*TRIGGER WARNING for suicidal thoughts
UPDATE! At the 1/11/22 the Sac County BOS meeting the Board adopted a resolution which approved the Department of Health Services (DHS) Assisted Outpatient Treatment (AOT) Implementation Plan, authorized the DHS to operationalize the AOT program, and allocated funding for staffing and equipment.
AOT, also known as “Laura’s Law,” was passed by the California Legislature in 2002 as Assembly Bill 1421. This law allows for court-ordered outpatient treatment for individuals with a mental illness, ages 18 and older, who meet limited legal criteria, such as when treatment would prevent a deterioration in their condition that would likely result in grave disability or harm to self and others.
In September of 2020, California passed Assembly Bill 1976, which requires counties to either implement an AOT program, or pass a resolution opting out of the program. Historically Sac County has not opted in to AOT programming.
The Sac BOS voted to implement an AOT program in May of 2021; at that time the BOS directed the Department of Health Services to gather community input on program implementation.
The following concerns were identified by the public:
1) the involuntary nature of AOT services
2) equity
3) criminalization/stigmatization of individuals with mental illness
4) training
Additionally, Sacramento County Mental Health Board (MHB) members participated in the community listening sessions, sought advice from other counties with AOT programs, and reviewed literature on AOT programs. In October of 2021, the MHB sent a letter within their recommendations, incorporating community feedback, to the BOS on program implementation. You can read the letter by clicking here.
Back in 2020, Supervisor Serna had requested a report back on AOT, which took place at the 1/11/22 meeting. Included in the agenda packet is the MHB's letter of recommendations regarding the county’s implementation of AOT and, from the slide deck (click here for slide deck) on the item, it looks like the County is talking about following the MHB recs.
However, as we know, the county frequently says one thing & does something entirely different, so we’ll see how it actually gets rolled out
One issue worth mentioning from what we reviewed in the presentation docs is that Sac County seems to be assuming that the mental health board will provide oversight of AOT to ensure accountability. No one has approached the MHB about that task. In fact, Los Angeles county has a whole separate oversight committee for their program - which Sac should also have.
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Hey y'all, for those who don't know me, my name is Andi, and I'm the Program Manager for SJPC. I had truly awful experience in our mental "health" system in October of this year, and I'm writing about it here as a therapeutic tool, as well as a means of letting folx know what happens when someone is put on a psychiatric hold. Obviously everyone's experience will be unique, but I have been inpatient in psych units voluntarily and involuntarily several times, but this was by far the worst experience I've had.
5150 is the number of the section of the Welfare and Institutions Code, which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled.
Intake/being placed on a hold
On Wednesday the 13th of October, 2021, I went to a private hospital in Sac that contracts with Kaiser to begin a mental health outpatient treatment program. I was beginning the process because I had been struggling with suicidal ideation. I was referred to this program by my psychiatrist at Kaiser, to whom I had disclosed having suicidal thoughts. She thought an outpatient program would be a good fit for me. I want to just start with a basic fact, that is common (in my experience) at most mental health hospitals - everything takes forever.
I was told to arrive at the facility at 7:45a, but there were no staff even present to assist me until a full hour later. Around 9:15a I was brought back for my intake, and then left in the lobby for another hour and half, just to be told that I couldn’t be admitted into the program. During the intake process I had answered all the standard questions about my mental health and functioning. I disclosed that I had been thinking about suicide, but specifically told the intake worker that I DID NOT have a plan to commit suicide, just ideation. However, I would find out later (when I was given a copy of the intake document) that, despite clarifying with me that I had NO plan, she wrote down that I DID in fact have a plan made. She also misgendered me on this form, despite my telling her my pronouns several times.
Another thing from the intake process - I was asked questions about my life functioning, one of these being whether or not I was able to feed myself. I answered that I wasn’t, because I was thinking in terms of preparing meals. My partner currently does all the cooking, but I am perfectly capable of eating pre-made stuff. However the intake processor did not ask any follow-up questions about my answer, and I would find out later that my answer to this question was one of the reasons given when pressed by my partner on why they would not release me. Maybe this was in reference to the concept of being "gravely disabled", which is considered a reason for placing someone on a hold, and is defined as follows:
Existing law, for the purposes of involuntary commitment and conservatorship, defines 'gravely disabled,' among other things, as a condition in which a person, as a result of a mental health disorder, is unable to provide for the basic personal needs of food, clothing, or shelter.
It is my opinion that this misinterpretation, along with the false assertion that I had a plan for suicide is what led them to decide that I was to be placed on a 5150 - a 3 day involuntary psychiatric hold. Myself and my partner, expressed that we did not think this hold was necessary, but it didn’t matter, the “team” had already decided.
Health insurance struggles
During my first full day at the hospital, I was visited by someone from the financial department, who informed me that my insurance (Kaiser) was going to charge me $250/day to stay at the hospital. I told this person I could not afford that. She told me that she couldn’t help me. I then went to try and talk to a staff person about why I needed to go home because I couldn’t afford to be there. At the time we were living on ONLY my income, and were worried about making rent the next month. There was no way we would be able to pay that bill.
I spoke with two or three staff who told me they couldn’t help me and that being here was for my own good, until I was directed to talk to the social worker I had been assigned. As of this point I hadn’t talked to this person at all, so I went looking for him. When I found him he told me he didn’t have time to talk. Later in the day I was actually able to talk to him, and told him the same thing I had told other staff, that I couldn’t afford to be there and that I didn’t need to be there.
For several minutes he pushed back saying that being here would help me, etc. I asked him how having an unpaid bill that would mess up my credit score and make it harder for me to find housing in the future would help me. He at least acknowledged that it wouldn’t help, but would not hear anything about me going home. He also eventually admitted (or at least it seemed like an admission) that they would not let me leave because the hospital didn’t want to be held liable if I did something to hurt myself. At that point I gave up on going home, and asked if there was at least a way to help with the financial burden of my stay. He told me he was going to call someone at Kaiser, disappeared into the office, and later left for the day without saying anything to me. I did not see him again until discharge.
Later that day I at least found a staff member who would empathize with the fact that I was being charged to be held involuntarily when I was already missing hours at work. However, minutes after she left I was visited by the Charge Nurse. I had thought the nurse was coming to talk to me because she had been informed by the other staff that I was upset, and wanted to help calm me down. So I told her what I was upset about. However, this person was not at all interested in understanding where I was coming from, in fact she actively argued with me when I said that the policy is unethical. She dismissed my concerns by saying that “if I went to the hospital after having a heart attack I would pay THAT copay." First of all, odds are that if I had a heart attack I would actually want to go to the hospital, rather than being forced there against my will. Furthermore, if I couldn’t afford the copay, I STILL wouldn’t be able to pay it. Regardless of what it was being charged for.
She also said that I needed to process how I was feeling with the staff. What staff? She clearly wasn’t a safe person. There were no therapy services offered, and as I will get into later, there were two groups a day, and that’s it. It turns out, the only person there even licensed as a therapist was the previously mentioned caseworker. So talking to that person certainly wouldn’t help. None of the staff I had interacted with were people that I would feel safe divulging personal information to. They had taken my phone. The only person available for me to “process” with was my partner, who I could call from the phone in the hallway - something I would have still been able to do if I had stayed home, seeing as I live with my partner. Last thing about this interaction - I told her that the intake worker had recorded my response wrong for having a suicide plan (I had seen the paperwork at this point).
Her response to this was that I COULD make a plan quickly if I wanted to.
Literally anyone COULD quickly make a suicide plan. Should they all be held against their will?
Misgendering/deadnaming
I’m transgender, I identify as male and use he/him pronouns. Previous to this stay, when I have been in an inpatient facility the staff have given me my own room, due to safety concerns. I told the intake worker this, and she said I would have to have a roommate. I insisted that I needed to have my own room, and she said she would try to figure it out, and asked what my gender preference for a roommate would be, if I had to have one. When I finally started the admission process upstairs, I told them the same thing, that I would like to have my own room as I felt unsafe sharing a room as a trans person. They told me the intake worker had told them that I said I WANTED a roommate.
I told them that this wasn’t the case, and asked again to have my own room. I don’t cry very often, but as I was sitting with the staff that was admitting me I couldn’t stop crying, because I was so stressed about having to be there, and having to be in a room for several days with a total stranger, not knowing how that stranger would react to trans folx. The admitting staff, seeing my crying, said “are you really THAT scared?”
*my roommate ended up being a cool person, but she never gendered me correctly, despite my attempts to let her know not to refer to me as a woman, this added a layer of stress to being in my room because I knew my identity wouldn’t be fully respected within its confines
Once I got into the facility I was misgendered constantly and consistently by staff. The name written by my door was my dead-name. I believe I had to tell most staff that I interacted with not to use my dead-name, despite the fact that my chosen name was on ALL of my paperwork and my insurance records. Some of them I had to tell over and over again. This included my psychiatrist, who used my deadname the first three times he saw me, despite me correcting him each time.
I was essentially never referred to by the correct pronouns. I had a hard enough time getting them to use my chosen name, there was no way they were also going to gender me correctly. That means that aside from being misgendered by all the clients (and not feeling safe correcting them), the (supposedly) professional staff were also unable to meet this basic need of mine.
This may not seem like a big deal, but it is really demoralizing to continually be denied the validity of your existence. To know that people are unable/unwilling to put that amount of effort into their interactions with you. It also makes you feel like a burden for asking them to respect you. I told one staff member that it was really upsetting to me that people were not using the correct name or pronouns, to which she replied “I think they just forget”.
Well yeah, that’s the point!
Lack of services/activities & groups
As I mentioned before there were no therapists or therapy services available to patients. As far as I understood it, social workers met with clients briefly and infrequently. Every other day (roughly) there was an art activity or clients were taken to the gym. The only thing that happened every day were groups, two 40 minute groups per day. Could these groups be helpful? Sure. Is attending a total of 80 minutes of a group per day, when you’re awake an average of 16 hours a day, going to solve your problems? No.
These were not intensive group therapy sessions. It varied depending on who was leading the group, but often all we did was go around the circle and take turns reading through handouts. At the start of every group, the facilitator would ask you to rate your mood, write it down, and not inquire further about how you were feeling, even if you had indicated being in a very bad place. I assume they do this to “track the mood of patients” for the psychiatrists, who are the ones in charge of when the patient is released.
To me it always felt triggering if I was in a bad place, because I would have to announce my mood and then not do any other processing. At best these groups may offer a new insight or two, at worst they are actively detrimental to the healing process because they cause stress and anxiety, and can contain unhelpful language. Mostly they’re just a waste of time.
One particularly upsetting example of the way group leaders talk to clients comes from a staff member who runs a majority of the groups in the hall I was in. She compared maintaining your mental health to building your credit score. Of all the condescending, unhelpful, capitalistic bullshit. This person would also loudly say “NO no no no” if a patient was doing something she didn’t like. Excellent way to talk to people under psychiatric stress.
One other note on the groups - they often feel coerced. Psychiatrists can use the fact that you’re not going to groups as a reason to legally continue to hold you. It doesn’t seem to matter if you don’t find them helpful, or if they stress you out, I think many people (like me) force themselves to attend so that it looks good on their progress report.
The point is, most of what you do in there is sit around. This is something all patients are aware of, and they are always trying to find something to do and engage with. Turns out there isn't much to engage with, and there are very few services offered, considering this is supposedly a place to heal and care for your mental health.
Staff incompetence
Aside from all the incompetence I have already gone over, the staff just generally did not seem to care, and did not engage with the patients in healthy ways. I repeatedly saw staff escalate situations by engaging in arguments with clients, or by responding to a statement/action/request with hostility. It was very obvious that there was no clear communication between staff members because they were quite often not on the same page. There were staff that would just sit down and text, even while they were ostensibly actively supervising clients. There were conflicts that took place with no staff on the floor to help because they were all in the nurse's office behind a locked door. Several times staff fought with each other out on the floor, for all the clients to hear. Perhaps the most upsetting thing was just that the staff did NOT engage with patients when they needed help, or when a patient needed to be calmed down in order to protect the safety of others. There was often no attempt to problem solve and/or de-escalate.
Medication/lithium levels check
Presumably, since this program was clearly not designed to be “therapeutic”, they would have done something to my medication routine, right? Wrong. The first time I saw my psychiatrist, we talked for a total of 5 minutes and he said he wasn’t going to make any changes. I found this odd because, why were they holding me here if they weren’t going to do anything for me? I would also realize later that it was odd that he hadn’t ordered any labs for me.
I take lithium, and one thing to check for in terms of my psychiatric treatment is how my lithium levels are doing. He could have, and should have, ordered a lithium lab for me. But he didn’t. Later my partner would call and demand to be told why the hospital was keeping me if they weren’t treating me, and he referenced the fact that my doctor had not ordered a lithium level check. The next day my psychiatrist told me he ordered a lithium lab for me. Interesting timing.
However this was Friday, and I couldn’t do the lab until Monday because the services weren’t available over the weekend. He told me I could leave on Tuesday. If this hold had really been 3 days I would have gone home 3 days earlier, on Saturday.
It is important to note that he said I could leave Tuesday BECAUSE I had to wait for the lab results from the testing on Monday. The following day (Saturday) my psychiatrist told me I could actually leave Monday. I asked him if I needed to wait for the results of the lab work. He said no, and that he could just send the results to me. If that was the case, why did I have to stay and do labs just to have them send me the results later? Why couldn’t I go do labs on my own? I should have been able to go home at the end of the 72 hours. Instead, I was put on a 5250 (a two week hold) so that they could hold me three more days.
This was clearly a very upsetting experience for, which did nothing to help alleviate the symptoms I was experiencing. This stay in the hospital was very triggering, and had I actively been suicidal when I went in, I can imagine how much worse I would have felt when I got out. ALSO this is all coming from a perspective of privilege - I'm white, I'm salaried and employed by a boss who is very understanding of mental health needs/crises, and I have a support network of friends and family.
What if I didn't have those things? What if I worked a job that didn't understand? Or worked an hourly job where each day I spent in the hospital meant a loss in income? People in these facilities are marginalized, held against their will, and often without effective advocates. The week following my discharge I ran into one of the clients I had been in-unit with. He had been evicted while he was in the hospital, and was outside a coffee shop asking for donations.
It is my opinion that these systems exist as a extension of the carceral state, and serve as a means of oppressing a subsection of the population that needs interventions motivated by love and not by profit.