A family's never-ending cycle

Seven years after voters passed Proposition 63 -- the landmark legislation that was supposed to radically improve mental health care in the state -- California is facing a deepening statewide mental health crisis. As the state struggles under the weight of a lingering recession and an enormous deficit, county mental health programs are often failing to provide care for even the sickest patients. In many cases, the minimal safety net that used to exist is disintegrating.

In the absence of care, many people with mental illnesses are instead cycling in and out of jails and emergency rooms. They are receiving treatment patched together by primary care providers.

This series describes why these cuts are occurring and how they are impacting people with serious mental illness and their families. Articles in the series writen by Jocelyn Wiener include:

Part 1: Mental health care breaking down in Stanislaus County

Part 2: A family's never-ending cycle

Part 3: Help eludes father until son ends up behind bars

Part 4: A shining light in Modesto

Part 5: Creative thinking a necessity in Stanislaus County 

The latest chapter of Kim Green’s recurring nightmare began last fall.

In October, her 24-year-old daughter - who suffers from severe bipolar disorder and a mood disorder related to schizophrenia – was booked into the county jail after being arrested on a probation violation. In December a judge declared the young woman incompetent to face charges and ordered her to Napa State Hospital to get well.

But with no beds available at Napa, Green said, her daughter instead spent five months in the jail.

Deputy David Frost, who oversees the jail’s two mental health wings, said it’s not uncommon for seriously ill inmates to wait there for months, even after a judge orders them transferred to a state hospital.

“The misconception is that mentally ill offenders are just these raging (people), punching walls. They’re not. They’re pretty much scared people,” Deputy Frost said.

In recent years, Stanislaus County – like counties around California – has been severely impacted by budget cuts to mental health services. As those services have disappeared, the number of people with mental illness landing behind bars has surged. In the past six years, the numbers of mentally ill inmates in the Stanislaus County jail increased nearly 50 percent, according to sheriff’s department data.

Around the state, many of the most seriously mentally ill inmates are now waiting three to six months in jail before a state hospital bed opens up, said Randall Hagar, director of government affairs for the California Psychiatric Association. He calls the situation, which he says has gotten worse in recent years, “tragic.”

“It’s terrible, because they’re just sitting there and they’re not getting any help,” said Shannon McBride, the deputy public defender representing Green’s daughter. “The environment is such that for a lot of them, they just get worse during that time.”

Green, a registered nurse, says her daughter has been sick since she was a little girl – at the age of four, she tearfully told Green that she didn’t want to be alive anymore. By six, she was hearing voices. Now her family watched, helpless, as she waited in jail, off her medication and increasingly lost in her delusions.

“I guarantee that with no help, she will end up dead or in the system," Green said.

Advocates emphasize that state hospitals are not ideal places for the majority of seriously mentally ill patients -- many of who might flourish if they received intensive support services in the community. But few suggest the jails are a better substitute.

“The criminalization of the mentally ill is Exhibit A for how, as a society, we have not made mental health a priority,” said Darrell Steinberg, state senate president pro tempore. Steinberg said this criminalization was one of the main reasons he authored the Mental Health Services Act, a 2004 ballot measure that levied a one percent tax on millionaires to fund innovative programs for the state’s mentally ill.

Stanislaus County has created several innovative programs out of that and other funding sources in recent years, including a few that specifically target the intersection of law enforcement and the mentally ill.

Innovations have included the creation of a special court to handle mental health cases, and a mobile community emergency response team that pairs mental health technicians and psychiatric nurses with officers responding to mental health crisis calls. The county also created intensive, coordinated support services for small groups of individuals with mental illnesses, including criminal offenders.

But these recent innovations have faced competition as core mental health services have been stripped away by budget cuts. And some programs – including the mental health court and the community emergency response teams -- have faced cutbacks due to budget constraints in the past several years.

“It’s hard when you see how effective you can be with your small group of people, but you know there’s probably 100 mentally ill in jail right now that would benefit …but we’re at capacity all the time,” said Debra Buckles, chief of forensic services for Stanislaus County Behavioral Health and Recovery Services.

Kim Green and her older daughter, Stephanie Hatfield, think about the shortage of services all the time.

One rainy day this March, Hatfield leaned forward in her seat in the downtown Modesto courtroom, straining to hear news of her little sister.  For up to 23 hours a day over the past several months, jail deputies had locked her sister inside a 6-foot-by-9-foot cell, furnished with a thin metal bunk, a small wood desk, a sink and a toilet, in the special wing that houses the sickest of the mentally ill – the 24-cell B-Mental Health Unit.

Today, the young woman was supposed to appear before a judge.

“I hope that’s her with the chains on,” Hatfield said, as she heard a metallic clinking coming from an adjacent room. “I just want to see her.”

A thin bearded man in a white and orange striped jumpsuit walked out instead.

Eventually, Hatfield was able to glean that her sister had been transferred to Napa State Hospital the day before – after five months in jail. Hatfield was relieved that her sister was not back out on the streets. At least not yet.

Her mother, Green, a registered nurse, describes her youngest daughter as a “sweet, loving, charismatic, artistic” person when she’s on her medication, though she’s “never been really okay, completely.” Starting when she was small, she was deemed sick enough to receive intensive mental health services from Stanislaus County, Green said.  Her daughter received excellent services from the county until she was 18, she said, including placement in high-level group homes that provided psychiatry and medication and follow-up.

But after the young woman legally became an adult, her mother said, those services largely dropped away. Her daughter fled a group-living environment where she felt threatened by other occupants. She ended up cycling between the streets, family members’ homes, and single-room occupancy hotel rooms that crawled with roaches and had no locks on the doors. On one occasion, a pimp held the young woman against her will, her mother said.

At some point, society began to classify her as a criminal. 

In 2008, the young woman spat on a jail deputy while being restrained and was charged with assaulting an officer, said McBride, her public defender. Ever since, probation violations on that one case have caused her to cycle in and out of jail and state mental hospitals, her mother said. Each time, once she stabilizes, a judge releases her to the streets with minimal follow-up by the mental health system, she said.

“It’s not that we’re denying that our loved one has a problem. But if there is no help available, people end up paying the cost,” Green said. “If they don’t have a program, a plan, a place that puts them in another direction, it’s guaranteed to fail.”

Joyce Plis, executive director of the Stanislaus County chapter of the National Alliance for the Mentally Ill, said families often seek help before their loved ones get in trouble with the law. But it can be “almost impossible” to find them services, she said, especially for those who don’t recognize how sick they are.

Instead, some individuals with mental illness end up committing crimes – petty theft, drug use, threatening or assaulting a friend or family member– and then landing in jail. Only there do they finally get some basic care, she said.

She describes life behind bars as “horrendously awful” for someone trying to get well, with inmates who are off their medications hallucinating and yelling. Treating individuals in jail and hospitals because they can’t get services beforehand also ends up being extremely expensive for the public, Plis said.

“People with mental illness don’t serve their time and get out,” she said. “They get stuck in there.”

Madelyn Schlaepfer, director of Stanislaus Behavioral and Recovery Services, said the county is working to find ways to keep sick people from cycling back into psychiatric hospitals and jails. The challenge, she says, is the scarcity of resources.

“It is really a struggle to find aftercare,” Schlaepfer said.

Law enforcement officials say those problems are being amplified by public safety realignment. Starting last fall, state prisons have been granting early release to increasing numbers of nonviolent offenders, adding additional pressures to county probation departments and jails. Stanislaus County expects to absorb 500 to 600 inmates every year. Many of them, said Sheriff Adam Christianson, have mental illnesses. Frequently, they land back in jail.

The jail system had a bed capacity problem before realignment, Christianson said. “Now that problem has been exacerbated exponentially.”

Dr. Antoun Manganas, medical director of Doctors Behavioral Health Center in Modesto, said the psychiatric crisis center has begun seeing very ill inmates appear at their doors on the day they are released from prison.

“All of a sudden they show up and they say, ‘I don’t have my medication, I don’t have money, and I don’t have a home,’” he said. “And they are in a crisis.”

Kim Green and her older daughter, Stephanie Hatfield, were hoping that wouldn’t be the outcome for Hatfield’s baby sister.

On her sister’s 24th birthday in March, Hatfield, her brother and sister-in-law visited the young woman at Napa State Hospital. Sitting at the visitors’ table, Hatfield thought her sister looked very pale and skinny. After spending so many months locked inside without medication, she said her sister was the sickest she’d ever seen her.

Hatfield’s sister told her that she was being taught about court in the state hospital. “The judge is there,” Hatfield recalled her sister saying. “So is the public defender. And the lady who takes notes on the typewriter. And the demons.”

This past Thursday morning, Hatfield rushed, once again, to the courthouse in downtown Modesto. After two months in the state mental hospital, her sister had just been transferred back to the jail, and was likely to be declared well enough to face her charges.

“I’m scared to death,” Hatfield said. “They’re just going to let her out. She’s not going to get the help she needs. And she’s going to be back on the streets.”

The bailiff called the courtroom to order. The judge entered. The public defenders and district attorneys took their seats.

And then Hatfield’s little sister appeared, her straight brown hair pulled into a ponytail, a grin stretched across her beaming young face.

She turned around to search for Hatfield, then smiled and waved.

“I’m going home,” she whispered.

A few minutes later, the judge read the charges aloud.

“No contest, sir,” the young woman said.

Time served, said the judge.

Hatfield’s eyes filled with tears, as she made plans to pick up her sister later that day.

“Now we start over again,” she said.

Bee Staff Writer Ken Carlson contributed to this story.


This article was originially published by The Modesto Bee.