In this memo, Jean Fraser, the director of health systems in San Mateo intentionally misleads board about Laura’s Law, failed to highlight Laura’s Law benefits and savings and shows no interest in serving the most seriously ill.. Ms. Fraser previously misled the San Mateo board in 2011 and we demonstrated how. Here are San Mateo mental illness tragedies that might have been prevented had the BOS enacted Laura’s Law previously. We hope the Board of Supervisors will overrule Ms. Fraser, by passing this resolution, and if need be, replace the health director with someone who is more honest with them and more interested in helping the seriously mentally ill. Money is not the issue. Leadership is.

To:                  Honorable Board of Supervisors
Through:        Jean S. Fraser, Health System Chief
From:             Louise F. Rogers, Deputy Chief
Stephen Kaplan, Behavioral Health and Recovery Services Director
Re:                 Follow-up Recommendations for Early Intervention with Mental Illness
Date:              February 5, 2013

Thank you for asking us for ideas in three areas:

  1.  What we can do in the mental health arena to prevent tragedies like the deaths at Sandy Hook school; and
  2. What we can do to respond to the concerns of families who advocate for implementing Laura’s Law.


Preventing a Sandy Hook crisis here
While it is important to note that people with mental illness are rarely violent, and are in fact more frequently the victims of violence themselves, the tragic events at Sandy Hook Elementary and other poignant examples remind us that even one person slipping through the cracks can devastate many lives.  Immediately after the event, Behavioral Health and Recovery Services (BHRS) and the County Office of Education began meeting to design a response.  This paper presents some initial recommendations.

People with mental illness who exhibit violent behaviors towards others (a very small percentage of mentally ill people overall) usually have been deeply traumatized by events that occurred when they were children or young adults. There are evidence-based practices that prevent and mitigate the effects of childhood trauma, but early identification and treatment are essential.

The Health System’s Pre to 3 program has had excellent results in reducing child abuse in San Mateo by sending public health nurses to visit all low income pregnant women in the county to assess them for risk factors and following up with appropriate education, treatment, and other interventions to give every family the tools and education they need to give their child a healthy, safe start in life. There is a waiting list for mental health services for 50 families in Pre to 3. There has also been a waiting list of 30 families referred by the Child Welfare System for Partners for Safe and Healthy Children.  Prompt and appropriate treatment is essential in order to reduce risk and increase families’ ability to provide safe and supportive environments.
When abuse prevention fails, it is critical to identify and treat traumatized children as quickly as possible. BHRS and Human Services Agency staff work together to respond immediately to children and youth in abusive and/or traumatic relationships. Recent advances in the field call for new interventions that historically have not been part of the menu of options. Additionally, the reach of our trauma response program was narrowed only to families on Medi-Cal as county funding declined.  We propose to restore funding so we can respond to every child in need with the appropriate treatment.

Additionally, while schools work with BHRS to provide mental health services for children in special education, a child’s problems must severely impact their school performance for the child to qualify.  Children who are still “getting by” in school but have experienced traumatic events, are socially isolated, are victims of bullying, or are depressed or otherwise vulnerable and deteriorating do not qualify for special education services.  If we can train teachers and other adults at schools to recognize children’s distress early, and then provide interventions at school to get the children back on the right track, we can avoid the need for special education services later and decrease the bullying and other victimization that so isolates and distresses these children.  BHRS and the County Office of Education have agreed to adopt Youth Mental Health First Aid as an evidence-based teacher/parent training model to achieve this recommendation.

Sadly, the initial onset of schizophrenia and bi-polar disorder, which usually occurs when youth are in high school or shortly thereafter, rarely is recognized for what it is.  As a result, youths with these disorders deteriorate, and their behavior becomes so odd that their relationships and lives come apart before the disease is recognized.  New research shows that when young people are identified and treated correctly when they have their first episode they can avoid the devastating impacts of the disease for themselves and their families and lose little of the momentum of their life’s trajectory.  We have instituted a model program to help clinicians identify the first schizophrenic crisis and get the youths immediately into treatment, thereby keeping the youths stable and functioning.  A similar approach is needed for bi-polar disorder.

Finally, sometimes families in crisis with a child or youth present to us for the first time at the San Mateo Medical Center’s Psychiatric Emergency Services (PES). Of the 260-300 young people who present to PES each year, slightly more than half are unknown to us previously.  At this time, BHRS only has the resources to follow up after discharge only with those individuals who are publicly insured. We believe that assessing, following-up, engaging and treating youth and young adults who appear in PES will prevent more significant problems later. We recommend expanding our young adult service to assure clinical follow-up occurs for all young people seen by PES.

Initial recommended programs to prevent a Sandy Hook tragedy in SMC:

  1. Expand Pre to 3/Partners for Safe and Healthy Children mental health treatment to reach every high-risk low-income family in the county.  Cost $420,000. Estimate 110 additional families served annually.
  2. Provide children who have been abused or traumatized with interventions to enable them to overcome the trauma. Cost $525,000, plus $10,000 one-time start up. Estimate 700 children/youth served annually.
  3. Train teachers, parents, other adults and young people to recognize early signs of mental distress through Youth Mental Health First Aid training; link at-risk children to services.  Cost $200,000. Estimate training 700 school personnel and high school juniors/seniors and 25-50 parents each year.
  4. Establish an early onset bi-polar disorder program to identify youths experiencing their first break. Cost $400,000. Estimate 40 additional youth and young adults served annually.
  5. Expand follow-up and support for youth/families after Psychiatric Emergency Services Cost $390,000.  Estimate serving 130 young adults annually.

Responding to concerns of family members who advocate for implementation of Laura’s Law

The system of care for people with serious mental illness has advanced a great deal since the 1960’s, when most of the mental health hospitals were closed.  However, the legal structure for handling people with serious mental illness has not changed much; it is still based on the notion that anyone who is sufficiently seriously mentally ill to required forced medication is also going to be in an institution.  Accordingly, in most counties, judges will only order forced medication if a patient is in an institution.  Patients who then become stable and are able to care for themselves (and thus no longer meet the legal requirement for being confined) are released from the institution and from the order requiring them to take medication.  As a result, some patients stop taking medications when they are released and decompensate.  Family members know that their loved ones could live outside of an institution if only they continued their medication; families are frustrated that they cannot get the courts to require medication while the patient is living in the community.

An additional frustration is that in many communities, families struggling with a relative in crisis find it very difficult to get their loved one into mental health treatment until and unless the relative so declines that the police or an ambulance must be called.  This is particularly true for middle-income families whose children are covered by private insurance, since the county system is almost entirely funded through, and geared toward serving beneficiaries of, Medi-Cal.

In response to these frustrations, some family members advocated for a law allowing courts to require mentally ill patients to take medication even when the patients are outside of an institution.  They also advocated for a legal route for family members to be able to get relatives into mental health treatment before the family has to call the police.

When family members were making this argument to legislators, advocates for people with mental illness were very concerned about the potential loss of rights for mentally ill people.  They had good reason to worry, as in the past some family members used mental health laws to restrain relatives for bad reasons.

The result of this conflict was Laura’s Law.  What Laura’s Law does do is offer families a way to petition for review of the mental status of a relative who meets certain criteria (hospitalization or incarceration twice in the last 36 months or violence towards self or others in last 48 months) and has not complied with voluntary treatment.  What Laura’s Law does not contain, however, is a process for force medicating patients.  That is why only one county has implemented it fully.  Unfortunately, many advocates do not understand this and press for implementation based on the mistaken impression that patients suffering from anosognosia (the inability to recognize one’s own mental illness) can be force medicated under Laura’s Law.

We are fortunate in San Mateo County that our courts do not read the mental health laws as restrictively as in many other counties.  Our judges will allow mentally ill patients to remain conserved even when they are released to the community.  We call these “community conservatorships,” meaning that the patient is able to live in the community with the support of our Full Services Partnership (also known as Assisted Outpatient Treatment).

There are currently 230 San Mateo residents conserved in the community. These community conservatorships are more powerful than Laura’s Law as they include (subject to a court decision) the power to medicate clients involuntarily.  Thus, we already accomplish one of the main goals of the advocates for Laura’s Law.  However, the number of people we can treat in the community is limited by the number of community conservatorship and Full Service Partnership slots we have.

The other goal – getting people into treatment before they decompensate and families have to call the police – is a very legitimate one.  Recognizing the horrible dilemma this creates for family members, last year Health and Behavioral Health System representatives worked with NAMI-SMC family member representatives, the Sheriff’s Office, Probation, local police, the District Attorney, and the Private Defender to develop a plan to address this issue.  The plan is outlined in the attached paper Fine-tuning SMC Alternatives to Incarceration for People with Mental Illness and/or Substance Use Problems: Consensus Recommendations for Strategies.

The highest priority strategies in that plan are summarized here.  Together these strategies represent an effective alternative to Laura’s Law for families in crisis in San Mateo County.

First, NAMI-SMC family representatives and BHRS worked together to develop the concept for early response to families with a loved one experiencing a serious deterioration in their mental health. Families will be able to call for help by contacting the BHRS outreach team directly. The response should be immediate and include an in-the-field evaluation of their loved one and timely linkage to resources. We are planning for a summer 2013 implementation.

Second, sometimes the response to a family calling for help for a loved one with mental illness in crisis will reveal a need for short-term residential respite (approximately ten days) for a person to stabilize. Police officers also have asked for a program for people with mental illness that police can use in lieu of taking them to jail. They reference the success of our First Chance program for DUI/public intoxication where police can leave people under the influence of alcohol knowing they will be stabilized and offered services. Currently, there is no equivalent program for adults with mental illness.  We believe that the early intervention for families in crisis must be paired with a residential respite program as an alternative to incarceration or hospitalization for men and women with a serious mental illness.

Third, there are times when families in crisis need access to residential substance abuse treatment for youth. Unfortunately, currently substance use treatment for youth is only available once they get arrested.  Families have requested that we add some substance use treatment for youths that is available before they get arrested.

Fourth, families complain that there is no help for those who fall through the cracks of the mental health safety net and end up in jail.  They point out that over two-thirds of the adults in our county jail with a mental illness/substance use disorder were unknown to BHRS prior to their arriving in jail.  In the worst situations, individuals are held for months while their competence to stand trial is determined, even when they are charged with minor crimes.  You may recall the sad case of the woman with severe mental illness whose husband picketed outside the county courthouse for weeks asking that his wife be treated, not jailed.

Currently, there is no organized system for reviewing the cases of mentally ill inmates and providing information to the DA, PD, Probation, Sheriff and Courts before decisions are made by the criminal justice system to see if a more cost-effective and/or humane response is warranted.  As a pilot program to see what might change, we propose to have BHRS staff member review every individual with significant mental illness and low level crimes identified by Correctional Health, Sheriff, District Attorney, Probation, Private Defender, or the Court for information about the person’s community treatment providers, plan and social supports and suggestions for an immediate alternate disposition that would be provided upon client consent to the Probation division in charge of preparing information and recommendations for the Court.

Recommended programs to respond to advocates for Laura’s Law:

  1. Pre-crisis Enhanced Outreach to Families. Cost $250,000, already fully funded using Mental Health Services Act funds.  Estimate 80 individuals and families served annually.
  2. Expand the number of community conservatorship slots and increase Full Service Partnership slots for youth and adults. Estimate 60 transition age youth and adults served in the first year, could rise to 125 clients in second and out years.  Cost $1,400,000 in first year, possibly rising as high as $2,650,000 in second year and thereafter.
  3. Create a short term residential respite, stabilization, and reconnection to treatment program for police/others to take people with mental illness. Cost $1,200,000 plus $750,000 one-time capital expense. Estimate 365 people will be served annually.
  4. Expand residential co-occurring treatment for youth. Cost $300,000. Estimate 15 youth served annually.
  5. As a pilot, review mentally ill individuals caught up in the criminal justice system for dispositions other than jail.  Cost $104,000 annually for two year pilot phase.  Estimate 150 adults served annually.