‘It’s Shocking,’ Assemblyman Says : Critics Hope to Reform State Mental Health Care

The mental health systems in California’s urban centers are so overburdened that seriously disturbed people often are treated with powerful medications and then released. Many others are forced to wait for treatment or are denied care of any kind.

San Francisco officials say police sometimes pick up seriously disturbed individuals only to be told that there is no hospital that can take them. With no other choice, the police must simply drop these mentally ill patients off in another part of the city. The practice is common enough that it has been given a name--”squad car therapy.”

These are only the most visible signs of a statewide mental health system that an increasing number of critics say is in disarray.

The system is, in fact, no system at all, said Assemblyman Bruce Bronzan (D-Fresno).

“Almost every place you turn you see a system that is nonexistent or in a state of collapse,” Bronzan said in a recent interview. “It’s shocking to me, when you see how human beings just completely fall through the cracks and are destroyed by the system, which does them as much damage as their mental illness.”

As chairman of a special committee that has been studying mental health for more than a year, Bronzan is sponsoring the most far-reaching reform of the state’s public mental health programs in 15 years, changes that would affect the way care is given in every part of the state.

The public system that Bronzan complains of is largely paid for with state funds but run by county governments. Money for mental health care and the availability of treatment programs vary widely from place to place. The major cities, where the problem is most severe, frequently offer the fewest services for mentally ill persons.

Bronzan, along with many other government leaders and health professionals, traces the problems to the shutting down of the state mental hospitals that began in the late 1950s and accelerated under then-Gov. Ronald Reagan a decade later.

‘A Nobel Gesture’

“Deinstitutionalization, where people were released from the state hospitals . . . on the theory that they don’t all belong in the giant warehouse, the snake pits of institutionalized care, and could be better treated in their local communities, was a noble gesture,” Bronzan said.

“Now we see tens of thousands of people on the streets, under bridges, on river banks and along railroad tracks.”

Bronzan acknowledged that the state did begin putting money into local mental health programs as the patients began leaving the mental hospitals in greater and greater numbers. But, he said, there has never been enough and the money has been unevenly distributed--the most going to counties that sought it most aggressively.

And, he complained, there has been no consistent policy about how it ought to be spent.

“In some counties, moderate disturbances are treated,” said Dr. John Richard Elpers, a psychiatrist who stepped down as Los Angeles County’s mental health director last September. “In Los Angeles, the fairly serious go without.”

A recent afternoon in the psychiatric emergency unit at Los Angeles County Harbor-UCLA Medical Center clearly illustrates the intense pressures that local mental health programs face.

There were two men in the unit’s locked “holding room,” an elongated, dingy space separated by heavy iron-mesh windows from the office that is the unit’s control center. One of the patients dozed on a chair; the other slept on one of the bright blue mats on the floor.

Patient ‘Eloped’

A bed for restraining violent patients was vacant. The presence of the bed, said Dr. Ricardo Mendoza, a UCLA clinical professor and the attending psychiatrist on the unit, is probably a fire code violation. But the bed is needed, so it remains.

Earlier in the day, a patient had bolted through an open door at the sight of a hypodermic needle and escaped from the lock-up. He had, in the vocabulary of the hospital, “eloped,” and he was never seen again. Another patient, ready for release, vanished while waiting for a van to take him to a bus station for the journey back to his home in Bishop.

Patients were everywhere, it seemed, spilling out into the hallways. A young man shuffled up and down the corridor, surrounded by his plainly exhausted relatives. His family said he hears voices and he appeared to the staff to be suicidal, perhaps homicidal as well. For several minutes, he disappeared too, but he was found again.

In quick succession, two more patients arrived.

First came a young college student who asked to be brought in because he feared that he was losing control of himself. The spirit of God, he told the staff, had convinced him that he must marry the 15-year-old daughter of his minister. The same spirit had been telling him to seek even younger children, he said.

He was immediately placed in the holding room until he could be evaluated.

Asked Repeatedly for Food

Then a bearded transient, reeking of urine, his hands bound by leather restraints, was brought in by police. He was agitated when the police picked him up, but now in the hospital he repeatedly asked for a meal and a place to sleep. Mendoza said be believed that the man was not, in fact, grievously mentally ill. But the unit was so busy that he was kept in restraints while he was cleaned up and fed.

As the emergency unit filled to capacity, Mendoza and the other staff tried to find places to send the patients who most clearly needed further hospitalization.

“Ideally, I like to keep people in the emergency room no more than 12 hours,” Mendoza said. “But we keep them 24 hours, 36, 48.”

In fact, Mendoza and the other staff spent a good part of the afternoon on the phone with other hospitals, trying to find beds--slots where the sickest of their patients could be placed for longer evaluation and treatment.

In theory, Mendoza would like to carefully choose the facility to which he sends his patients, matching an individual patient’s needs with what a treatment program has to offer. Also, in theory, patients should move from hospital care to less intensive residential treatment and eventually to outpatient therapy. But Mendoza and others say there are few alternative settings for public patients following hospitalization, so the few hospital beds are always occupied.

3 Beds Found

At 5 p.m. on this day, to the cheers of Mendoza, nurse Balbir Bajwa-Goldsmith was able to wrangle three beds from the county system--one at Metropolitan State Hospital in Norwalk, which reserves some beds for county patients, and two at Olive View Medical Center, a county-run facility in Van Nuys.

Harbor serves an area of more than 2 million people, but the medical center has only 20 beds for psychiatric patients. At times, the psychiatric emergency staff has had to put patients to bed in the hospital cafeteria.

The numbers are so small for an area so large that the situation is described as “an abomination” by former mental health director Elpers, now a professor at Harbor.

“The problem is not whether people are doing a good job,” said Dr. Martin Mueller, who shares with Mendoza the responsibility for running Harbor’s psychiatric emergency unit. “It’s people not having the resources to do a good job.”

Those resources are coming, said Dr. D. Michael O’Connor, state director of mental health.

O’Connor proudly pointed out that Gov. George Deukmejian, for the second year in a row, is proposing substantial increases for funding of local mental health programs and improvements in state hospitals--labeled a “mental health initiative” by the Administration.

‘In the Pipeline’

“The big bonanza has not yet been felt out in the communities,” O’Connor said in a recent interview. “But it is on its way. It’s in the pipeline.”

Elpers and others complain, however, that even after two years of increases, local mental health programs would still not be able to provide the same level of care that they could in the 1970s because of funding cuts suffered during a time of staggering inflation.

Bronzan agrees. “Counties that had good mental health systems 10 years ago, 15 years ago, now have a skeleton of what they used to have,” he said.

And money is not the only problem facing mental health services.

Bronzan, Elpers and others complain that there is no consistent direction to mental health programs throughout the state.

O’Connor, who is widely respected in the mental health community, is the sixth director since a separate Department of Mental Health was formed in 1978.

“The department has been a chicken without a head,” said Henry S. Basayne, executive director of the state Mental Health Assn., a nonprofit group that has been, through court action and legislative proposals, working to expand mental health services.

That lack of stability in leadership is something that O’Connor is determined to address. It also is the reason, according to department staff, why O’Connor dropped out of competition for another Administration job this year. He was one of the finalists considered to head the larger state Department of Health Services.

Local Control Supported

O’Connor repeats without qualification the Deukmejian Administration philosophy that local communities ought to have control over how they spend the money sent to them from Sacramento.

“We believe that the citizens at the local level are the best decision makers with regard to the exact nature of the programs they provide for their citizens,” he said. “We are increasing by tens of millions of dollars the state’s commitment, but we are saying to the county, ‘You must spend it on mental health. You can’t use it to fill potholes.’ ”

The Administration also is trying to equalize county mental health spending by giving the biggest funding increases to those with the lowest per capita spending.

Elpers complained that county supervisors around the state at times have used mental health funds to support other county services. He said that when he helped organize the mental health department in Los Angeles County in 1978, he identified $1.5 million earmarked for the mentally ill that “was clearly (used) not for mental health support, but for other things.”

And because of an absence of state direction, Elpers and others agree, services offered in one county may be absent in the next.

“We don’t have a system; we just call it a system,” said Tony Hoffman, volunteer lobbyist for the California Alliance for the Mentally Ill, a group formed by families of the mentally ill. “There are just some services out there, and the poor mentally ill or the families . . . have to go out and find the facilities and find something that the patient fits into.”

Living Under a Bridge

Hoffman made the point with a story about a mother who called him to say that her son was living under the Dumbarton Bridge in the San Francisco Bay Area.

“No mental health workers would see him. The police wouldn’t go. He had no change of clothes and looked like something that came out of the sewer. I had to tell her she could do nothing. I had to say that one day he would get hungry, go somewhere and steal some food and then the police would pick him up. Isn’t that something to have to tell someone?”

Hoffman praised Deukmejian for putting long overdue money into improving state hospitals, but he charged that the governor “is not aware of the problems in the community. . . . This is unusual for a Republican, an attempt to just throw money at a problem and fix it. That’s unusual.”

And Bronzan, too, believes that money is not enough, that strong leadership is needed from the state to give coherence to a patchwork system. His legislation, introduced Monday with the backing of both Assembly Speaker Willie Brown (D-San Francisco) and Assembly Republican Leader Pat Nolan of Glendale, would:

- Provide an additional $23 million for a variety of programs that would assist certain categories of the mentally ill, including those who are homeless, in jail or elderly and living alone.

- Require that the state Department of Mental Health define what services should be offered in each county and distribute $35 million over the next three years to eliminate differences in county spending.

- Urge an expansion of hospital spaces available for involuntary commitment while increasing the number of non-hospital treatment facilities.

- Make it possible for health professionals to require certain mentally ill patients to seek regular treatment in outpatient clinics.

- Increase Medi-Cal services for the mentally ill by doubling the number of office visits covered.

Critics Want More

The legislation does not go as far or as fast as some critics of the mental health system would like.

After seeing a draft of the Bronzan bill, Elpers expressed disappointment. “I looked at it and said there’s nothing here that would change the way the local board and the local director would have to behave.”

Because it would cast the state in the role of setting the agenda for community mental health programs, Bronzan’s bill may be on a collision course with the Deukmejian Administration, which wants to leave decisions on how to care for the mentally ill to the counties that run the programs.

“Having no state (mental health) policy is what we’ve had for 15 years,” Bronzan said, “and the system is an utter disaster.”

Next: Finding the Money.