Get off BART at San Francisco's Powell Street station and you enter an open-air insane asylum. A woman crouches on the sidewalk, screaming obscenities. A man stumbles in circles, haunted by demonic voices. Hands reach out and rattle cups for spare change; voices curse those who pass by. For more than three decades, California has turned its back on those who suffer from severe mental illness, treating them as unfortunate fixtures in our urban landscape rather than as human beings who desperately need medication, treatment and housing in order to cope with their illnesses. What will it take for the Legislature to act? Will a mentally ill person have to pound an 18-wheeler through the walls of the State Capitol as undeniable proof of the system's failure?
One actually did.
On the night of Jan. 16, Mike Bowers, a 37-year-old trucker with a long history of severe mental illness and a certitude he was 'King of the New World Order,' smashed his big rig into the south side of the Capitol. A year earlier, Bowers had been released from a hospital because he did not meet the state's stringent criteria for involuntary treatment.
California's pathetic patchwork of services and outdated laws mock the magnitude of the problem.
�We spend billions of dollars dealing with the consequences of mental illness rather than spending that money wisely on adequate services,' the Little Hoover Commission, an independent state oversight group, concluded in November.
Today, 50,000 or more Californians wander the streets homeless. One-third of them suffer from severe mental illness, according to various studies.
Without treatment or medication, many of them end up committing petty crimes -- living in abandoned cars, squatting in backyards or stealing food. A few commit more serious, violent crimes.
Prisons and jails have become, in effect, California's hospitals of last resort for the mentally ill. An estimated 30,000 mentally ill people are behind bars at any given time. Each night a person spends in jail costs taxpayers three times the dollars needed to treat a patient with medication in a residential care facility.
How did it get to be this way?
The short answer is 'deinstitutionalization.' During the 1960s, many people began accusing the state mental hospitals of violating the civil rights of patients. Some families did, of course, commit incorrigible teenagers or eccentric relatives to years of involuntary confinement and unspeakable treatment. Nurse Ratched, the sadistic nurse famously portrayed in the book and film 'One Flew Over The Cuckoo's Nest,' became a symbol of institutional indifference to the mentally ill.
By the late 1960s, the idea that the mentally ill were not so different from the rest of us, or perhaps were even a little bit more sane, became trendy. Reformers dreamed of taking the mentally ill out of the large institutions and housing them in smaller, community-based residences where they could live more productive and fulfilling lives.
In 1967, Gov. Ronald Reagan signed the Lanterman-Petris-Short Act (LPS), which went into effect in 1969 and quickly became a national model. Among other things, it prohibited forced medication or extended hospital stays without a judicial hearing.
A mental patient could be held for 72 hours only if he or she engaged in an act of serious violence or demonstrated a likelihood of suicide or an inability to provide their own food, shelter or clothing due to mental illness. But 72 hours was rarely enough time to stabilize someone with medication. Only in extreme cases could someone be held another two weeks for evaluation and treatment.
As a practical matter, involuntary commitment was no longer a plausible option.
As one psychiatrist in a Bay Area hospital observed, 'By the time someone's been pumped full of Thorazine for 14 days, if they still seem dangerous to a judge, they have to be really dangerous.'
The LPS Act emptied out the state's mental hospitals but resulted in an explosion of homelessness. Legislators never provided enough money for community-based programs to provide treatment and shelter. Even the most modest programs encountered local resistance.
'No neighborhood wanted the mentally ill living among them,' recalled former state Sen. Tom Bates.
Lanterman later expressed regret at the way the law was carried out. 'I wanted the law to help the mentally ill,' he said. 'I never meant for it to prevent those who need care from receiving it.'
But that's exactly what happened for three decades.
In 1999, the Legislature finally funded pilot projects in Stanislaus, Los Angeles and Sacramento counties that offered comprehensive treatment for the mentally ill. And they appeared to work. Within the first four months, the $10 million pilot program helped move 1,000 people off the streets and into support systems of care.
Last year, Assemblyman Darrell Steinberg, D-Sacramento, sponsored legislation to allocate $54.9 million to expand these pilot programs to 24 counties and two cities during the next three years.
But the current funding levels are ludicrously lean. San Francisco, for example, has received enough money to help 120 people -- or roughly the number of homeless people that could be found on a block of Market Street.
The fact is, we know what's needed. The problems of the homeless mentally ill are neither inscrutable nor intractable. What's missing is not knowledge; it's political will.
We need teams of outreach workers, residential treatment centers, shelters for the mentally ill, temporary and long-term housing, and mobile treatment teams - - made up of psychiatrists, nurses, employment counselors, case managers, and rehabilitation specialists.
But such programs now can only reach those people who are willing to accept treatment. We also need to reform the LPS Act so that those who are in acute crises can receive involuntary outpatient medication -- and, when necessary, inpatient treatment.
Last year, Assemblywoman Helen Thomson, D-Davis, and Sen. Don Perata, D- Oakland, sponsored legislation that would have reformed the 30-year-old LPS Act and allowed California to join the 27 other states that can consider a patient's history of mental illness, as well as his or her current state of mental and physical deterioration. It cleared the Assembly 53-16, only to be stopped cold by Senate President Pro Tem John Burton, who vowed, 'It ain't going to happen.'
Burton said he was trying to protect the civil rights of mental patients -- the 1960s argument. But to leave an untreated person wandering the streets, scrounging for food, stalking doorways for shelter -- tormented all the while by hallucinations -- is not an acceptable definition of freedom.
The severely mentally ill often don't know they need help. In fact, a distorted sense of well-being is typical of people suffering from paranoid psychosis, bipolar disorder and major depression.
Despite his opposition to involuntary treatment, Burton is among the strongest advocates of spending money to help the homeless mentally ill. He has even argued that treatment for severe mental illness should be an entitlement -- like public education -- for Californians.
Gov. Gray Davis and the Legislature must act to end the shameful and costly neglect of those who suffer severe mental illness and homelessness. No more excuses. There is nothing moral, just or defensible about allowing people to live and die on the streets of California.
-- A Shameful, Costly Policy
-- Governor, Legislature Must Act
-- No More Excuses
'A Slow Suicide'
Michael, 75, suffers from schizophrenia. But he doesn't know it.
Once an energetic engineer, he is now paranoid and refuses any treatment. Convinced that all food is contaminated or poisoned, he has stopped eating and has withered to 120 pounds on a 6-foot frame. Isolated and suspicious, he is, as a relative explains, on his way to 'a slow suicide.'
Michael does not appear in the statistics that count those who are in jail, in hospitals or on the streets. He is not likely to commit a headline-grabbing violent crime.
He never harms anyone but himself.
Michael rarely leaves his apartment. If his older sister didn't manage his daily affairs, paying for his small apartment with his SSI check, Michael probably would be evicted and join the homeless on the streets.
One of the many signs of severe mental illness is that an individual cannot recognize that he or she has an acute need for assistance.
For relatives, it is a heartbreaking experience to watch a loved one suffer and not be able to help them. The sensitive subject of involuntary treatment often escalates into a fierce struggle between patients-rights groups and families of the mentally ill.
It comes down to the meaning of freedom. Patient-rights groups, such as the California Association of Mental Health Patients' Rights Advocates, strongly believe that civil rights should be paramount.
If people refuse treatment, it is their right to do so. If they want to live in a muddy encampment, that is their choice. They believe, as Mary Kate Connor, the dedicated director of San Francisco's Caduceus Outreach Services says, 'If we really offer sufficient service and adequate treatment, the homeless mentally ill will come.'
Meanwhile, helpless relatives watch as Michael deteriorates, knowing that by law they cannot force him to accept involuntary treatment or commitment.
'He will die,' says one relative, 'because we cannot force him to help himself.'
A Hand Reaches Out
When Duane Chapman drives up to a homeless encampment in Contra Costa County, the men and women don't scatter or hide their beer. They crawl out of their tents, get up from the ground and greet him with smiles.'
Hey, Duane, when you goin' to bring that sleeping bag?' a grizzled man asks. One woman, recently robbed by her homeless brother, no longer has the identification she needs to use county facilities. She pleads, 'Is there any way I can get to Martinez to get my birth certificate?' A man thanks Duane for the batteries that power the walkie-talkie he uses to keep track of his girlfriend, who often wanders off from the camp and gets lost.
Duane Chapman probably knows more about the mentally ill homeless than anyone at the county Health Service Department. He is a street-smart miracle worker who knows how to approach and engage the homeless. They turn to him for rides, toothbrushes, tents, bedding, clothes.
Duane knows who they are, how they came to be homeless, what they need, where they hide. Where others see overpasses and large expanses of suburban greenery, Duane sees the camouflage of encampments. He can tell you the history of the people who live hidden within a given circle of shrubs and trees.
He can make a diagnosis with a quick glance. 'Look at how normal that man is walking. When he was off his meds, he used to take a few steps, suddenly stop, and go into a catatonic state.'
When he sees someone who looks disoriented, Duane stops to find out what has happened. 'You off your meds, Joe?' With a slight nod, the man mumbles, 'I lost them.' Duane calls the local mental health crisis clinic to say that Joe is on his way.
Duane knows that many are using alcohol and drugs to ease their pain. 'You have to deal with these addictions, or you'll never get them off the street. But the real problem is that there's no place to go. No room in shelters, no residential treatment centers.
'A few years ago, Duane decided to go undercover to see how the system treats the mentally ill homeless. He went to a hospital and described himself as suicidal and experiencing chest pains. After the doctors checked his heart, they said he was fine and that he could go. 'And where was I supposed to go?' Duane asked.
He knew the answer. There was none.
In Contra Costa County, the one mental health shelter is in Antioch. It has just 20 beds. 'We can call the free 800 shelter hotline number, but there's never any beds available,' Duane says. 'If someone is seriously disturbed, we can bring him to the county hospital's psychiatric emergency services. They hold him for 72 hours -- which is never enough time to stabilize anyone with medication. Then they put him in a taxi and discharge him. But where? To the streets. If the guy's done something illegal -- like living in an abandoned car or house -- sometimes the police will pick him up for vagrancy and put him in jail. When he's released, he's back on the streets.
'It is only this kind of intensive outreach work that can begin to solve the multiple problems experienced by the severely mentally ill.
'We need 100 people like Duane,' says a director of a mental health crisis clinic in Richmond. 'But there's just so little money for outreach workers. And even if the Legislature gave us all the money we needed to hire and train hundreds of Duanes, where would we house all the people that they brought into for treatment?
'Duane has one answer to the housing crisis. As he drives around Richmond, he eyes the abandoned buildings. 'See that huge building over there? We could house about 300 of the mentally ill homeless there. They could receive treatment for their addictions, medicine for their mental illnesses, they could get off the streets and live inside in dignity.
'He shrugs. 'But they'll never do it. People don't care about the homeless and they're afraid of the mentally ill.'
What Legislators Need to Do�
