Wanda Irons was curled up in the back of the Tulare County Mental Health Department cruiser, sedated for her trip to the Kaweah Delta mental health facility that had become her second home.
She awoke, then protested with thuds to the safety glass and iron grating that separated her from her handlers. From Iron’s perspective on that evening one year ago, it was a forced return to a place that had not treated her mental illness, but exacerbated it.
“I was angry, kicking and screaming. I just didn’t want to go back,” said Irons, 46, who had spent the previous six months in and out of Kaweah Delta in Visalia.
A year later, Irons does not view those Tulare County Mental Health Department case managers as captors, but as ushers to an astounding life turnaround that has seen no subsequent hospitalizations.
Her time at Kaweah was a month-long stint closely monitored by a Tulare County Mental Health Department therapist. While she was there, slots were reserved for her in a battery of coordinated services upon release. They enabled her to find an apartment within two months, reconnect with estranged family within four, and drive her own car within a year. Irons began a job search last month.
And she is not alone. Using funds from the controversial Proposition 63 mental health services millionaires’ tax, Tulare County has corralled 22 of its most resource-draining and resistant patients into a system-wide “mental health redesign.” The toughest 22 are on track to reduce their hospitalizations by at least a third in the coming year compared to last, according to figures provided by the county.
More importantly, county health officials said, their documented sessions of engagement in voluntary outpatient treatment — in getting off the streets and out of hospital emergency rooms — is on track to increase by more than 700%.
“It’s recovery in its broadest sense,” said Dr. Timothy Durick, director of the Tulare County Mental Health Department. “They are stable. They are developing lives for themselves, reunifying with family members, as well as being able to find employment.
“We never want to give up on anyone,” he said.
Tulare County’s Mental Health Redesign was first profiled in The Bee a year ago, but in those earlier stages the focus was on “consumers” who often wanted treatment.
The department’s mission has now broadened to those who have summarily, and sometimes violently, refused treatment.
The expansion is more surprising when one considers the troubles of Proposition 63, which funds California’s sprawling Mental Health Services Act and has raised $13 billion statewide since passage a decade ago.
The Little Hoover Commission, an oversight agency that reports to the governor and Legislature, found in November that the multibillion-dollar act had yet to demonstrate that it “made California a better place for the estimated 2.2 million adults with a mental health need.”
The report went on to describe a glacial pace by counties, which were charged with developing their own programs tailored to their own mental health needs. The report detailed a lack of oversight and statistics gathering by several state entities that were supposed to track, and push for, county progress.
Tulare County mental health began training staff for what Durick calls a “paradigm shift” in outreach and treatment in 2011. It formally began implementation of the redesign in early 2014.
It was a relatively short period, Durick believes, for department staff to buy into a professionally challenging linchpin: patients would now be called “consumers” and they would literally have a seat at the table on outreach strategies for themselves and their peers.
Irons is now part of an outreach team much like the one that corralled her, a volunteer earning stipends that are limited to a maximum of $100 a month.
She has her own key card to enter the mental health department’s main facility in Visalia and typically helps out, plus receives her own treatment, three times a week. She is a member of the “Assertive Community Team” that seeks to reach potential consumers resistant to treatment, just as she was once.
In some cases they are people Irons knows from her time in institutions, so her insights are heard, she said.
“She was either using, or off her meds. I was able to make them aware of that,” Irons said of a prospective consumer that the assertive team was trying to enlist in treatment. “She was talking to herself and talking to me as if I was a drug dealer. ... They were able to keep her out of the hospital by monitoring her daily.”
Still, traditional mental health professionals working side-by-side with the people they treat has not always gone smoothly.
Juaniece Armstrong, a consumer who has transitioned to a paid position as program coordinator for volunteers, recalled a recent episode. A new consumer requested volunteer work.
A clinical staff member, Armstrong said, told the consumer that he or she had not progressed far enough in treatment.
“I lost it. I told this person it was our job to make it happen for this consumer, not tell them it couldn’t be done,” said Armstrong.
Armstrong said she later apologized to the staff member. The consumer was ultimately placed in a volunteer position.
Armstrong herself was given similar work in the early stages of her treatment, before holding the job she has now.
Changing professional culture
The redesign is “based as much as possible on what the consumer wants,” said Kent Henry, wellness and recovery manager with Tulare County mental health. Henry said he only deviates from the redesign philosophy when a consumer is “for instance, a danger to himself or others, or is using drugs.”
Dawan Utecht, Fresno County Behavioral Health Director, said her department has also invested in peers. They sit on advisory boards that outline broader systematic approaches to outreach with “their lived experience,” she said.
Fresno has not, however, gone as far as Tulare’ County’s stipend system of direct involvement by consumers who were once the hardest to reach.
Utecht called the use of peers challenging for any county because traditional mental health staff not only have to buy in, but so do county officials who ultimately approve the methods.
“Part of the culture that has to be changed isn’t just the culture in my department,” said Utecht. “It’s also the culture around my department.”
But even as Tulare County discarded the traditional power structure between health professional and patient, the largest counties in the state have moved toward a model that codifies it in place.
Adopted with much media attention last spring in Orange, San Francisco and Los Angeles counties, “Laura’s Law” seeks to establish outreach teams like those found in Tulare County. And it seeks to place the most difficult patients in treatment.
But those teams will be made up of traditional mental health professionals. And even more troubling for Durick, a judge is empowered to order the treatment.
“Studies have shown that forced treatment is ineffective,” Durick said. “Through the redesign, we’re trying to engage people rather than force them to come.”
Durick is right to be concerned. In what could become a funding tug of war between voluntary and involuntary approaches, Proposition 63 dollars are also funding Laura’s Law.
In fact, counties would not even consider Laura’s Law until state officials said in 2008 that Proposition 63 funding could be used for its implementation.
Even then, all counties held out but Nevada, where the law’s namesake Laura Wilcox was killed in 2001 by a man who had refused mental health treatment. Most cited the very reservations with forced treatment that Durick continues to stand by.
Patient involvement key
Still, mental health consumer Mark James offered a unique perspective on why Tulare County’s approach, though not court ordered, is also not passive.
During a recent roundtable interview with traditional mental health staff and consumers who now work beside them, James, 57, told a story.
Eleven months ago, he walked up to the processing window at the main county mental health facility in Visalia, the latest in his dazed efforts over the years to seek treatment for bipolar disorder and methamphetamine addiction.
“They asked, ‘What’s your name?’ I said, ‘Mark James,’” he recounted, grinning like a Cheshire cat for the sentences to come. “Then she goes, ‘Mark James?’ I said, ‘Yah.’ ... She pushed a button … then it goes, weh, weh, weh and a cage come down out of the ceiling, all around me.”
“This is all metaphoric. We don’t really have a cage,” Henry clarified, himself smiling.
James’ account made a larger point. Included in the Mental Health Redesign is a new level of information sharing in which potential consumers are flagged if they have a history of homelessness, frequent emergency room visits, or have been in and out of mental health facilities.
James met all the criteria, and the intake worker who met him that day immediately contacted Carrie Rodriguez Mason, a department therapist who had his medical and personal history at the ready.
“She took me into her office and in 30 minutes took me off of the street, and put me into a place where I had a bed, something to eat, and a roof over my head,” said James.
He is now one of the most animated and vocal members of the assertive team that Irons is also on, is in partial remission and has graduated from supervised housing to unsupervised. He has also begun looking for a job.
Irons said her hospital stays were akin to forced treatment. She recalled times in which she tried to tell doctors her medications were causing paranoia she did not have before.
The usual response, she said, was for the hospital to “guinea pig” her on medications that silenced her perspective.
Asked if her recovery would have been possible through court-ordered treatment like Laura’s Law, her answer was not only swift. It reflected how far she’s come.
“No. ... When you’re mentally ill and you’re off your medication you don’t have reasoning like everybody else,” she said. “Now I have reasoning.”