PPAC's Advocate-in Chief Makes News
Capitol Weekly Interview:
Randall Hagar and mental health care
by Sigrid Bathen,
Randall Hagar has been in the forefront of major mental health policy and legislation in California for decades. As the father of a severely mentally ill adult son and longtime legislative advocate for California psychiatrists, he has deep knowledge of both family struggles and the complex intricacies of mental health policy. He represented the California Psychiatric Association for nearly 20 years, and since 2020 represents a successor organization, the Psychiatric Physicians Alliance of California. He also actively advises community groups, families and legislators and has written much of California’s major mental health legislation.
When did you become interested in mental health advocacy?
I think I caught the buzz from my mother, Phyllis Hagar, who was a first-generation legislative advocate for the Sacramento chapter of the California Mental Health Association. She was a volunteer, a member of the board of directors, and served on the state legislative council. She was active in the Democratic Party. She testified in the Legislature on mental health issues and prison overcrowding, wrote letters to editors, won awards for her advocacy.
She also suffered from depression and anxiety and was drawn to improving conditions. She became severely depressed, suffered from at least one anxiety disorder, and was twice hospitalized in psychiatric hospitals for several weeks at a time. She and my father, Kenneth, met at Northern Arizona University, and their first teaching jobs were in a one-room school in Rocklin (Placer County). He was a junior high school vice-principal in the San Juan Unified School District in Sacramento County. She taught second grade in Citrus Heights for 15 years, then quit teaching and devoted her life to serving the mental health association.
When my son was diagnosed, like many family members facing that news, I didn’t know what to do. He was living with me, and I struggled to figure out how to cope with him. I was desperate, and I enrolled in a family education course through the Sacramento chapter of the California Alliance on Mental Illness (the National Alliance on Mental Illness, or NAMI, is an influential organization representing families, with state and local chapters throughout the U.S.), which I learned about when my son had been hospitalized at Sutter. I became a volunteer for the Sacramento chapter, and I was trained to teach those courses, then became a trainer for other teachers, eventually a national trainer for the first family educators at affiliates in Nevada and Hawaii. The family-to-family courses taught survival skills for family members, understanding how the brain works, communication, coping and advocacy skills. I eventually became the program director for family education in California.
Because of my interest in politics, and my earlier work with the Associated Students at UCD, I started working with psychiatrists on legislative issues. I told them they needed to become members of NAMI, to learn what it’s like on the other side of the fence where the family is. My first issue as a California advocate was to advocate for fair housing, learning the intricacies of the 1968 fair housing amendments to the U.S. Civil Rights Act of 1964.
I became a NAMI-California board member in 1998, and was president of the Sacramento chapter. I couldn’t be both an employee and on the board, so I chose to be actively involved with legislation and chaired the state board’s legislative committee, working with [then-Assemblywoman] Helen Thomson (D-Davis) on Laura’s Law. (Editor’s Note: Laura’s Law, one of the few legal avenues for family members to get help for mentally ill relatives)
How did your experiences with your son inform your work as a legislative advocate?
During my testimony in legislative hearings on Laura’s Law in 2001-02, I said that my son (Chris) had been arrested in three counties, was homeless for 18 months, hospitalized seven or eight times in five different counties. I was educated, well-connected, and there was nothing I could do. He was totally on his own journey, and I was helpless to keep him in the hospital. I testified that one feature of his life that made a huge impression on me is that until age 18, he was under the jurisdiction of the juvenile court, and a probation officer would regularly come out, interview us both, ask how he was doing, if he was keeping appointments, taking his meds. That was a kind of structure that kept him from getting into worse trouble. I learned that a legal structure could be very helpful in keeping a person stable and avoiding worse outcomes. But when he turned 18, and was no longer under the jurisdiction of the juvenile court, he stopped taking his meds, and entered the cycle of homelessness, hospitalizations, arrests.
What role did the news media play in passage of the bill?
“… Editorial boards of newspapers throughout California supported Laura’s Law, and the LA Times won a Pulitzer for editorial writing, for a series of editorials urging mental health reform. I remember one of the headlines in that series, based on my interviews and testimony, was “Make Chris Take His Meds.”
You have represented psychiatrists for more than two decades. What are the major themes of that advocacy?
My agenda has been consistent from my time with NAMI. There are signature themes. The first mental health insurance parity bill (requiring that physical and mental illness be treated equally by insurers and providers) was my bill, Laura’s Law was my bill. I helped write and get them on the governor’s desk. CPA (the California Psychiatric Association) was one of the first groups questioning why we are putting so many mentally ill people in jail. We supported bills for mental health offender programs, for better outreach to severely mentally ill people who were homeless, bills against suspending or curtailing Medi-Cal benefits for people in jails. We advocated for rational release times, not 2 a.m. with no shoes. We worked with the California Sheriff’s association to get the state to underwrite psychotropic medication costs in jail, where newer, more effective antidepressants and antipsychotics weren’t fully available.
Jails and prisons are often called “the new asylums.” How have you addressed the criminalizing of mental illness?
By the late 1990s, the mentally ill offender crime reduction statute was passed, which appropriated $55 million annually for treatment programs to prevent re-offending. In 2000-2002, Darrell Steinberg (now Sacramento mayor, former state Senate president) authored a series of three bills which provided assertive outreach and community treatment for homeless individuals with mental illness. Then Helen Thomson offered a package of four mental health bills, one of which was Laura’s Law (Assisted Outpatient Treatment or AOT) in 2002. All relate back to release of people from state hospitals and lack of resources for them in the community. Collectively, these measures signaled a renaissance in public policy to provide adequate support for people with severe mental illness. Steinberg and Thomson were the leaders for a long time, since they first were elected.
As a result of recent legislation to strengthen it – and data showing significant success, cost savings — Laura’s Law has been widely adopted by the counties. And Gov. Newsom’s current CARE Court plan to expand civil court referrals has received widespread support among legislators. Does this mean major change?
It’s a work in progress, still, but I feel hopeful that CARE Court really puts the onus on counties to step up programs for the most severely mentally ill, people in the streets and in jail. It has the potential to be very effective. It will take good implementation. Counties are going to have to have their noses to the grindstone and be very diligent, or there will be sanctions. The state’s ability to fine counties for non-performance — or even put programs in receivership — is another key feature. SB 1338 (the governor’s CARE Court bill, by Sen. Susan Eggman, D-Stockton, and Sen. Tom Umberg, D-Santa Ana) was passed overwhelmingly by the Legislature, and is expected to be signed by the governor.
$65 million was also recently added in the 2022-23 state budget to help the courts create CARE Court programs, with legal representation for participants, but the actual legal mechanism has been fuzzy from the start. Have those issues been clarified?
The current version engages [local] Legal Aid Societies through the state Bar, which funds them, to provide representation. But there are no clear criteria. It is clear that the governor would prefer that Legal Aid provide representation, or (as a last resort), a public defender.
Very recent amendments to CARE Court legislation require the counties of Glenn, Orange, Riverside, San Diego, Stanislaus, and Tuolumne and the City and County of San Francisco to implement the program beginning Oct. 1, 2023, and the remaining counties to start programs no later than Dec. 1, 2024. $57 million was also added in the state budget for local implementation.
The bill requires that each participant be assigned a support person, who can be a family member. How will that be implemented?
There are no restrictions for who can be a support person, and the state will provide training in court processes, county services, and the law, but a support person is not required to get training. It’s unclear whether they would be paid, the bill is silent on that, though I believe that is the intent. $65 million in the state budget is linked to the bill for court services.
I think it (the CARE Court bill) has been much improved over the initial version, which lacked specifics. It’s been a difficult needle for the administration to thread. The court procedures have been amended, made much more specific, and there is now explicit authorization for a medication order by a judge, but it’s not really enforceable. If a person is noncompliant, there is no immediate remedy – so, for instance, they can’t be held in contempt of court.
Overall, has there been progress after all these years?
For the first time, we’re making more progress than in past years … This is the first year in which we’re actually going to get data from the counties on MHSA. We’re actually going to get accountability, data, get more time for people in inpatient units. That’s going to be very helpful. Strategic planning based on the information that we get is going to be really important.
In terms of the atmosphere in the Legislature, the fact is that there are so many bills. Sixty-nine bills are on my watch list that have to do with mental health: mental health of firefighters, effects of COVID on mental health, sharing data with the state Department of Justice. There is so much interest, so many bills. If half of them get signed, this will be a renaissance. Not all are big global shifts, like CARE Court, but they’re all important.
A community-based Regional Center system for developmentally disabled residents leaving the state hospitals was created decades ago. Is that regional model getting more attention today in mental health care?
Requiring local agencies to do planning on a regional basis would be a departure, and more regional planning – a regional government model — for people with mental illness, would be helpful. One of our bills would harness the association of local governments into the planning process so you get regional planning. These are local elected officials getting together to talk about shared problems. People with mental illness don’t always stay in one place, they are wandering from county to county, yet services vary from county to county and are not coordinated….
Can families expect more support in the current atmosphere?
If I’ve learned anything, it’s how much the families are the unspoken, unacknowledged, exploited partners in the care system, often hoping their family member commits a crime so they will be arrested and get treatment in jail. Families have long been default social workers. The experience of trying to get care in the community can be overwhelming. When things don’t work, the families are there, they have to step in when no one else will. They struggle, and they don’t have resources or support or training. My son has been in an inpatient psychiatric unit on a conservatorship for 18 months, and is now in a locked facility that provides rehabilitation services. His condition is improving, and I’m not having the same issues.
When my wife and I lived in midtown … sometimes we’d wake up and my son would be sleeping on our front porch. We had options that other families didn’t have. I could call somebody in a treatment program and someone would come over and pick him up. But other families lack this type of support. I remember thinking about the family that contemplated urging their ill family member to throw a brick through a window so he could be arrested and get treatment. In many ways, that’s still where we are.
Abbreviated from the complete article in Capitol Weekly HERE
There were fits and starts with the legislation. We introduced a huge omnibus bill, AB 1800, in 2000, affecting outpatient treatment and commitment, conservatorships, expanding the “grave disability” standard under Lanterman-Petris-Short (LPS, the massive 1967 legislation which rigidly controls health care policy in California), and streamlining the process for certifying further intensive treatment. Those were only a few of many bills during that period.