EXPERIENCE & EDUCATION
Why I do this...
I’m often asked what it was about the severely mentally ill that won my heart. The best, most respectful response I can offer is to ask people to think of themselves and those they love. Imagine that through no fault of your own you were stricken with an illness that was at best devastating and at worst terminal, that took everything from you including your voice, and society’s response was to judge, fear, punish, and/or pretend not to see you, to abruptly redefine you as a different species because it would be uncomfortable to be that cruel to an actual human, to leave you to die on the street rather than to pledge themselves to your safety, health, and dignity. Imagine that if you did finally receive the level of care you required, you found that the best life you could hope for looked nothing like the one you’d lost and was fraught with tedium, loneliness, infantilization, exploitation, deprivation, stigma, and medication side effects. Again, let’s say that’s you. Do you believe that any decent person who looked you in the eye and came to know you would wish for you to have everything they wished for themselves? That any decent person would be angered and pained because you had been treated unjustly? That any decent person would pledge to do whatever they could to make things right when you couldn’t do it for yourself? It’s a no-brainer, right?
During my first ten years in the field, I thought there must be too few decent people in the world. It took that long to learn that everyone I blamed for my clients’ suffering was doing the best they could with the information and resources they had. I started out angry at inpatient psychiatrists because it looked like the buck stopped with them, but most were doing their absolute best with imperfect medication, scarce hospital beds, pressure to discharge sooner than later, and inadequate resources to help their patients remain stable in the community post-discharge. Now I regard many of those doctors with immense respect. For a while I blamed the insurance gatekeepers who would not authorize sufficient inpatient treatment… until I realized that they were doing their absolute best too. They are dedicated and compassionate, but are given only a few dollars to spread across a vast region teeming with need, and so day in and day out they must make minutely-informed, heart-wrenching decisions about who will get what. I also blamed local elected officials who appeared to use century-old census data when funding services for their most vulnerable constituents. But, after all, we get the leaders we elect.
There is no time for blame: only for learning and for work. There are many devoted professionals who know exactly what must be done for the severely mentally ill but cannot, on their own, make it happen. There are countless others who can and would make it happen but simply don’t know how. My mission is to directly alleviate as much suffering as I can, to make it easier for other professionals working in their local mental health systems to do the same, and to show like-hearted members of society how urgently their help is needed and the many ways in which they can reach out.
Many years ago, like a lot of future therapists, I sought therapy for my own psychological distress, improved enough to think, “I want to do this for other people,” and went back to school at night to learn how.
I stay in this field to fight injustice, to restore dignity and health, to let my clients know they are not alone, and to raise awareness until someday we as a people can say we are doing right by the least fortunate among us.
When individuals with severe mental illness cannot maintain stability in the community and meet criteria for involuntary hospitalization and treatment, they must be treated on locked LPS-designated acute-care hospital units for periods ranging from a few days to several weeks. Joseph worked as a psychiatric social worker on two such units in San Diego, at Alvarado Parkway Institute and Promise Hospital. Some individuals on these acute-care units cannot achieve stability there, even after several admissions, and are transferred to locked Mental Health Rehabilitation Centers / IMDs for long-term involuntary treatment lasting several months, in some cases longer than a year. Joseph also worked at an IMD, as a rehabilitation therapist and treatment coordinator at Telecare Cresta Loma. When individuals are discharged from MHRC/IMDs and face the challenge of reintegrating into the community, they are assigned mandatory intensive case managers who strive to ensure they are always appropriately provided with shelter, food, clothing, treatment, counseling, opportunities for enrichment, and moral support. Joseph worked as an intensive case manager at Telecare Access, where his caseload comprised the top fifty utilizers of MediCal mental health services in San Diego County.
In order for an individual to receive long-term involuntary treatment at an MHRC and be compelled to accept intensive case management, the treatment team on an LPS-designated acute-care unit must successfully refer them for LPS conservatorship authorizing the restriction of their rights. For seven and a half years, Joseph worked as an LPS Investigator in the Office of the Public Conservator for San Diego County, evaluating LPS referrals from local psychiatric units, researching and filing conservatorships in court on behalf of the gravely disabled, and working to ensure that LPS conservatees’ needs were met, their rights honored, and their psychiatric and medical treatment held to the highest ethical standard.
Acute hospitalization, long-term hospitalization, and intensive case management. They are vital, interrelated, and interdependent services, and LPS conservatorship authorizes their involuntary delivery. Joseph is the only mental health professional in San Diego County with direct work experience in all four settings. He has also worked in outpatient psychiatric day treatment at API and, for one year, with mentally ill young people and their families at Crossroads Family Center.
Why is this experience important?
To obtain the treatment and care you need for your underserved, severely mentally ill loved one, you might well begin with an understanding of the California Welfare and Institutions Code, Division 5 (Community Mental Health Services), Part 1 (The Lanterman-Petris-Short Act), Chapters 1-3. After all, the LPS Act creates the very possibility for involuntary treatment in California, defines every aspect of it, and dictates the actions of all professionals involved.
On the other hand, if you stood up at the annual conference of the CAPAPGPC and asked LPS conservatorship investigators and program managers from around the state about the realities of involuntary treatment across California’s 58 counties, it would be difficult to believe they were all subject to the same law. Counties with no locked psychiatric facilities transport their severely-decompensated clients to larger counties for inpatient treatment but remotely maintain responsibility for their well-being. Statewide, LPS-designated locked acute units utilize the 14-day involuntary hold, however many never seek court orders authorizing 180-day holds for imminently-dangerous clients, or second 14-day holds for suicidal clients. Article 4.7 was added to the LPS Act in 1988, allowing counties to utilize a 30-day hold rather than misuse temporary LPS conservatorships, but San Diego County only chose to use this hold in 2014. Also in San Diego County, in the absence of a humane alternative, the Public Conservator routinely files LPS conservatorships for clients who are incapacitated by dementia but do not resist placement or treatment, while most other counties use only the less-restrictive probate conservatorship.
You could say it’s a good thing. Seemingly-passive legislation rendered in broad terms allows counties to proceed according to their needs and resources, and within counties treatment teams can respond, to some extent, to challenging diversities of client presentation. Especially reassuring is the extent to which the LPS Act has succeeded in realizing its legislative intent to end inappropriate and indefinite involuntary holds after the innumerable horrors perpetrated against the mentally ill in the pre-LPS era.
Unfortunately, the LPS Act has been less successful at achieving another of its objectives, namely that those with mental disorders be provided prompt evaluation and treatment. Its slow, spacious language offers local governments the flexibility to assign a low cash value to human life and provide inadequate, inexpensive service, and so countless people who desperately need involuntary treatment do not receive it or must wait too long for it at every level. Those who dispute this are also fond of the argument that a psychotic homeless individual who subsists on actual garbage can’t be gravely disabled if they’re not losing weight, or that there is no basis to hospitalize an individual whose chronic psychotic behavior has earned them an eviction notice if all thirty days have not yet passed, since technically they’re not homeless yet.
It’s important to know the WIC. But to know the law is valueless without understanding its implementation: not just what it says, but what it does and doesn’t do. How does it shape daily practice, and how does daily practice proceed in spite of it? How many individuals require the treatment and services it describes, and how many actually get it? How do professionals at every level, from the streets to the courts, interpret behaviors and symptoms so that individuals will or will not be found to meet criteria for involuntary treatment? To be blunt: what are dedicated, talented mental health professionals compelled to do and say so that the number of individuals characterized as meeting criteria for involuntary treatment does not exceed the system’s capacity to fund that treatment? And how can the carefully-formulated words and actions of loved ones and advocates tip the scales in favor of appropriate treatment, delivered sooner than later? Thanks to his uniquely comprehensive scope of experience in the realm of involuntary psychiatric treatment, Joseph has the answers to these questions.
California Board of Behavioral Sciences MFC49494, Marriage and Family Therapist
MA / MFT, United States International University (merged with California School of Professional Psychology to become Alliant International University)
BA / Literature and Writing, University of California at San Diego