been found incompetent to stand trial).

Because of revised questions and an added provider in 2013, comparing 2013 homeless numbers to 2012 is inexact. Over all, though, Homeless Services reported a slight decrease in the number of new persons reporting mental health issues in 2012 (575 out of 1451 new “intakes” or 40%) versus 2013 (483 out of 1258 or 38%). But of clients whose first intake was in 2012, 257 were still being served by one or more Homeless Services programs in 2013. From July 1, 2012 to June 30, 2013, there were 137 homeless persons admitted to the PHF, approximately 16% of all PHF admissions.

“According to the federal Substance Abuse and Mental Health Services Administration, homelessness exacerbates mental illness,” Weir stated. “Therefore, housing is an important part of the treatment. In particular, the Housing First model has shown promise for moving chronically homeless individuals with severe and persistent mental illness off the street.

“As a first step towards increasing resources for people with severe mental illness, particularly those who have co-occurring substance abuse disorders and chronic health conditions, the County recently issued a Request for Proposals to serve 50 of the most vulnerable, chronically homeless persons.”

The RFP explains the program and Housing First model: “The ‘Housing First’ approach has emerged as a favored policy in addressing issues of homelessness. … ‘Housing First’ places people into permanent housing and then provides behavioral health treatment, case management, and other services needed to allow the clients to stabilize in place and to maintain their housing. The model does not require people to be well before putting them into housing, nor does it require clients to participate in any services other than case management as a condition of receiving housing. The ‘Housing First’ model is considered by HUD and other federal agencies to be a best practice for ending homelessness among those who have been chronically homeless, because use of this model consistently demonstrates a decreased use of emergency services, criminal justice resources, and many other public services.”

The RFP continues: “As part of a strategic planning effort in March of 2013, the Homeless Services Oversight Council (HSOC) identified ‘Housing First’ as a priority. To address this priority, HSOC voted in May of 2013 to join the 100,000 Homes Campaign, a national effort that emphasizes a ‘Housing First’ approach to housing highly vulnerable, chronically homeless individuals.”

Explained Weir: “Mental health treatment is not necessarily the first action that should be taken to get homeless persons with mental illness off the streets, nor are clients required to obtain treatment prior to being housed. Treatment often comes after the clients are housed.

“We are also looking at some additional opportunities to expand the number of permanent housing units in the Continuum of Care’s Supportive Housing Program, although whether or not funding is available for this will depend on the aftermath of the federal budget Sequestration.  Additionally, we have asked the agencies that run the existing Supportive Housing Program beds to agree to give priority to chronically homeless persons—who must have a disability, such as mental illness, to be considered chronically homeless—if units become available in their existing Supportive Housing Program.”

“When the HSOC held discussions last year about the Psychiatric Health Facility, it noted that some of the homeless persons being discharged from the PHF were sent to the homeless shelter because of a lack of suitable housing options. The Housing First program and the expansion of permanent, supportive housing would be a first step in helping homeless persons with mental illness to move out of the shelters and off the streets and into more appropriate housing with the supportive help they need to keep them stabilized in housing.

“To be clear, these would be only first steps. In order to fully serve all the homeless persons with mental illness, we would need to significantly increase both our housing and supportive services for this population. We will continue to pursue additional federal and state funding to expand resources needed.”

Finding funding is a full-time, never-ending pursuit for providers, particularly when new funds for new programs can’t keep up with federal cuts that undermine existing programs.

“Recent federal cuts have made our efforts more challenging.” Weir noted. “In particular, the federal Budget Sequestration has put one of our permanent, supportive housing programs at risk of losing its federal funding. Also, a change in the major federal homeless assistance program that funds some of the case management services provided to homeless persons placed into permanent housing has limited the amount of time that case management services may be provided to six months. When someone with a severe and persistent mental illness is placed into permanent housing, they will often continue to need services well beyond six months.

“Cuts to the federal Housing Choice Voucher program have reduced the number of housing subsidies available to place people into permanent housing. Also, cuts at the state level have reduced funding available to build supportive housing for extremely low-income persons with disabilities.”

Limited number of mental health providers

Replied Grace McIntosh, Deputy Director of the Community Action Partnership of San Luis Obispo (CAPSLO): “While some of our programs see relatively few individuals with mental health issues, other programs, such as Homeless Services, see a larger number. Since mental illness is a major contributing factor to homelessness it would make sense that mentally ill individuals remain in our homeless program for longer periods of time and are more challenging to place into permanent housing. The numbers have remained fairly steady as many individuals are in services for a number of years.”

The need for more funding extends beyond the areas of mental health and housing, McIntosh points out.

“I think most non-profit providers and the county would agree that there is a need for more funding, not only in the area of mental health services, but drug and alcohol services and affordable housing as well. Funding for mental health services for children is an area that needs to be increased as some of our programs are seeing a larger number of younger children presenting behaviors that challenge their ability to be successful in preschool and school.”

McIntosh is among several county officials and professionals who believe Medi-Cal will help more homeless receive care. (See separate article.)

Explained McIntosh: “With expanded Medi-Cal now including mental health services, there will be the opportunity for qualifying individuals to receive these services. I think there may be difficulties with access given the limited number of providers in the county. The issue of a limited number of mental health providers is not only in our county—it is a national issue that I believe is going to need to be addressed in the very near future. Funding is always an issue that providers struggle with. In addition to public dollars most non-profit agencies also look to the community for support.”

A little togetherness is helping providers deal with funding issues. Forming a network allows them to continue to provide essential services, individually and collectively, which benefits clients and community.

“Given the obvious funding gaps, service providers countywide are partnering as best they can to meet the needs of the mentally ill,” McIntosh stated.

“The SAFE program is one concrete example of non-profit service providers, schools and county departments working together to provide preventive and therapeutic services to children and their families. Transitions-Mental Health is partnering with County Mental Health in providing outreach to mentally ill homeless individuals to try to get them into services. ECHO is completing the expansion of their overnight shelter to meet the increase in the numbers of homeless individuals and families in the north county coming for services.”

Lack of funding, lack of advocacy for children

“The final judgment in the lawsuit known as ‘Katie A.’ resulted in some additional resources,” responded Lee Collins, Director of the County Department of Social Services and Child Welfare Services (CWS). CWS is not a provider of care. “We are a broker for care, referring children and advocating on their behalf,” Collins explained.

“Now some additional therapists have been added, some additional contracts have been let—primarily to Family Care Network, the organization that is our most trusted provider of services—and we expect to see a gradual, incremental increase in services. We fund a great deal of mental health services out of our own funding, because we decided that we could not let children languish without care until we’d won the battle on their behalf.”

“We funded the Kinship Center’s expansion into San Luis Obispo County, an organization that primarily serves relatives who are taking care of children. (Think grandmothers, taking care of grandchildren who have been removed from their parents, for example.)  We paid for it ourselves and have done so for many years now. We pay for a host of ‘wraparound’ services provided by the Family Care Network, including therapeutic services provided by their staff.

“Still,” Collins added, “the available resources are woefully inadequate. There is a lack of funding—State, Federal and Local—but there also is a lack of advocacy on behalf of these children. They are seen as just one more ‘constituent’ group in need, among many. We see it differently, of course, because we see the pain endured by these children and by their family members.”

Most significantly, more people are eligible and more services will be offered under the Affordable Care Act, including mental health.

“We believe that the Affordable Care Act will be instrumental in expanding access to Mental Health services. (See separate article.)

Collins sees the need to establish an “intensive residential treatment center for children. Not a group home, and certainly not the PHF, but we do need a place where children can be hospitalized and treated in a safe environment.” Combining with Santa Barbara or another county on a regional facility might make it more economically viable.

“And we have to find a way to serve children who are not in CWS or Probation, rather than trying to convince those parents—as has been reported repeatedly—that they should ‘give up’ their children to the CWS system as the only means of getting care…”

He believes the mental health services gap will narrow when the width and breadth of the community comes to the full realization that the problem must become a priority, and a solution is possible.

“Our community—including advocates, the Board of Supervisors, school administrators, policy makers, media—must become aware of the extent of the issue, and of the deleterious effects that untreated mental health conditions can have on the children but also on the community at large. Untreated mental health issues can lead to increased incarceration, drug and alcohol addiction, unplanned pregnancy, domestic violence and the continuation of a cycle of abuse. We need to illustrate the issue in real terms that make sense to the average citizen who will want ‘something to be done.’ Then we have to show that funding really is available, whether through Medi-Cal or private insurance, or from cost avoidance in other systems, to effect a real solution.”

Keeping pace with the growth in needs

Jeff Hamm, Director, County Health Agency, and Anne Robin, Behavioral Health Administrator, County Health Agency, won’t characterize the status of mental health care in the county as a crisis, rather part of a nationwide increase in demand for services.

“We don’t believe there is a crisis. There are rising demands for mental health services statewide, even nationwide, as more people become aware of the benefit of mental health services and the stigma related to seeking these services has reduced. Approximately 1 in 4 adults will have need for mental health services during their lifetime; development of the capacity necessary to provide access to services has not kept pace with the growth in needs.

“Unfortunately, during the recent recession, capacity has remained static or has been reduced. There is reason to be optimistic about the immediate future, however. The Medi-Cal expansion component of federal health care reform (Affordable Care Act) will allow previously ineligible persons (primarily childless adults) to become eligible, and the expanded scope of benefits will be of tremendous help to those with mild to moderate levels of mental illness.

“The Affordable Care Act has increased funding for all levels of mental health services. In the past, only individuals with serious mental health needs have had access to care under Medi-Cal. Now there are additional levels of care available (individual and group psychotherapy, psychiatric consultation) for all Medi-Cal eligible individuals. This will allow the County services to focus more closely on those individuals and families who have the most serious illness and need for rehabilitative services. The ‘primary level of care’ for mental health services, for those individuals with mild to moderate illness, may also prevent individuals from becoming more seriously impacted by their symptoms.

“Not all homeless individuals have serious mental illness. Many do have trauma, anxiety, depression, and substance use disorders. Housing First models provide a safe place to assist individuals to deal with whatever their service needs may be. Shelters are simply a starting place; more permanent supportive housing are a much better solution to the problems of homelessness. Whatever the other challenges a homeless individual may face, the insecurity of day to day life on the streets creates an enormous barrier to recovery/wellness/health.

“The Affordable Care Act is expected to have a tremendous positive effect on bridging the gap between demand and supply. The coming months and years will shed light on the extent to which the problem has been substantively reduced.”

Creating more truly affordable housing

Increased attention of the unwanted variety was drawn to the Central Coast late last year, causing quite a stir in influential circles, when the annual homeless assessment report ranked SLO County third worst in the nation with 90% of the county’s homeless unsheltered.

This resulted in Jerry Rioux of SLO County Housing Trust Fund authoring some recommendations on how to remedy the situation, such as allowing greater flexibility with existing housing to open up more alternative housing opportunities. Rioux agrees with the Housing First concept.

“Individuals who are homeless will be better able to deal will their other challenges if they first have sufficient food and a roof over their heads,” he noted.

The Homeless Services Oversight Council (HSOC) recently adopted his recommendations to directly address the basic needs of “food and roof” as the best step forward out of homelessness.

The motion encourages the County and every city in the county to include various programs/policies in the Housing Elements of their General Plans. The state requires that they all update their Housing Elements by June 30, 2014.

Before his motion was approved by the HSOC, Rioux explained why it was needed.

“I prepared the motion because I am concerned that it will be impossible to make much progress placing people who are homeless—for any reason—into housing unless we create more truly affordable housing throughout the county. I strongly believe that we need more small apartment units, granny flats, rooming and boarding houses, group homes, mobile homes, etc. The motion encourages County and cities to facilitate these types of housing.”

Embracing the ‘village’ philosophy of treatment

The County contracts with Transitions-Mental Health Association to runs its Full Service Partnership Homeless Outreach Team that conducts outreach and screening of homeless persons with mental illness. The team has helped to house 27 individuals with severe and persistent mental illness since January 1, 2013.

Transitions staff—Jill Bolster-White, Executive Director, Transitions-Mental Health Association, San Luis Obispo; Barry Johnson, Division Director–Rehabilitation and Advocacy Programs; Jessica Arnott, Outreach and Education Program Manager; Henry Herrera, Family Services Program Manager; and Shannon McOuat, Marketing and Outreach Coordinator—responded to The ROCK survey as a “village.”

“The term ‘crisis’ may be more extreme than what we are facing currently,” they stated, “but there is certainly a need for a greater spotlight on mental health in our community, and there are some critical gaps that, if filled, would help people get the help they need in a timely way.“

Transitions staff believes that cost-effective preventative and early-intervention services can help avoid the high price tag of chronic mental illness in the future—frequent crisis hospitalizations, incarcerations, broken families, homelessness.

“Housing is a significant problem for many members of the community; but people who are mentally ill and poor are more likely to become homeless than those without a mental illness. For that reason, housing that is safe, affordable and located close to services is paramount to successful recovery from mental illness. When a person is experiencing a mental health crisis, there needs to be a solid system in place to help the person as quickly and effectively as possible, and that is not always the case locally.”

They also expressed the need for “a more warm and welcoming mental health services system, starting with the Psychiatric Health Facility (PHF), which is an institutional and clinical setting. The PHF needs to be a place of refuge and safety for people who are experiencing one of the most devastating times in their lives.”

Transitions’ work as an independent outpatient facility has helped the County narrow the gap by providing the focused treatment that often isn’t available anywhere else.

“Non-profits such as Transitions-Mental Health Association can and do work well with county mental health services, private therapists and family practice doctors. The saying ‘it takes a village’ is truly applicable to community mental health; we must include the family, the school, the employer, friends and our entire community to help anyone who struggles with mental illness.

“Services such as family support groups to help caregivers and families; Wellness Centers that provide support and education about living with mental illness; employment for people who want to work but have been prevented from working due to their illness; SLO Hotline that offers a human voice 24 hours a day; outreach services for those who are homeless and suffer from untreated mental illness—can all provide a basic safety net of services for people here in San Luis Obispo County.

“In many ways, we are well on our way to accomplishing this already. We still have leaps and bounds to go, but we are able to provide a variety of services and programs that can help those in our community who otherwise might not receive services from the county.”

Long waiting lists for subsidized housing

Pearl Munak, President of Transitional Food & Shelter in Paso Robles, works with the physically disabled. Some homeless have both mental and physical disabilities. Munak believes more resources are needed to place against the problem, including building shelters and offering subsidized housing for mentally ill homeless.

“There is not nearly enough subsidized housing in our county for those who need it,” Munak stated. “That is why we are third in the nation in unsheltered homeless. People go to a shelter and caseworkers can’t get them into permanent subsidized housing. The County is supposedly pursuing a Housing First strategy, to get people into housing and then solve their problems, not try to solve their problems before they can get into housing.”

“Subsidized housing is either for families or for seniors. Some senior housing is for seniors-only, some also take disabled. But there are no subsidized apartment complexes devoted exclusively to disabled…”

“Transitions-Mental Health Association provides some transitional housing for homeless, where people can stay for up to two years and have a caseworker working with them. At the end of that time, they should be able to get into permanent housing. However, they have a very long waiting list, about a year. This program also takes persons with physical disabilities. It needs to be expanded and funds are needed to expand it.

“We could pass another proposition to add a surtax on another 1% of high income, or tax highest incomes more.”

Munak recently received a grant check from Paso Robles Wine Country Alliance Foundation for $4,500, to be used for sheltering physically disabled homeless from Paso Robles.

“We serve the whole county,” Munak remarked, “but the Alliance has a program of grants to charities serving Paso Robles, so we will use this grant for our Roblans only. The Alliance raises funds through the Wine Festival Futures Auction and the Wine Country ebay Auction, featuring lots donated by winery, hospitality and associate Alliance members.”

 

More Homeless Eligible, More Mental Health Services Coming Under Expanded Medi-Cal Via ACA

Politics aside, the Affordable Care Act aka Obamacare is finally expanding health care to those who need it most—SLO County’s chronically homeless and mentally ill homeless.

acaPolitics aside, the Affordable Care Act aka Obamacare is finally expanding health care to those who need it most—SLO County’s chronically homeless and mentally ill homeless—and it’s giving SLO County health care officials and professionals a reason for some short-term optimism amid the many ongoing challenges.

Here’s what SLO County health care officials and professionals had to say about the Affordable Care Act in a February survey by The ROCK on the status of homelessness and mental health services in the county:

“There are some changes coming as a result of the Affordable Care Act that may expand both mental health and substance abuse treatment services available to people on Medi-Cal,” stated Laurel Weir, Home Services Coordinator, County Health Department.

“This has the potential to create additional mental health resources, particularly for homeless persons with mental health issues whose issues do not rise to the level of severe and persistent illness. Previously, such individuals generally were not eligible for Medi-Cal. Now, they will be eligible for Medi-Cal for the first time, which may create an opportunity for more mental health services for those persons.”

Grace McIntosh, Deputy Director, CAPSLO: “With expanded Medi-Cal now including mental health services, there will be the opportunity for qualifying individuals to receive these services. I think there may be difficulties with access given the limited number of providers in the county. The issue of a limited number of mental health providers is not only in our county—it is a national issue that I believe is going to need to be addressed in the very near future. “

While the recession has impacted County Health’s capacity to treat more people, Jeff Hamm, Director, and Anne Robin, Behavior Analyst, County Health Department, are optimistic about the immediate future, thanks to the ACA.

“The Medi-Cal expansion component of federal health care reform (Affordable Care Act) will allow previously ineligible persons (primarily childless adults) to become eligible, and the expanded scope of benefits will be of tremendous help to those with mild to moderate levels of mental illness.

“The Affordable Care act has increased funding for all levels of mental health services. In the past, only individuals with serious mental health needs have had access to care under Medi-Cal. Now there are additional levels of care available (individual and group psychotherapy, psychiatric consultation) for all Medi-Cal eligible individuals.This will allow the County services to focus more closely on those individuals and families who have the most serious illness and need for rehabilitative services. The ‘primary level of care’ for mental health services, for those individuals with mild to moderate illness, may also prevent individuals from becoming more seriously impacted by their symptoms.

“The Affordable Care Act is expected to have a tremendous positive effect on bridging the gap between demand and supply. The coming months and years will shed light on the extent to which the problem has been substantively reduced.”

District 3 Supervisor Adam Hill served as the founding chair of the HSOC and chair of the capital campaign for a new homeless services center: “The Affordable Care Act will allow us to increase capacity for both mental health services and for drug and alcohol treatment. A detox is needed, and proposals are being developed for how that could/should happen.”

Lee Collins, Director of the County’s Department of Social Services: “We believe that the Affordable Care Act will be instrumental in expanding access to Mental Health services. More persons are eligible, yes, but more services—and especially MH services—now must be included in health plans in order to implement ‘parity’ provisions. We believe that CHC (Community Health Center) will become—and certainly should become—a primary resource to serve both children and adults. They will not need to consider the ‘medical necessity’ threshold that serves to deny so many children the ‘specialty services’ that our County’s MH staff provide, even though we believe that most of our children in care really do meet the standard of care. The expectation is that CHC will build capacity—and already have begun to do so—and that a certain momentum may be created to help expand care on a community-wide basis.”

“Mental healthcare can be expected to expand now because of the ACA,” responded Pearl Munak, President, Transitional Food & Shelter in Paso Robles.

“Medi-Cal is being expanded thru ACA to cover mental health care, but the pay rate is low. CHC takes Medi-Cal and is about the only doctor that will. Maybe CHC will hire some mental health professionals or County Mental Health will be able to hire more. Counselors at Mental Health are usually licensed clinical social workers.

“The ACA expands Medi-Cal to cover not just families with children and those on SSI, but also any person whose income is below 133% of poverty level, a huge expansion in California and other states which have accepted this expansion. Texas and other Southern states have refused to accept this expansion even though it is 100% paid for by the feds for the first year and maybe beyond that; maybe first two or three years and then it goes down to 90%. … The county will save a bundle because they are phasing out County Medical Services Program because of ACA, since all poor people can now get Medi-Cal and go to CHC. CHC will probably be expanding.”

SLO County Sheriff Parkinson: 'We Can’t Arrest Our Way Out’ of Mental Illness Crisis

America’s jails and prisons have become our mental hospitals, according to a 2010 study by the National Sheriffs’ Association and Treatment Advocacy Center, and almost five years later, “The way we do business, the pure volume alone, has become alarming to everybody at this point,” said San Luis Obispo County Sheriff Ian Parkinson.

UPDATE: The article below was published in March 2014. On May 23, an emotionally-disturbed student attending the University of California, Santa Barbara in Isla Vista, California, killed six UCSB students and injured 13 people before taking his own life. Police visited 22-year-old Elliot Rodger at his apartment in late April and found him calm and polite, offering them no indication that he or anyone else were in danger. Hidden in his room were three guns… Four days later, on May 27, a patient at high-security Atascadero State Hospital was allegedly killed by another patient, and an employee was injured, in a hospital dorm room. An inmate, 34, was booked into San Luis Obispo County Jail the next day on suspicion of murder. The suspect had a history of assault and destructive behavior…

 

America’s jails and prisons have become our mental hospitals, according to a 2010 study by the National Sheriffs’ Association and Treatment Advocacy Center, and almost five years later, “The way we do business, the pure volume alone, has become alarming to everybody at this point,” said San Luis Obispo County Sheriff Ian Parkinson.

“That’s what makes it urgent that we are finally starting to realize that we’ve got a problem,” he recently told The ROCK.

The “problem” in 2014 is defined by a complex mix of laws, regulations, policies and budgetary restrictions, where state and local government bear the brunt of responsibility for treatment of the mentally ill. Finding effective patient care may depend on where someone lives in the state or county. A modern, capsule, historical overview of America’s care, and lack of it, for the mentally ill can be illustrated by the old balloon theory—push in one side and it pops out the other. Empty the psychiatric hospitals—and today there are more than three times more seriously mentally ill people in U.S. jails and prisons than in hospitals.

At least 16% of inmates in U.S. jails and prisons have a serious mental illness. In 1983 the percentage was 6.4%. So in less than three decades the percentage of seriously mentally ill prisoners has almost tripled, according to 2006 Bureau of Justice Statistics.

There is a direct and persistent connection between the lack of treatment for mental illness and the commission of crimes, petty and violent. There are the headline-stealing mass killings that are impossible to ignore, yet continue: the Aurora, Colorado movie theater shooting; the Navy shipyard killings in Washington, D.C.; the mass killings at Sandy Hook Elementary School; and even the Gus Deeds attack and suicide in Virginia, though not a mass killing—for want of one psychiatric bed. Each individual was in a psychiatric crisis and didn’t receive the help they desperately needed when they needed it, before tragedy struck.

Sheriff Parkinson, along with other sheriffs in the California State Sheriffs’ Association, recently discussed the impact of the mentally ill on law enforcement with Governor Brown. “He wants to solve problems,” Parkinson said. “He recognizes the problem. It’s been around and continues to be an issue.”

Atascadero State Hospital

San Luis Obispo County is unusual from a law enforcement perspective because it is the location of Atascadero State Hospital, one of five state hospitals. Atascadero State “provides inpatient forensic services for adult males who are court committed from throughout the State of California,” according to its web site. “The majority of the patient population (capacity 1,275 beds) consists of: mentally ill inmates; mentally disordered offenders; patients who have been found incompetent to stand trial; and patients who have been found not guilty by reason of insanity.” Patients need to be stabilized with medication. They often pose a threat to themselves and others.

A standing shortage of psychiatrists and a staff spread thin have resulted in fewer patients admitted to the facility. Still, with reduced capabilities and a full patient load, working at Atascadero State has occasionally proved dangerous to doctors, staff and inmates.

For Parkinson, who has been dealing with Atascadero State for some time, it’s an all too familiar pattern: Patients are sent there because they’ve been deemed incompetent to stand trial or be prosecuted for a crime because of their mental illness. Then, Parkinson said, they commit another crime by assaulting a staff member, and because Atascadero State doesn’t have an inside lockdown facility, that person is brought to county jail and booked for a crime.

“Which is really ironic,” he said, “considering they’re already in there (at Atascadero State) because they’re not [legally] capable of committing a crime, now they’ve just been booked for committing another crime that they’re not capable of.”

The ironies begin to pile up, one on top of the other. At Atascadero State, if patients are not taking medication voluntarily, they can be force-medicated to stabilize them. That’s not the case in county jail.

“They come down to a facility that is not really set up for the mentally ill, especially that level, and then we can’t force-medicate them,” Parkinson said. “We can only provide voluntary medication. So if they don’t take their medication, they continue to degrade.

“It’s just a vicious loop, and it’s frustrating because it is no solution for the problem.”

Parkinson has been working directly with Governor Brown’s office to deal with the impacts of Atascadero State on the county jail system, and they’ve been helpful, he said.

“We’ve gone from—at times we’ve had in the tens to upwards of almost 20 in custody from Atascadero State—down to a very few. I think at the last count I asked for a couple of weeks ago, we had one from Atascadero State in the (jail) hospital. So that’s a unique problem to us in this county. Couple that with the local problem that everybody’s experiencing, and it’s just a issue.”

Mass shootings

Parkinson is candid about the state of America’s mental illness treatment capabilities. He believes the vicious loop has a momentum that is difficult to stop with legislation and lockup alone.

“I personally believe that our mental health situation throughout the country has been getting worse. We have some obvious indicators of that.

“A while back (in February 2013) I sent a letter (to Vice President Joe Biden) regarding gun control. Obviously, people could interpret that letter the way they want. My problem, not to roll this into a gun-control issue by any means, was the fact that we look for a simple solution to a complex problem, and when you talk about the school shootings that have occurred, those people have been mentally ill, and yet we are trying to regulate our way out of it, and that was the issue I had.”

The extreme cases of school shootings are deeply emotional to everyone, and the typical reaction, Parkinson said, is to attempt “to solve this with regulation, and it’s no resolution to the problem. They’ll never regulate their way out of a situation involving the mentally ill. They have to take a multi-tiered approach.”

Nationally, the high rate of mental illness in jails reflects their role in the criminal justice system. According to the National Sheriffs Association study, jails are a hub. They receive offenders after an arrest and hold them for a short period of time (usually less than a year) pending arraignment, trial, conviction or sentencing, and hold mentally ill persons pending a move to an appropriate mental health facility. State and Federal prisoners typically serve more than one year.

Dealing with the mentally ill in the public sector, on the street on a daily basis, is also a serious concern for local law enforcement. Parkinson said a typical situation starts with someone constantly trespassing because he or she is sleeping on the steps of a closed business and the police are called. If that person doesn’t leave the premises, they are arrested for trespassing and end up in county jail.

“They’re kind of the other extreme. It’s a quality of life, petty crime, but because of their mental illness they end up in county jail. And again,” he emphasizes, “we’re regulating something that we’re never going to get a handle on by arresting our way out of it or regulating our way out of it, and we just don’t seem to get it.

“It’s a point of frustration with all the sheriffs because no matter what size your jail is, you have a percentage of your jail that is mentally ill, and they require special treatment, special care and special security; because in some cases they’re extremely violent and require two staff members to move them when they come out of their cell.

“In some cases they are at the point where they’re rubbing feces all over of the jail and themselves, so we have to get them out, clean them up, clean their cell out, put them back, and they repeat the same behavior. So they’re obviously suffering from severe mental illness, and none of our jails are really built to deal with it.”

No full-time psychiatrist

SLO County Jail holds a daily average of about 750 prisoners, men and women, some with various degrees of mental disabilities. A new, expanded women’s jail for 200 female inmates, which should relieve the overcrowding that existed in the old women’s jail, is under construction and expected to be operational in late 2016. However, generally speaking, rolling out current statistical trends through the second half of the decade predetermines that the prospects for significantly lowering the actual numbers of mentally ill that pass through our jails and prisons remain dim, unless the focus sharpens on solutions that are implemented and begin to chip away at the problem, Parkinson said.

“First, it starts with recognizing that we have an issue and not reacting emotionally with simple solutions to a more difficult problem. Second, we’ve got to realize that in many cases these people are patients, not necessarily inmates. So how do you treat a patient? Obviously by getting him in an environment that’s conducive to them improving their mental illness, in some cases (receiving) medication.”

County jail doesn’t have a psychiatrist on staff at all times, so patients can’t be force-medicated, even when it’s best for them. Medicating them doesn’t mean placing them in a vegetative state; it means they’re behaving, and “that helps improve their understanding of the situation they’re in and their ability to make decisions on their own,” Parkinson said.

“That requires money. You’ve got to have a full-time psychiatrist in the jail, and that’s expensive. We have limited visits from a psychiatrist. We have four full-time mental health therapists in the jail, and we’re challenged by that.”

California courts recognize this challenge, since it is a judge that determines if a person is incapable as a result of mental illness, where they need to go next, and for how long. They could be sent to the 1,287-patient-capacity Patton State Hospital in San Bernadino, a major psychiatric institution, or back to mental health for focused treatment. Yet neither the 14- or 16-bed mental health facility, nor Patton, has the room to house them, said Parkinson.

“So we’re on this waiting list and, of course, the (patients) are longer and longer in jail and deteriorating.

“Then the defense attorney says that the sheriff has not moved this person from the jail, and the judge says (to me), ‘why haven’t you moved this person out of jail into a facility?’ and I say, ‘because I don’t get to force my way into these facilities and drop him off on the doorstep.’ If there’s no room and they’re not going to accept him, I’ve got no choice but to continue to house them.

“It’s a huge challenge, and that’s kind of what we presented to the Governor; that we have to come up with other solutions.”

Prisoners in line for breakfast at CMC, December 2013. (Photo: Andrew Burton/Getty)
Prisoners in line for breakfast at CMC, December 2013. (Photo: Andrew Burton/Getty)

Complex local situation

Located practically across Highway 1 from the County Sheriff’s Department and jail, three miles north of San Luis Obispo, is the CMC, the California Men’s Colony, a sprawling state prison where a new 50-bed mental health center opened in August 2013. [As of February 18, 2014, CMC’s mental health outpatient population was 1,416 and inpatient 48. On February 7, CMC had 42.5 psychologists, 20 social workers and 18.25 psychiatrists.] The CMC facility would seem to be a natural option for the county’s mentally ill inmates, but Parkinson explains that despite the close proximity that’s not how it works out in reality.

“The problem is with the prison count,” he said. “Three federal judges are watching the numbers going into the institutions. Now when something happens at Atascadero State, the easiest solution is you don’t bring them to our facility, you bring them to CMC, into their lockdown mental health facility.

“(But) that means you’re adding numbers to CMC’s count, which is really counter to what the judges are prescribing to the state. So it creates a real dilemma for them as well. We don’t have enough mental health hospital beds, either at the local or state level. We have a growing issue and we’re not prepared to treat it.”

Meanwhile, on the street on SLO, where 90% of the homeless are unsheltered, the mentally ill homeless continue to impact local law enforcement, generating calls to police because citizens either feel threatened by their behavior, or believe the person in question really needs help.

“We go out there (when called),” Parkinson said, “and they don’t qualify as somebody that can be taken to mental health; because they’re definitely suffering from mental illness, but they can take care of themselves to some degree as prescribed by law, and we can’t take people and say, ‘you really need help and we’re locking you down.’ In many cases they are camping out. A lot of them are trespassing type offenses, or they’re walking out in the middle of traffic, not trying to hurt themselves, but just because of their mental illness.”

While most mentally ill people are not dangerous, thousands are institutionalized by court order because they are a danger to themselves and others, and about 10% of homicides and countless suicides can be attributed to individuals suffering from serious mental illness, including the commission of shocking crimes that devastate our society.

“Putting it in perspective, we have a little of both,” Parkinson said. “We have the high-end ones illustrated by the school shootings. Sandy Hook is a great example. [Adam Lanza] was diagnosed with mental illness and decides he’s going to go out and commit the ultimate crime and kill people. He’s not concerned with whether or not he can have a loaded gun in public or even have a gun, and one certainly could argue that his mother probably never should have had guns in the house. Not a good combination.

“But the reality is that’s an extreme case of mental illness that is repeating itself throughout our society, and most or our school shootings and/or mass shootings involve mental illness. So I think we have both extremes, and we certainly have something in the middle.”

When working in jail with mentally ill inmates, the risk of violence is real. A few weeks earlier, one of Parkinson’s deputies was assaulted, a female deputy by a female inmate, leaving scratches all over her face. “It’s not uncommon to have issues like that,” he said. “In that case it’s not a trespassing charge per se now. Now it’s raised the bar to combative and violent, and we’re tasked with caring for these people.”

Outpatient care

Parkinson makes a case for the effectiveness of outpatient treatment. The Sheriff’s Department works with outside mental health facilities to relieve pressure on a crowded jail system not built to provide for the mentally ill, and to get patients the focused treatment they need.

“We work as closely with them as possible,” he said, citing the success they’ve had with San Luis Obispo-based nonprofit, Transitions-Mental Health Association, which offers programs at more than 35 locations in San Luis Obispo and North Santa Barbara counties.

Transitions-Mental Health recently held a class in jail, and about 37% of those that went through the class have since been released from custody and made contact with Transitions for treatment, “which is a huge step,” Parkinson said. “They’re getting the mental health programming in the jail, and now they transition out of custody, and actually made contact, which is ultimately what we really push them to do.

“We also have a half-time deputy that does nothing but work in partnership with mental health in the field. Her job is to identify the people out on the street, try to get them into outpatient treatment, and see if they can get treated out in the field so they don’t end up in custody. For the ones in custody, she works directly with our mental health therapist inside to transition them when they come out in getting them to mental health treatment on the outside.

“Our goal is to manage them when they get out and not just say, ‘okay, you’re done, now go out.’ We really want to hand them off to our mental health people when they get out of jail to get them to continue to take medications, in some cases get them into housing when we can, and obviously treatment.”

Sheriff Parkinson, a law enforcement officer for almost 30 years, clearly recognizes the enormity of the challenge, which is why he stresses the urgency to address it and address it correctly. He sees the gaps in the system widening.

“It’s urgent because we are at capacity in the sense that we’re running out of the means to provide them with treatment as a patient. It’s always been present; we’ve always had mentally ill in jail. That’s not unusual. At some point in time that’s always going to happen, and it’s always going to happen to a percentage. That’s because they’re outside and maybe not popping up on the radar per se. Then they commit a crime that lands them in here.

“I think the way we do business, the pure volume alone, has become alarming to everybody at this point, and so that’s what makes it urgent, that we are finally starting to realize that we’ve got a problem.”

Despite the perils of his department’s task and the ongoing frustrations in trying to manage the diverse mental health needs of inmates, Parkinson believes that good communications with Governor Brown’s office will eventually lead to real solutions.

“I’m optimistic, and I only say that because of the dealings that I’ve had with his office regarding Atascadero State. We put together conference call meetings, we discussed the issues. They did take actions, and it really significantly reduced the number of people that came from Atascadero State.”

Parkinson wants to make it clear that they are not trying to pass along the problem, in this case the patient, when the patient shouldn’t be in jail.

“We’re not trying kiss off our problem on to somebody else. What trying to provide what’s in the best interests of the patient. We do that by not putting them in a facility that’s not set up and capable of providing for their health and welfare.

“The Governor responded to that, and I was very optimistic that they get it. So we’re taking some steps. When we had that discussion with the Governor a couple of weeks ago, and all the sheriffs were there—out of 58 there were probably 45 at the meeting—we all gave him the same message, and I think he heard it. Whether your jail typically houses 50 people, or is in the thousands like L.A., it’s the same problem. It’s all relative to the size of your jail.

“So the message was very clear to the Governor,” Parkinson said, “and he took it very seriously that we’ve got to do something. We’ve got to figure out a plan to solve this. We just simply cannot regulate our way out of this issue.”

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SAN LUIS OBISPO COUNTY JAIL, CAPACITY AND MENTALLY ILL PERSONS SNAPSHOT SUMMARY, MARCH 11, 2014

Board-Rated Capacity: 646 (includes Men’s and Women’s Honor Farm)
Self-Rated Capacity: 797 (includes Men’s and Women’s Honor Farm)

As of 6:00 a.m. 768 inmates were in custody. Although the number does not exceed the Self-Rated Capacity, just because there are 797 beds available does not mean someone can be placed in each bed. Depending on the classification of the inmate, it may not be possible to place a certain inmate in the same cell with other inmates, which means that a double-bunked cell may only have one inmate. In addition, only one of the buildings (40 beds) is used for beds at the female honor farm. The second is used for programming (subtract 40 beds from total). A more telling number would be that the in-custody population this morning was 768 with 35 male inmates and 8 female inmates not having a bed and required to sleep on the floor on a floor bed with mattress.

Total mental health contacts with inmates by mental health staff:
2012, approximately 6,700 contacts
2013, approximately 7,000 contacts
(Source: Undersheriff Tim Olivas, San Luis Obispo County Sheriff’s Department)

 

THE MENTALLY ILL IN U.S. JAILS AND PRISONS – BY THE NUMBERS

• U.S. prisons and jails house 10 times as many people with severe mental illness than psychiatric hospitals.

• At midyear 2005 more than half of all prison and jail inmates had a mental health problem, including 705,600 inmates in State prisons, 78,800 in Federal prisons, and 479,900 in local jails. These estimates represented 56% of State prisoners, 45% of Federal prisoners, and 64% of jail inmates.

• Jail inmates had the highest rate of symptoms of a mental health disorder (60%), followed by State (49%), and Federal prisoners (40%).

• Around 40% of individuals with severe mental illness have been in prison at some time in their lives. Nearly a quarter of both State prisoners and jail inmates who had a mental health problem, compared to a fifth of those without, had served three or more prior incarcerations.

• In 1955 there was one psychiatric bed for every 300 Americans. In 2005 there was one psychiatric bed for every 3,000 Americans—the majority of which are filled by court-ordered forensic cases and thus are not really available.

• Female inmates had higher rates of mental health problems than male inmates (State prisons: 73% of females and 55% of males; local jails: 75% of females and 63% of males).

• State prisoners who had a mental health problem were twice as likely as those without to have been homeless in the year before their arrest (13% compared to 6%).

• Jail inmates who had a mental health problem (24%) were three times as likely as jail inmates without (8%) to report being physically or sexually abused in the past.

• The number of doctors on staff at Atascadero State Hospital has dropped about 33% since September 2012, according to an October 2013 Tribune article. The hospital, which treats mentally ill, violent offenders, has about 22.5 psychiatrists on staff, down from 33.7% in September 2012. The facility is licensed for 1,275 patients.

• Over 1 in 3 State prisoners and 1 in 6 jail inmates who had a mental health problem had received treatment since admission.

(Source: Bureau of Justice Statistics, September 2006 Special Report: “Mental Health Problems of Prison and Jail Inmates” and Treatment Advocacy Center, 2004-2005 data)