A paradigm shift in public health policy works to reverse decades of indifference and create new opportunities for the mentally ill to find treatment
By John Conroy
The epiphany that would save Sarah Jakle’s life began with a suicide attempt.
“I was on the phone with two of my best friends, and one of them said, ‘Nobody knows who you are anymore. Nobody knows who you’ve become,’” Jakle said. “I realized at that moment that ‘Sarah’ as I knew her had died. I was sort of just carrying around a corpse.”
At that fraught moment in 1999 Jakle was a 22-year-old acting student. Long bouts of bawling that had begun in 1997 were just one symptom that her life was running off the rails. “I started crying for hours and hours and hours, but because I was in grad school for acting people thought I was just working through stuff,” Jakle said.
Diagnosed while in school with mixed-state rapid-cycling bipolar disorder, which manifested itself in sudden bursts of depression and mania, Jakle had already been hospitalized three times and was attempting to manage the disease with alcohol — “trying to obliterate my brain.” The organ, she said, “was screaming at me to shut it down.”
During the conversation, Jakle, now living back at her family home in Santa Monica, decided to do just that. Her parents were away for the weekend. “I fell apart on the phone, went upstairs, took all the medication I could find, lay down on the bed, and waited to die,” Jakle said. Just then, there was a knock on the door. Her friends on the phone, she said, had “realized this was a very bad situation and called 911.” From Boston.
Despite thinking she was a burden to everyone and better off dead, Jakle answered the knock. “For some reason breaking down the door to my parents’ house was unacceptable,” she recalled drolly, “so I had to open the door. When I opened it, there were police officers there. They did not believe me when I was sobbing hysterically and said I was fine.”
The officers placed Jakle under a 72-hour psychiatric hold.
“When I was in the psych ward, that was my revelation. That’s what changed everything. I realized I could either die or do something differently. I decided to start complying with my treatment, to take my medication on time and in the right amounts and, most importantly, to stop drinking,” she said.
The trauma’s aftermath marked the beginning of Jakle’s transition both to a healthier life and to advocating for others whose lives are turned upside down by the twinned problems of mental illness and homelessness. Through her struggles, she became acutely aware of the scores of clearly mentally ill street people who roamed her hometown like ghosts. Unlike them, though, Jakle knew she would get better, “because I knew I was sick,” she said. “I was taking my medication. I was going to a psychiatrist. I had the chance to get better.”
Jakle did get better: She stopped drinking for good, took her meds, underwent behavioral therapy and became happily married last year. But Jakle held on to the realization that her path to a better life might be out of reach for others.
In 1999, Jakle began volunteering at Step Up on Second, a Santa Monica-based nonprofit that offers outreach and supportive programs for the homeless and the mentally ill. A Yale graduate with a literature degree, she helped set up a creative writing group there that grew to serve about 25 people, a success that gave Jakle the confidence in 2002 to apply for the UCLA master’s program in public policy. She completed the program in 2004, returned to Step Up on Second to take a job as a senior peer advocate, and went on to receive a master’s degree in social work from USC in 2011. A stable Jakle then began working at the Westside office of the National Alliance on Mental Illness (NAMI) as a program director and volunteer coordinator. She’s currently focused on public speaking and is writing a book about her experience.
“If I can find such joy, meaning and purpose after living at such depths of despair and chaos, others can too,” she said.
New hope for the mentally ill
Giving the mentally ill and homeless “the chance to get better,” as Jakle put it, aptly describes the ongoing mission of NAMI, the Los Angeles County Dept. of Mental Health and organizations throughout the Westside. As harrowing as it is, Jakle’s story offers hope and shows that treatment can work — if the person needing care is open to accepting help, and if he or she can find it.
A 2013 National Survey on Drug Use and Health by the federal Substance Abuse and Mental Health Services Administration concluded that nearly one in five American adults experienced some form of mental illness during the survey year. A 2011 study by the agency found that about 30% of chronically homeless people in the U.S. suffered from mental health conditions such as schizophrenia, bipolar disorder and substance use disorder. Half of the homeless population with mental disorders also experienced co-occurring substance use disorders, the study estimated.
Delivering humane and effective treatment to the mentally ill and homeless entails overcoming a number of public policy challenges — among them denial, stigma, political inertia, funding shortages, a lack of housing, and a dearth of psychiatric beds.
However, legislative developments at the national, state and county levels reflect a growing awareness that prior approaches to treatment weren’t working. These developments include:
• The Patient Protection and Affordable Care Act: National health care reform that took effect this year, also known as Obamacare, mandated mental health coverage as an essential health insurance benefit.
• The Mental Health Services Act: 2004’s voter-approved Proposition 63 increased funding for county mental health programs.
• California Senate Bill 82: This 2013 state law funds mobile crisis support and residential treatment to reduce reliance on hospital emergency rooms, and mental health agencies are currently submitting proposals for funding.
• Laura’s Law: State legislation implemented by Los Angeles County in July that allows judges to order treatment for people with severe mental health issues who repeatedly refuse voluntary programs.
The Mental Health Services Act has been a welcome boost in the 10 years since its passage. MHSA-generated funds have enabled counties to subsidize the building of permanent housing units for the mentally ill and homeless. Step Up on Second in Santa Monica and the Venice Community Housing Corp. have benefited from MHSA funding, with the Venice Community Housing Corp. using a portion of those funds to build the Horizon Apartment Project.
Robin Kay, chief deputy director of the L.A. County Dept. of Mental Health, said the department’s budget has increased significantly since the MHSA went into effect. “Our annual budget is around $2 billion for the entire Dept. of Mental Health,” she said. “In 2004, before MHSA and certainly before the Affordable Care Act, it was, I’m going to guess, less than half that amount.”
As the department’s former district manager for county Service Area 5, Kay was instrumental in setting up the infrastructure for treating the mentally ill in the Westside.
Between 2005 and this year, the county has been able “to fill in those components of the mental health continuum that were missing,” Kay said. “In 2005 we focused on people with the highest level of mental health need, people with serious and persistent mental illness. We didn’t have the funding to do much more than that. Now because of the MHSA we have the wonderful gift of increased funding that will allow us to serve people who have specialty mental health needs, and that’s important.”
Clients with specialty mental health needs are those with “serious, significant difficulty in functioning,” Kay said, and fall under the continuum of county care. Those less impaired by mental health conditions are now covered for the first time by managed primary care plans under the Affordable Care Act.
More people seeking help
Westside mental health services providers under contract with the county have seen an increase in the number of people coming to them for treatment since implementation of the Affordable Care Act, said Kita Curry, president and CEO of Didi Hirsch Mental Health Services in Culver City.
From Jan. 1 through June 30, federal funds transferred through the county have resulted in an increase of $1.7 million in services over the same period last year, Curry said, noting that the federal government pays 100% of the new services. L.A. County will also receive $35 million through California’s SB82 legislation to create more than 600 beds at new crisis residential centers and $5 million for mobile crisis support teams. There are only two such centers in the county now, she said.
By mid-August, Didi Hirsch had treated 93 clients through the Affordable Care Act’s Medicaid expansion that began Jan. 1, according to Curry. These clients were seen at Jump Street and Excelsior House — the organization’s two crisis residential mental health programs — and Via Avanta, Didi Hirsch’s residential treatment program for dual-diagnosed homeless mothers. An additional 379 clients were treated at three of Didi Hirsch’s outpatient clinics. In the Westside’s Service Area 5 about one-third of the residential clients were seen at the Jump Street facility and another one-third at Didi Hirsch’s Culver City headquarters, she said. The average cost per client was $615 per month, which includes therapy, psychiatry, care coordination and housing when needed.
“It’s just really astounding in California how well the Affordable Care Act is rolling out,” Curry said. “I think it’s partly because California started reaching out to people who would qualify before the Affordable Care Act went into effect. California was already bringing those people into the fold.”
Jacquelyn Wilcoxen, the current district chief for Service Area 5, said there’s been “a gradual increase” in the number of people receiving mental health treatment through her office on West Washington Boulevard. She expects the modest pace to pick up once California’s Dept. of Health Care Services, which administers the Medi-Cal program, works through the backlog of applications it has received in the Affordable Care Act’s initial enrollment period. “I don’t think we’ve seen the full effect of the expansion of the Affordable Care Act,” said Wilcoxen, who expects clients will find their way to the department’s specialty mental health care services after first seeing their primary care doctors. “Our big focus this year is on access.”
At the moment Wilcoxen and her Westside staff are on the lookout for wait lists and potential bottlenecks. “Right now, my big focus is on the front door, making sure that people can get mental health assessments when they’re requested as much as possible,” she said.
The challenge for the department is that “a lot of people don’t come to our doors,” so she is working on expanding the number of outreach teams.
Many of the homeless and mentally ill “need persuasion, engagement and outreach,” Wilcoxen said. “We have those resources, but we’re always looking to add to them. That’s what the public sees a lot — folks who have problems out in the streets but who aren’t necessarily coming in asking for services.”
Wilcoxen said St. Joseph Center in Venice has successfully helped homeless individuals through an innovative program that combines medical, substance abuse and mental health professionals in mobile teams.
“But our experience tells us that it can take months and months of engagement. We’ll treat them on the street if they allow us,” she said. “Our desire is to link them up with housing and get them off the street. We know what to do, and we’re looking to expand that.”
Housing first: a new approach
Despite appearances, the Westside has fewer homeless persons and provides better programs for the homeless compared with other areas of the county, Wilcoxen said.
The most recent count by the county’s housing authority shows that the Antelope Valley/Palmdale area has the fastest growing homeless population and a greater demand for services than the Westside, she said. “Historically, the Westside has done well. I’m a little bit nervous to even get into it, because I don’t want to pit one area against another. But we do the best that we can with our homeless.”
Project 50, a program for the most vulnerable chronically homeless in Skid Row initiated in December 2007 by Los Angeles County Supervisor Zev Yaroslavsky, has been successfully replicated in Venice, Santa Monica, Hollywood and the San Fernando Valley, according to Flora Gil Krisiloff, a senior field deputy in Yaroslavky’s office who focuses on mental health and homelessness. Based on the idea of permanent supportive housing, the Project 50 concept removes the conditions usually tied to housing the homeless.
It’s “not a program where you have to be totally sober or have to do xyz before you get into permanent supportive housing,” Krisiloff said. “The approach is ‘housing first.’”
Qualified applicants receive the key to an apartment and are provided with “an integrative, supportive services team of health care, mental health care and substance abuse services,” Krisiloff said. The program has a retention rate of approximately 85%, she said, singling out the partner organizations Step Up on Second, the Ocean Park Community Center, Upward Bound House in Santa Monica and St. Joseph Center.
Utilizing Project 50 funds, St. Joseph Center supportive housing programs have taken 227 people off the streets since 2010 — 146 of them from Venice and the remainder from either Santa Monica or Culver City, said St. Joseph Center Executive Director Va Lecia Adams Kellum. These programs have had a retention rate of 93% at the 12-month mark, she said.
“We have the working model. It’s the resources that are often missing,” Kellum said.
The combination of Project 50, Mental Health Services Act and Affordable Care Act funding has allowed St. Joseph Center to expand the roster of mental health professionals on its staff, increasing the effectiveness of its outreach efforts and providing a continuum of wraparound services needed to successfully bring people off the streets and into treatment and housing, she said.
Krisiloff said providing a permanent home is the key to optimizing the benefits of integrated mental health and substance abuse services.
“With permanent housing someone recovering from a breakdown has a better opportunity to heal,” she said. “When you’re mentally ill and living on the street, that’s a tough environment to become stabilized in. The biggest challenge right now is there’s not enough affordable housing especially targeting the mentally ill or the homeless.”
Advocates for the mentally ill also single out the lack of psychiatric beds as an acute issue that needs to be addressed.
A 2012 Substance Abuse and Mental Health Services Administration study cited by Jakle found that the number of beds in California decreased from 98,000 in 1990 to 59,000 by 2000.
Fifteen psychiatric experts consulted in 2008 reached the consensus that 40 to 60 beds per 100,000 people is the minimum number required, provided that sufficient outpatient services are available, according to Dr. E. Fuller Torrey, founder of the Treatment Advocacy Center in Virginia and a research psychiatrist specializing in schizophrenia and bipolar disorder. That number is about four times more beds than exist at present, he said.
Wilcoxen acknowledged that a “very limited” number of psychiatric beds is a problem.
The Mental Health Services Act provides funds only for outpatient services. She said the lack of funding for beds was most likely “an intentional policy decision” as a way to keep from holding people against their will — “but that means you’re going to see people in a lot more distress in the community or in jail.”
Beds, not bars
Jailing the mentally ill is one of the major failings of the current treatment regime, argue advocates for the mentally ill.
Sylvia Thompson, president of NAMI Westside, said the “criminal justice component” of mental health treatment is a major area of focus for the organization.
In particular, Thompson takes issue with the language in Section 5150 of the California law that determines when an individual in the throes of a psychiatric breakdown can be taken in by police for a 72-hour psychiatric hold.
“A danger to others, or to himself or herself” is the suspect wording.
“Just that language criminalizes mental illness,” Thompson said. “The police can’t do anything until they see he’s a danger to himself or others. The other part of that language is ‘or gravely disabled.’ No one pays attention to the ‘gravely disabled’ part. We should not be waiting until someone is ‘a danger to herself or others,’ because we’ve lost an opportunity to get in before the spiral happens.” Other countries “use the terminology ‘need for treatment.’ It’s a very different paradigm, and it’s a different approach to wellness,” she added.
“Twin Towers has become a warehouse for the mentally ill,” said Thompson, referring to the wing of the county jail that houses mentally ill prisoners that even some judges have called a de facto mental institution. “It’s horrific what’s been going on. I want to get to the people before they commit the crime that takes them to jail. We want to get to our loved ones before they go down that path. That reform is desperately needed in this county without a doubt.”
On Oct. 7, the L.A. County Board of Supervisors earmarked $20 million to fund mental health services and substance abuse treatment, including the diversion of some mentally ill criminal offenders from the jails to supportive housing programs. The county was facing a possible U.S. Dept. of Justice consent decree because its jails are not equipped to handle mentally ill inmates.
“Jail only makes the mentally ill sicker,” reads a statement by Supervisor Mark Ridley-Thomas, who brought the idea to the board. “Unnecessarily jailing people with mental illness is not only expensive, because they can be treated for a fraction of the cost using community-based programs, but it is also harsh and insensitive, and, dare I say, inhumane.”
NAMI also believes the 72-hour hold is itself inadequate for proper treatment. It takes more than 72 hours to fully recover from a mental breakdown that requires hospitalization, said Thompson, whose late mother had schizophrenia. “To think that we can fix this in 72 hours? If it weren’t so tragic, it would be laughable.”
Follow-up by professionals and extended hospitalization are needed for a better chance of recovery, she said.
“That’s where the beds come into play. That’s where a state-of-the-art mental hospital for L.A. County would be necessary,” Thompson continued.
She emphasized, however, that this isn’t a recommendation that the stabilized patient “live there forever. The next step is to go into a quality facility that can help you reintegrate into society little by little.”
Laura’s Law: imposing help
NAMI praised the board’s recent passage of Laura’s Law as a positive development, even as some patients’ rights advocates and even a few mental health professionals either disagree or express uncertainty about the law’s effectiveness.
Named for a woman killed by a patient at the Nevada County clinic where she worked, Laura’s Law allows judges to impose court-ordered mental health treatment for those who have been jailed or hospitalized due to mental illness at least twice in three years. The L.A. County Board of Supervisors enacted Laura’s Law in July.
Thompson is adamant about the benefits of court-ordered assisted outpatient treatment for people like her mother, a talented woman who spoke seven languages fluently and played piano but was incapable of recognizing that she was seriously ill. Proponents claim that versions of the law approved elsewhere have saved taxpayer money by reducing imprisonment, homelessness, substance abuse and ER visits by the chronically mentally ill.
As a client advocate, Thompson said she firmly believes “in self-determination when someone is capable of directing her own care.” Laura’s Law, she said, “is a temporary conservatorship for a reason: It’s for one year, and it has to be renewed.”
But she also sees an irrational disconnect in the way that society treats someone with mental illness and someone with Alzheimer’s disease or dementia — namely that we’re willing to navigate concerns about self-determination when it comes to treatment for one group, but not the other.
When it comes to Alzheimer’s and dementia, “we say: ‘because we care about your safety, we need to make this decision’ [to provide treatment],” Thompson said. By comparison, advocates of Laura’s Law interventions argue, we generally aren’t as willing to do the same for people with other mental health conditions who clearly struggle to care for themselves.
Wilcoxen, however, is among those wary of overselling the law’s benefits. She noted that the statute adds the “element of outpatient coercion” to the already effective work of the mental health department’s engagement teams, adding that it’s “very controversial whether or not coercion will give us better outcomes than what our teams already do.”
Resources dedicated to Laura’s Law are expected to accommodate up to 300 eligible people throughout the entire county, and Wilcoxen believes that the Westside will probably account for fewer than 60.
Despite continuing challenges, Thompson is pleased with the general trend of expanding mental health care opportunities and services on the Westside.
“Someone with mental illness isn’t any different from you or me,” she said. “They want the same things. They want a quality of life. They want to be well. They want to have a purpose and make a meaningful contribution to the world. And we all benefit when someone with mental illness is supported in the recovery process, because we get that amazing person back in the community.”
And that can happen only if that person is given at least the chance to get better.
When Jakle speaks publicly, she shares the deeply personal aspects of her struggle with mental illness.
“But I really emphasize the hope aspect: What I went through, what I’ve achieved, and what I believe anyone can do given the opportunities,” she said. “I really don’t think I’m unique.”
Hope for the homeless and mentally ill: Donna’ story
Donna Gill spent most of her adult life homeless, couch-surfing or sleeping on the streets of Venice — a condition precipitated by struggles with mental illness and the illicit drugs she used to self-medicate her inner turmoil, fear and anguish.
“I was diagnosed at a young age with attention deficit [disorder], depression, anxiety,” said Gill, 49. A physical assault in 1997 left her with what she said was later diagnosed as “post-traumatic stress disorder, borderline schizophrenia … hearing voices and things like that.”
Gill seemed like a hopeless case — at least that’s how she recalls feeling about it. But her life began to change eight years ago, when she finally asked for help at St. Joseph Center’s homeless outreach facility on Lincoln Boulevard.
Under the guidance of St. Joseph Center’s wraparound case management services, Gill started trying to get clean — attending a sobriety program while also receiving medical help through the Los Angeles County Dept. of Mental Health’s Edelman Treatment Center on West Washington Boulevard.
“After I started taking my medications on time every day, I started feeling better about things. For such a long time I didn’t want to feel, being out in that situation,” she said.
It was a long road: Gill suffered a relapse and continuing bouts of homelessness, including nearly a year spent living at an encampment in the Ballona Wetlands.
But Gill stuck it out, and for the past several years she’s been sober and living in her own apartment with county rental assistance. In 2011 she completed a vocational culinary training program at St. Joseph Center and went on to continue her studies at Los Angeles Trade Technical College. She now hopes to earn an associate’s degree.
Gill’s message for those beginning similar journeys: You’re not a hopeless case. If I can do it, you can.”
— Joe Piasecki