COUNTY REPORT: Mental Health : Critics Say Crisis Mental Patients Ignored : Treatment: Emergency teams are accused of not responding. The department says a massive overhaul is showing signs of success.

While a massive overhaul of the Ventura County Mental Health Department has dramatically increased treatment for most of the county’s mentally ill, critics say the new system is still ignoring the most serious problem cases.

Nearly three years into the four-year, $16-million overhaul, the department has already drastically reshaped itself in an effort to make Ventura County’s public mental health system a model for counties throughout the state.

It has doubled its community-based casework staff to 120, formed them into teams and dispatched them to 10 neighborhood treatment clinics countywide for the seriously mentally ill.

It has expanded specialized teams for psychiatric inpatients, jail inmates, homeless people and the elderly.

And it has revived a mobile crisis intervention team to usher severely psychotic people into psychiatric care.

But parents say the new crisis team refuses to roll when their mentally ill sons and daughters are suffering dangerous psychotic episodes.

Caseworkers say that internal communication is so poor that they seldom talk with top administrators, and that they often learn second-hand that their acutely ill patients have been hospitalized.

And neighbors and patients’ family members have complained repeatedly about severely ill people wandering away from the county mental health inpatient unit in Ventura.

Last week, those complaints were supported by an investigation by the California Medical Licensing Board.

The board cited numerous deficiencies in security, treatment and staffing at the inpatient unit after a walkaway patient, Michael Merriman, committed suicide on March 23.

The department is revising its inpatient unit policies, but if it fails to correct the flaws, it faces penalties ranging from a simple reprimand to forced closure of the unit, board officials said.

And despite the overhaul, some critics say the system is still too narrowly focused to treat all of the county’s 2,000 seriously mentally ill.

“A person (must) fit into the appropriate box--being very easily treatable, is not disturbing the peace, is easy to medicate, goes along with therapy--that is the target population,” said Mark Florio, a patients’ advocate and member of the county Mental Health Advisory Board.

“The rest of them are down in the river bottom,” he said. “The rest are those who choose not to go into medication or therapy or have been locked up in jail. . . . These are the ones that have unfortunately fallen through the cracks.”

“It is totally false,” county Mental Health Director Randall Feltman said of allegations that the sickest patients are ignored.

“We are the only county in California that has established for children and adults a priority population of seriously mentally ill people,” Feltman said last week. “There are some people who refuse mental health treatment, and the law does not allow us to force people into treatment. That is a small, very high-profile group of people.”

Feltman charts the overhaul’s success in numbers, reflected in the department’s January, 1992, progress report:

- The department’s social workers, doctors, nurses and psychiatric technicians were averaging 16,000 face-to-face patient contacts per month in that period, up from 13,000 per month in the 1991 fiscal year, Feltman said.

- The department helped more patients find and keep jobs, increasing the number of patients employed by private companies from 151 in January, 1991, to 273 a year later.

- The new mobile crisis intervention team drove into the field to evaluate 75 severely psychotic patients, while office-based crisis workers met with 194 walk-in emergency patients and fielded 1,062 hot line calls.

- The department also provided 364 overnight stays to homeless mentally ill people in January, in motels, rooming houses and shelters.

- And minor offenders who faced jail sentences in January totaling 559 days were released instead to psychiatric care, thanks to the department’s new forensics team.

“We’re building a system from the ground up,” Feltman said. “For all of us, it has been 60 to 80 hours a week for three years. We have changed more and done more of substance in this department for the past three years than we did in the previous 20.”

But critics inside and outside the department cite its failures in human terms.

They say the overhaul’s biggest failure is the most visible and crucial link between the mentally ill and the care they need--the mobile crisis team.

The team was revived last year after an earlier version was eliminated by post-Proposition 13 budget cuts in 1980.

With 20 nurses and psychiatric technicians and a psychiatrist, the team helps police and family members deal with patients having severe psychotic episodes. If needed, the team’s psychiatrist can sign papers to have the patient hospitalized for either a 72-hour hold or a 14-day stay.

But Deputy Public Defender Caroline Connor, who represents such patients in court, said the team refused to pick up her own 26-year-old son when he suffered a psychotic episode last fall in Oxnard. A crisis team staffer told her the team was busy on another call and suggested she call police.

Because police terrify her son, she had to wrestle him into the county inpatient unit alone at 2 a.m.

“I’m with a reluctant kid, 6 foot tall, and he keeps walking away from me” as inpatient unit workers looked on, Connor said. “I’m 5 foot 3 and weigh 100 pounds.”

” . . . I said, ‘Can you call the crisis team?”’ she recalled. “Fifteen minutes later, someone saunters down. And there are patients sitting there, smoking. The door is not locked, no one is paying any attention to them, they could have walked off any time, and I’m saying, ‘What the hell is this?’ I’m just appalled.”

Sami Calado said she asked the crisis team last December to evaluate whether her increasingly ill son should be committed.

Stricken by countless anxieties, compelled to wash himself repeatedly, shave off all his body hair and cut his eyelashes, the 22-year-old man was slipping into deep paranoia in the Ventura motel room where his county caseworker had housed him, his mother said.

“He called one night. He was very stressed and asked me if I had seen him die,” said Calado, a member of the county Mental Health Advisory Board and the Alliance for the Mentally Ill. “He was really talking out of his head.”

The crisis team refused to answer the call because he had a history of pushing or hitting anyone who told him what to do, Calado said.

She finally had to call police. They jailed him on a petty misdemeanor that was dropped the following month, after his mother picked him up on Christmas Eve and his neighborhood casework team helped him recover.

Betty Ryerson, operator of a small psychiatric board-and-care home, said she sometimes bends the truth so the team will help her head off a severely ill resident’s downward slide.

“By the time you call the crisis team, you’ve got a crisis,” Ryerson said. “You don’t say he’s ‘decompensating;’ you say he’s threatening or he’s talking suicide.”

Feltman and crisis team head Mary Riley said the team never ignores calls, but sometimes it simply cannot step in.

By law, the team can have patients committed against their will only if they are in danger of hurting someone else, killing themselves, or being unable to care for themselves, the officials said.

“The laws,” Calado replied bitterly. “That’s what they always fall back on.”

“The people in crisis are not getting all the attention they need,” said Richard (Rip) Vanremortel, a 17-year Ventura County caseworker.

He said police picked up a severely ill man two weeks ago from a Ventura motel room where the crisis team had placed him.

“The guy had been up all the night; he tore all the paneling off the walls; he left the water running all night . . . and basically my co-worker took him to the inpatient unit,” said Vanremortel, who ran the county’s mobile crisis team from 1974 until its elimination in 1980.

“I don’t know if it’s poor clinical judgment; I don’t know if it’s stupidity or if they just don’t know any better,” he said. “But for someone that’s acutely psychotic, you put them in a hospital. You don’t put them in a motel room.”

Riley, the psychiatric nurse who heads the crisis team, said she is surprised by the complaints. She said critics are welcome to talk to her in person. But she also said that family members sometimes overreact slightly to their relatives’ mental illness.

“I’m satisfied that the crisis team’s decisions about when they roll are very well thought-out,” Riley said. “When you’re in the situation, sometimes it’s like having a gun pointed at you. Sometimes perceptions can be colored by anxiety.”

But caseworkers also complained of communication problems within the department.

“The consensus is . . . that the crisis team is not really responsive to our needs,” said one veteran caseworker.

The caseworker, who asked not to be identified, said he and his colleagues often have trouble getting information about their patients from the crisis team and the inpatient unit.

“They say, ‘Gee, that wasn’t my shift, that’s somebody else’s shift,’ ” he said. “Sometimes they won’t even tell us our client was there. Once a client had to tell me. The administration needs to work out those kinds of nut-and-bolt issues much more effectively than they have been.”

Penny Matthews, head of acute care for the department, said the team faxes case logs and treatment reports to the patients’ neighborhood caseworkers every day.

“It’s 100% improved over the old system” of sending such reports through the county’s internal mail system, which often took several days, Matthews said.

“We’ve undergone a lot of changes, and it’s been very difficult,” Feltman said. “The staff have undergone a lot of changes. If some of the staff are frustrated, I understand that.”

The year-old crisis team’s staff is learning by doing and is still fairly green, officials admitted.

“They’re constantly being trained,” Feltman said. “Some were complete novices to mental health.”

Vanremortel and other caseworkers complained that Feltman and other top administrators hardly ever visit the teams that they are so busily overhauling.

Feltman agreed. “We have 20 different sites, we have 50 different programs, and I visit the teams regularly every week,” he said. “But I will not see them more than once a year. . . . I would like to be visiting the staff more frequently.”

Patients’ families, caseworkers and advocates have praised the department’s reorganization of its casework teams for improving outpatient treatment.

But they say the crisis team’s failures and the suicide of an AWOL patient from the inpatient unit are signs that more work is needed on a system that seems inherently flawed by the very laws that it uses to protect patients’ rights.

Michael Merriman, 28, had been under the system’s care for 10 years when he was taken to the inpatient unit’s courtroom for a commitment hearing March 17, said his father, Tony Merriman of Camarillo.

Last week, board investigators cited the inpatient unit staff for numerous violations of California’s public hospital laws in handling his case.

Although Merriman entered the unit severely underweight and a known flight risk, technicians failed to heed caseworkers’ notes.

Instead of high-visibility pajamas to discourage him from fleeing, workers allowed Merriman to wear street clothes. Although a doctor had ordered staff to check his weight daily and blood pressure three times a day, there was no evidence this had been done, the board found.

Faced with yet another 14-day hospitalization during which doctors would try to quell his psychoses, he bolted, and a courtroom escort failed to stop him, the board found.

Five days later, Merriman was found hanging by the neck from a belt looped around a tree in the Ventura River bottom, police said.

Finally, the board concluded its investigation--started by a complaint from Tony Merriman--by citing the inpatient unit for failing to report Merriman’s death to the state Department of Health.

Michael Merriman killed himself just nine weeks after another walkaway psychiatric patient was accused of murder.

The department had erected a 5-foot-high cedar fence and promised better security around the inpatient unit following the January fatal stabbing of 90-year-old Velasta Johnson.

Johnson was allegedly slain by Kevin Kolodziej, a psychiatric patient who had walked away from the Ventura County Medical Center while awaiting commitment to the inpatient unit.

Numbly, Tony Merriman, a psychiatric nursing coordinator at Camarillo State Hospital, described his son’s contacts with the system over 10 years.

His anger boiled slowly to the surface as he told of how the system failed to help his son fight off the illness that drove him to suicide.

Michael was paranoid-schizophrenic, operating under deep delusions concerning God and the devil, Tony Merriman said.

Whenever his parents sought a court-ordered conservatorship to get him treatment that he needed but did not want, Michael Merriman often was able to act sane enough to satisfy the judge, his father said.

Then, as with all schizophrenics, his illness would flare up, sometimes so severely that he endangered himself or others--the legal requirement to have him committed against his will.

At various times he tore the wires from his grandmother’s walls, set his hands on fire, smashed an old woman’s dog to death on the sidewalk, spent his Social Security benefits on drugs and kicked in the TV set because “They were controlling his life and broadcasting it from coast to coast,” his father said.

Despite repeated commitments following these psychotic episodes, judges are required by law to ignore all prior treatment that Michael received in the Mental Health Department.

By law, “Every time a person is viewed in the mental health system, they’re viewed as a first-time client,” Tony Merriman said.

After the Mental Health Department began overhauling its system, it assigned a new caseworker to Michael who was “just wonderful,” according to his father and stepmother.

The caseworker met regularly with Michael, got him monthly shots of antipsychotic drugs and made sure his rooming house rent was paid. But neither she nor anyone else in the system could stop him from walking out and killing himself, his parents said.

“It was a long, long story of the same thing: Michael needing care and not getting care,” said his stepmother, Clare Merriman. “There has got to be some continuity.”

Frances O’Farrell, who served on the Mental Health Advisory Board and has watched the system handle her schizophrenic son for 25 years, agreed.

“We have to have a continuum of care for all these people,” O’Farrell said. “They cannot be grouped together or expected to fit into a quote-unquote ‘system.’ They are individuals like the rest of us so-called normal people. The system must fluctuate to meet their individual needs.”

Some in the system believe the overhaul simply needs more time.

“It took them three years to get the teams set up, I don’t think they’re giving them the chance,” said Kathy Higgins, president of SHARE, a self-help group for psychiatric patients.

“The teams are set up and running now,” said Higgins, who said she is managing her schizophrenia with the help of her doctor, the mental health system and other support groups in the county. “I think within the next two years, we’ll see a mental health system. You know, change doesn’t happen overnight.”

The department is seeking a two-year funding extension for the extra caseworkers, the mobile crisis team and the other services encompassed in the overhaul, through an Assembly bill sponsored by Assemblywoman Cathie Wright (R-Simi Valley.)

And plans are being finalized to build a 50-bed locked inpatient unit in Ventura and a 30-bed halfway house on Lewis Road near Camarillo.

There are some confirmed success stories:

Psychiatric patient Steve Kilner said the new system is working for him.

Regular doses of antipsychotic drugs and tranquilizers have quieted the internal voices and religious delusions that once plagued him.

County caseworkers have helped him enroll at Ventura Community College, where he hopes to earn a horticulture license so he can set up a landscaping business.

Kilner misses the outpatient day-care program that once took him on trips to museums and gave him a place to socialize. But he is looking toward the future.

“The system works if you work with it,” he said. “If you fight it, you don’t get anywhere.”

But some others are doomed to suffer their illness despite the best efforts of the system and their families, because the law protects them, said Leo O’Hearn, a patients’ attorney.

O’Hearn and others inside and outside the system believe the law should be changed so care can be given to patients who need it, but refuse it.

“If you start out with people who don’t think they should be confined . . . and they don’t get confined, they wind up in the jails or prisons or in the cemetery like Merriman,” said O’Hearn, father of a mentally ill son and a member of Alliance for the Mentally Ill.

“You can’t be treated against your consent, but these people can’t give consent. That’s the problem. They don’t have the mental capacity.”

COUNTY MENTAL HEALTH CHANGES:

Ventura County is more than halfway through a four-year, $16-million overhaul of its mental health care system. The key components are the hiring of new caseworkers, creation of a mobile crisis team for house calls to severely ill patients, and the addition of specialist teams focusing on such groups as the elderly and the homeless.

CASEWORK TEAMS: The county has doubled its staff of caseworkers for seriously mentally ill adults to 120, split into 10 teams operating throughout the county. Caseworkers counsel patients and help them find doctors, housing and sometimes jobs. They also often manage personal finances, doling out Social Security benefits in the form of rent payments and food vouchers and giving patients enough cash for personal expenses.

Hours Spent Treating Patients (Fiscal Years) 1988-89: 9,975 1991-92*: 20,400 MOBILE CRISIS TEAM: This is a 21-member emergency response team to handle mental health crisis situations. On call 24 hours a day, seven days a week, the unit uses two-member field teams to deal with patients suffering severe psychotic episodes. When a patient needs to be involuntarily hospitalized, a psychiatrist is on call to order a 72-hour hold. The staff also runs a hotline and walk-in office.

Number of face-to-face contacts (Fiscal Years) 1988-89: 0 1991-92*: 3,121 SPECIALTY TEAMS: The 121 employees on these teams focus on special groups of mental patients--those who are homeless, in jail, addicted to drugs, older than age 65, or sick enough to require inpatient treatment. Most work at the department’s Inpatient Unit in Ventura.

Average Number of Clients Served Monthly (Fiscal Years) Elderly Patients Team: 140 Homeless Team: 132 Forensics Team (jail): 25

* Projected

Comparing Mental Health Spending

With the passage in 1988 of Assembly Bill 3777, the Legislature agreed to feed $4 million per year into a four-year pilot plan to make the Ventura County Mental Health Department into a model for such departments throughout California. This is how the money was spent before and after the funding was approved: Before the Overhaul, 1988-89 Evaluation: $230,300 Administration-Quality Assurance: $2,798,100 Childrens’s Services: $2,520,500 Elderly Services: $461,800 Adult Caseworkers: $5,345,800 Homeless Team: $107,300 Other Special Services: $863,600 Stationary Crisis Team: $385,670 Inpatient Unit: $3,924,200 Locked Nursing Home: $128,600 State Hospital: $3,200,000 Total Budget: $20,484,500

After the Overhaul, 1991-92 Evaluation: $478,900 Administration-Quality Assurance: $2,719,100 Childrens’s Services: $3,651,700 Elderly Services: $907,900 Adult Caseworkers: $7,713,000 Homeless Team: $425,050 Other Special Services: $1,483,600 Mobile Crisis Team: $682,200 Inpatient Unit: $4,616,100 Locked Nursing Home: $1,027,700 State Hospital: $3,433,500 Total Budget: $27,138,700 Source: Ventura County Mental Health, Systems Evaluation Section. April, 1992.