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Willie L. Brown, Jr.
Mayor

Susan Mizner
Acting Director, MOD

                                                                                      Ed Evans, Chair
                                                                                      Vincent Behan
                                                                                      Norma Block
                                                                                      Jack Fagan
                                                                                      Eugene T. Flannery
                                                                                      Elizabeth Grigsby
                                                                                      Michael Kwok
                                                                                      August Longo
                                                                                      Ruth Nunez
                                                                                      Jul Lynn Parsons
                                                                                      Denise Senhaux

                                         Mayor’s Disability Council
                                       Minutes
                           21 November 2003

1 ROLL CALL

Mayor’s Disability Council Members Present: Vincent Behan, Norma Block, Ed Evans, Jack Fagan, Eugene T. Flannery, Elizabeth Grigsby, Michael Kwok, Ruth Nunez, Jul Lynn Parsons and Denise Senhaux.

Excused Absent: August Longo

Mayor’s Office on Disability: Susan Mizner, Acting Director; Richard Skaff, Deputy Director; Ken Stein, Program Administrator, Josie J. Lee, Council Clerk and Howard O. Wong, Council Clerk.

Ed Evans, Chair, called the meeting to order at 1:03 p.m.

2 APPROVAL OF THE AGENDA

The Council approved the agenda for the November 21, 2003 Mayor’s Disability Council (MDC).

3 APPROVAL OF THE MINUTES

The minutes from the meeting of October 24, 2003 were approved.

4 PUBLIC COMMENT

Lori Guidos, made suggestions to increase access to MDC meetings: She suggested that the bridge line phone number be posted on the television screen during the meeting. Secondly, she noted that SFGTV lists the dates of the monthly MDC meetings, but not the time of the meetings. Finally, she asked when other committee and Board of Supervisor’s meetings would have a telephone bridge line as well.

Ed Evans, Chair, responded that Ms. Guidos could provide her contact information to the Council Clerk (Howard O. Wong), to be added on to the regular mailing list, which will provide her with the bridge line telephone number and the times for the monthly meetings.

Ms. Guidos was also informed that with 72-hours notice, other meetings in City Hall could have a telephone bridge line available. MOD is working to have available on a regular basis.

Lou (last name unclear due to technical difficulties) – suggested that City Hall provide electric carts for the public, just as grocery stores do. As someone with a mobility impairment, but who does not use a wheelchair, she finds it difficult getting around City Hall.

5 REPORT FROM THE CHAIR

Ed Evans reported that a number of people had expressed concerns about motorcycles, electric scooters, etc. parked on sidewalks. In fact, sidewalk parking is banned in San Francisco. Mr. Evans urged the San Francisco Police Department to take a very aggressive stand in ridding the sidewalks of these hazards.

Susan Mizner, Acting Director for Mayor’s Office on Disability (MOD), responded to Mr. Evans that the Pedestrian Safety Committee was meeting on Monday, November 24, 2003 at 5:30PM in City Hall. They will be discussing issue of motorcycles parked on sidewalk.

6 REPORT FROM THE ACTING DIRECTOR

Susan Mizner, Acting Director for Mayor’s Office on Disability (MOD), reported that MOD presented its Housing Impediments report to a Subcommittee of the Board of Supervisors, and the Board of Supervisors has expressed a strong interest and wants to follow up on this issue. In the meantime, MOD and the Mayor’s Office on Housing will be working together to provide some additional information to the Supervisors and will report on this at a future meeting.

Ms. Mizner reported that MOD is currently revising the City's ADA (Americans with Disabilities Act) Grievance Procedure. The ADA requires that local governments adopt internal grievance procedures that provide prompt and fair resolution of complaints from the public that allege disability discrimination. MOD has contracted with consultants to research best practices from other cities ADA Grievance Procedures. They completed their findings and came up with a draft proposal. MOD is currently having the draft reviewed by the City's ADA Coordinators. The Programmatic Access Committee and the MDC will be asked to provide review the procedure and provide their input as well.

Lastly, the MDC by-laws mandate two Co-Chairs for the council. Ed Evan, Chair, has been holding this position on his own for the last 10 months while the Council membership was increased. Next month the MDC will hold an election for a second Co-Chair.

Ms. Mizner encouraged people who have any questions or comments about the work of MOD to call the office at 554-6789 (voice), or 554-6799 (TTY).

7 CONTINUED DISCUSSION – WHETHER SAN FRANCISCO SHOULD IMPLEMENT AB 1421, A MEASURE THAT PROVIDES FOR INVOLUNTARY PSYCHIATRIC TREATMENT AND ASSISTED OUTPATIENT TREATMENT.

Presentations by Community Behavioral Health Services, Mental Health Board, Mental Health Association, San Francisco Police Department, Mental Health Service Providers, and others.

Norma Block re-introduced AB 1421 to continue discussion of this item from the previous MDC meeting. AB 1421 is also known as Laura’s Law. It deals with assisted psychiatric outpatient treatment for mental health clients.

Robert Douglas, Mental Health Board, reported that this issue had been discussed at a recent Mental Health Board Meeting. He noted that mandatory inpatient treatment for psychiatric disabilities is already part of state law. If someone is suspected of being dangerous to oneself or to others or is gravely disabled, they can be placed on a 72-hour hold. When the 72-hours expires, the doctor can put the individual on a 15-day hold to receive inpatient treatment. AB 1421, provides for involuntary outpatient treatment under certain circumstances. For instance, the Director of Mental Health can force an evaluation and file a petition with the Superior Court. If approved, the Superior Court can order the individual to outpatient treatment for six months.

It is up to the Board of Supervisors to implement this law. No funding from the State can be taken from existing voluntary programs to be put toward this program. AB1421 services must include housing, case management and mental health services. There can be no more than ten clients per mental health worker. So far, Los Angeles is the only county that has implemented this program, and there, it is only used for people in the criminal justice system. No other counties have implemented this law. Mr. Douglas believes that this may be because they wish to avoid the costly litigation that they believe would accompany its implementation.

The Mental Health Board received information and testimony on both sides of this issue, discussed it, and could not come to an agreement. Family members point out that having a psychiatric disability is a very painful experience for both the individual and the families, while consumers point out that there are civil rights issues involved. Some people, who are not opposed to involuntary treatment, are nonetheless opposed to this particular law because of the way it was written.

Edwin Batongbacal, Community Behavioral Health Services (CBHS) provided background for the Council on how mental health services are provided in San Francisco.

The mental health system in San Francisco has a wide range of services. Services include socialization programs, vocational support and training programs. Mental health services are provided in housing programs, such as supportive and cooperative housing; residential care facilities, and homeless shelters. If hospitalization is needed for persons with psychiatric disabilities, there are acute diversion units that complement acute inpatient hospital beds, psychiatric hospitals, long-term care facilities (such as skilled nursing facilities), the mobile crisis treatment team and psychiatric emergency services at San Francisco General Hospital. This system is funded from a variety of sources, including the County general fund, Medi-Cal and other monies from the State. At a cost of almost $165 million this fiscal year, the system of care has served almost 23,000 individuals.

Mental health services are currently merging with substance abuse services into a new community behavioral health service system. Sixty to seventy percent of individuals who have substance abuse disabilities or mental illness are dual-diagnosed. In San Francisco, there are over 4,200 clients in the Department of Mental Health who are being served by both mental health and substance abuse services. Integration of service delivery is important in order to improve the quality of care provided to people with recurring disorders.

Last year, CBHS began implementing an “Advance Access" program, whereby an intake assessment is completed within 24 to 48 hours of referral. In the past, it could take 7-8 weeks before an assessment was done. CBHS provides services to medically indigent adults who lack health insurance or who have no personal means to pay for the services.

In regard to barriers to physical accessibility, each provider in the CBHS system of care has to be certified. The certification process includes checking that providers meet ADA disability requirements.

People with developmental disabilities cannot be discriminated against in the provision of services. CBHS has a mental health case manager who is developing expertise in this area. CBHS also has a memorandum of understanding with the Golden Gate Regional Center.

Several other models are somewhat comparable to AB 1421. These include AB 2034 and the Behavioral Health Court. AB 2034 is an integrated service project funded to serve homeless individuals who have severe psychiatric symptoms as well as repeated hospitalizations or incarcerations. There is a great deal of consumer involvement in this program. The results are impressive, and include a 40% reduction in psychiatric hospitalization; a 75% reduction in days of incarceration; an 84% reduction in days of homelessness; and a 45% increase in annual average days employed for their population.

The Behavioral Health Court is different from AB 1421 in that it provides an opportunity and a choice for mentally ill offenders to receive services from a non-criminalized vantage point, from the judicial system. It receives approximately five referrals a week.

Eugene T. Flannery inquired if implementing AB1421 would add to the continuum of care in San Francisco. Also, he was wondering if this program's positive impact would ultimately reduce future costs.

Mr. Batongbacal responded that he believe it would add to care, but expressed concerns about the efficiency and the extra costs associated with implementation. These extra costs include the court processes, court oversight, pre-filing investigation work, etc. Also, he questioned if it would be cost-effective to implement this program rather than putting money into the existing AB 2034 programs. The bigger question is what is the most efficient way to provide treatment.

Sergeant Michael Sullivan, San Francisco Police Department spoke on the three choices officers face when they arrive at a crime scene; jail, "5150" or neither. If the individual has not engaged in any criminal activity and they don’t fit the criteria for 5150, but they need some psychological/mental assistance, the police officer faces a very difficult decision, particularly in light of the absence of adequate mental health referral services.

The police department is working on trainings in conjunction with community mental health services. Sgt. Sullivan feels that a 24-hour Mobile Crisis unit would be helpful because the current one stops operating at 9:00PM. As a result, the night officers are frustrated due to lack of resources available to them. A 24-hour Mobile Crisis drop-in service would be a resource to police officers, paramedics, firefighters, etc. at any time of the day or night. Overall, there seems to be a huge disconnect between treatment and law enforcement.

Ruth Nunez, asked how long the officer has to go through a training regarding working with the mentally ill community – is it a one-time training or once every year? Sgt. Sullivan responded he and other officers have taken a 40-hour intensive course offered quarterly by Community Mental Health. The class does a lot of role-playing. In addition, every two they are required by State law to receive continued education on mental health.

Eugene Flannery asked if Sgt. Sullivan could provide a personal or professional opinion on whether the police, in general, spend an inordinate amount of time responding to non-criminal situations that involve people with mental problems. Sgt. Sullivan responded in both his personal and professional opinion, the answer was “yes.”

Dr. Pablo Stewart, Haight Ashbury Free Clinics supports AB 1421. Dr. Stewart encouraged the Council to give up preconceived notions about what mental illness is and what involuntary treatment is. He feels strongly that “treatment” works and it is successful. Treatment keeps people out of trouble and it costs less than no treatment. Mental illness detracts from one’s ability to give informed consent. Informed consent for anyone is a complicated process: the individual must be aware of his/her condition, the variety of treatments available to him/her, the side effects of the treatment options, etc. Therefore, most people rely on medical professionals to guide and give them advice.

Untreated, mental illness leads to a variety of bad outcomes including deterioration of the person’s quality of life, suicidal tendencies, increased drug and alcohol abuse, and increased medical problems. Studies have shown that 20%of all prisoners are psychotic at the time of admission. AB1421 would significantly turn that around and provide a decrease in costs to other parts of the system. California has services available that are not available in other states. These include services that are culturally competent services. On the other hand, the mental health system is severely overburdened.

The mental health system is in the middle of a pharmacological revolution. This is the age of very good treatments. Medical treatments today are much better than they were five or ten years ago. The real problem with psychiatric medications is their underutilization, not their over-utilization.

Belinda Lyons, Mental Health Association (MHA) opposes AB 1421.

The MHA of San Francisco supports an early intervention and recovery model. It also supports voluntary community-based services provided in the least restrictive setting. All people should have equal access to full, appropriate, quality, voluntary, community-based, consumer-guided, and culturally sensitive services, regardless of the ability to pay. The full inclusion and involvement of consumers and family members is a core value of their organization.

Some of the concerns that they have about AB 1421 are:

the current lack of resources to provide voluntary services.
the fact that AB 1421 is called the "Laura’s Law" reinforces stigma and promotes stereotypes about people with mental illness as being both violent and dangerous.
there is a great deal of fear in the community about people being forced into treatment against their will.

The positive relationship between service provider and client is critical in the recovery process. If AB 1421 is implemented, it would put individuals through a series of procedures and court proceedings – it would be very expensive and not necessarily therapeutic. However, when people who are chronically homeless with serious mental illness receive voluntary flexible services, access to housing, and vocational opportunities, they can and have done better.

AB 1421 is very similar to an existing program, AB 34. The only difference is that AB34 is completely voluntary. It provides services here and in thirty other counties in California. It has been very successful and has resulted in an 84% reduction in homelessness, as well as reductions in incarcerations and hospitalization. People are concerned about how an implementation of AB1421 would affect the relationship between the service provider and client, which must be based on trust. Would this affect the success AB 34 been having? Ms. Lyons supports a greater reliance upon voluntary integrated service programs like AB 34, which have already proven themselves to be successful.

MHA is putting their efforts toward promoting funding community-based mental health programs that work. The association supports the Mental Health Services Act and is hoping that it could get onto the November 2004 ballot. This initiative would provide an array of voluntary preventive mental health services based on the AB 34 model. The Act would be funded by a tax on annual incomes over one million, taking 1 cent of every dollar earned OVER 1 million. Additional information about the Mental Health Initiative is posted on the website: www.mentalhealthcampaign.org.

Eugene Flannery agreed the therapeutic relationship between the caregiver and client is an integral part of treatment. He has concerns that if this relationship becomes involuntary, that this would affect the success of the treatment.

Mr. Flannery noted that individuals in court-ordered substance abuse treatment programs are also participants in involuntary programs that would be comparable to the programs mandated by AB1421, such as Walden House (WH). WH has services where people from the criminal justice systems are mixed in with other populations in the mental health system, and that it seems to work successfully there.

Dr. Abner Boles, Executive Director, Westside Community Mental Health (WCMH) Dr. Boles explained that WCMH provides mental health services for severely emotionally troubled adults, children and families. They also provide substance abuse services, including methadone detox and maintenance. Dr. Boles strongly opposes the implementation of AB 1421 because it is redundant to the current service delivery system. AB 1421 would create additional costs where there are not adequate services currently. He believes this initiative would primarily affect those individuals who find it difficult to access services for two reasons – the first one is that these services don’t necessarily fit their needs, and the second is that services aren’t necessarily accessible or appropriate to their needs.

Dr. Boles reported that San Francisco has a very poor success rate in providing ongoing care for African American men who are released from locked facilities, including long-term treatment facilities outside of the county. The implementation of AB1421 would target those individuals and actually criminalize their behavior. The county needs to have more access to residential care and supported housing for individuals who are severely troubled and unable to access these services rather than force them into care.

WCMH has a methadone detox program that is a six-month program. Currently the program has a 50% client base from court-referred cases. Some of the clients don’t complete the program because they are mandated by the court and this doesn't ensure that they will stay with the program. Therefore, the mental health system needs to present a different package with more aggressive outreach. It is difficult to initiate another court process or legal process because it will lead to a greater deterrent to people seeking voluntary care.

Dr. Boles noted that literature supporting AB 1421 failed to reference recent studies indicating that successful voluntary programs exist for those individuals who historically have not utilized traditional mental heath care services.

Johnathan Vernick, Baker Places (BP), presented some information about Baker Places, which opposes AB 1421. Baker Places is a non-profit organization with 11 residential treatment programs for people with mental health problems, as well as people with substance abuse issues. They provide two medically-managed detox programs. Through a collaborative effort with the hotel operators, BP also provides case management services to many people who are living in residential hotels.

Mr. Vernick believes that providing good services to people involves “rehabilitation.” In other words, creating opportunities for people to take control over their own lives and be able to learn to function independently. Institutions such as skilled nursing facilities don’t create that opportunity because they are trying to control behaviors that might be a threat to other people, or might be a danger to the clients themselves.

Baker Places works with people who are dually diagnosed and picked up off the street. Many of them refused treatment before; they would be called “treatment-resistant.” But with the environment at Baker Places, in which they participate in their own treatment, they are successful. AB 1421 puts the ability to work in a rehabilitative way with clients at risk.

Mr. Vernick testified that San Francisco does not have enough services for the mentally ill, and the current budget crisis implementing AB 1421 would be unrealistic. It is a very expensive program, not only because of the services required, but also because of the associated court costs.

Steve Fields, Progress Foundation (PF) opposes the implementation of AB 1421. PF has been providing services to the severely mentally ill since 1969. Mr. Fields said that there is a pattern in mental health that the clients are blamed and we try to control their behavior – which has never worked.

Mr. Fields reported that there is no study that supports the idea of involuntary coercive treatment for people with severe mental illness. In the frequently cited Rand Study, they found that of the 8 states with provisions for involuntary outpatient treatment, at best they showed no difference in outcomes, and at worst they showed a diminution in participation. It did show that wherever a state added services coincident with involuntary outpatient work, they got better results on the part of the people who came voluntarily to the expanded services.

Mr. Fields asked the Council why the City should consider rolling back fundamental civil rights provisions for people with mental illness when there is no evidence-based practice to show that it works.

Mr. Fields said that the literature does show, repeatedly, that if you provide what the consumer needs, and mold the service in response to those needs, you get engagement where before, you seemed to be getting resistance.

The problem in San Francisco, according to Mr. Fields, is that we have continued to lose beds for people with severe psychiatric illnesses. There have not been the resources to keep pace with the growth and needs of the population. In fact, San Francisco has lost beds since 1982.

AB 1421 requires that, before you make someone participate in a program involuntarily, they have to have been offered voluntary participation in a voluntary program that meets their needs. If San Francisco can’t offer a voluntary choice for every person we want to go through this elongated judicial process, then AB 1421 cannot be implemented.

PUBLIC COMMENT

Jerry Grace, an Oakland resident, spoke of his concerns about the alleged abuse in heath care – hospitals and group homes. Also, that more money is needed for health care.

Dale Milfay, National Alliance from Mentally Ill, said that her son would benefit from AB 1421. Her son has run away from existing programs, but he does follow the law and would take his medications if he were ordered to. She feels that forced treatment can greatly reduce overall system costs.

Maureen Cattanach, Family & Friends of the Mental Health Rehabilitation Center, noted that a lot of mentally disabled people won’t take their medication because of side effects and are in denial. She has seen people going in and out of emergency rooms, get stabilized and return back to the hospital. Also, a lot of these people end up in the streets and in jail. Therefore, many changes are needed in the mental health system.

Tom Purvis, a member of NAMI and AASCEND, spoke about a family member who he cares for, who refuses to leave her home and is on a downhill spiral. He feels something needs to be done in the mental health system.

Raymond Vega, knows an individual with mental illness and an alcohol abuse problem. He is not in the criminal system because he has not committed any crime. However, if he were a criminal, there would be more programs available to him. During the holidays, additional services are needed for people with mental illness.

Delphine Brody, HART Committee Member, opposes the implementation of AB 1421 because she believes it violates the Olmstead Act. This act mandates that people live in the least restrictive community-based settings for as long as they are able to do so.

Alan Shipley, a client advocate, opposes AB 1421. There were two similar measures, AB 1800 and AB 1828, on the State level which were proposed awhile back, but the mental health community was able to get the legislators put that aside. He believes that AB 1421 would take away the “faith” clients have in the mental health system.

Scott Clark, a member of AB 2034 Consumer Advisory Board, feels that more people should be involved with groups such as support groups for the mentally ill as a part of their treatment process. He is currently a co-facilitator of a new support group for schizophrenia and schizo-effective disorders.

Linda Chapman, SPUR and Homeless Task Force, said that we need to use our resources more wisely. She pointed out that a report from the state of California indicates successful results from AB 2034. This measure assisted severely mentally ill individuals who are homeless and provided them supportive housing, intense treatment, etc. This resulted in a 78% decrease in hospitalization. Also, the number of days of incarceration dropped 85% and the number of days of being homeless 69%. The Continuum of Care Report lists approximately 7,000 units of supportive housing currently in place. Individuals need to take advantage of the existing resources, such as those noted above.