The Honorable Assembly Member Jim Wood 
Chair, Assembly Health Committee 
1020 N Street, Room 390 
Sacramento, California 95814 

RE: SB 43 (Eggman) as amended 4/27/23 – Supplemental opposition letter providing alternative framework 

Dear Assembly Member Wood: 

Disability Rights California (DRC) submits this letter to provide a vision for mental health in California that respects the liberties, autonomy, and dignity of individuals with mental health disabilities. In particular, our vision addresses the real needs of Californians who are unhoused and living with severe and persistent mental illness. Our proposal relies on evidence-based practices supported by years of research from across the country. 

If the State of California is serious about solving our housing and mental health crises, we must invest in the below community-based services instead of pursuing legislation to expand involuntary commitment. 

SUMMARY 

1. Require counties to offer permanent affordable housing to people with severe and persistent mental illness, and ensure that counties have necessary funding for this purpose. 
2. Ensure that people with severe mental illness have the support they need to stay in housing by requiring counties to offer Assertive Community Treatment to all individuals with severe and persistent mental illness, and ensure counties have necessary funding for this purpose. 
3. Require counties to provide crisis services adhering to recovery-oriented principles by increasing state funding for crisis services. Allow counties to choose crisis services based on community need and tie funding increases to fidelity with recovery-oriented principles. 

DISCUSSION 

1. Permanent Affordable Housing 

Senate Bill (SB) 43 will not help unhoused individuals in the community who are experiencing untreated or undertreated mental illness, contrary to the author’s stated intent.1 The bill relies on involuntary treatment, which does not solve houselessness. Instead, decades of research shows that mental health treatment is far more effective when people are safely housed in permanent affordable housing.2 

For unhoused individuals, stability and continuity of care is next to impossible. Individuals are rarely offered immediate, voluntary, and affordable housing assistance, even when participating in intensive outpatient treatment programs or following in-patient hospitalization. For individuals who are never provided the stability needed to achieve wellness, the lack of permanent affordable housing perpetuates a revolving door of houselessness and in-patient hospitalization. 

Offering permanent affordable housing to people with severe and persistent mental illness greatly reduces suffering, and allows people to maintain housing while engaging in treatment and recovery. It also drastically reduces costs of emergency services and hospitalizations.3 The failure to offer permanent affordable housing for this population is inhumane and fiscally irresponsible. 

Existing law requires adherence to Housing First principles in programs addressing houselessness.4 To ensure program success, housing must be offered on the basis of eligibility and not participation. This means people should be offered immediate access to permanent affordable housing with no readiness requirements. 

In contrast, involuntary treatment can exacerbate symptoms when individuals are destabilized by being taken against their will, and then released into the community again without housing support. Instead of perpetuating short-term deprivations of civil rights to get people off the streets, California should pursue comprehensive housing strategies to help people get stabilized and well long-term. 

2. Assertive Community Treatment 

The author of SB 43 notes there are too many individuals in our state falling through the cracks and onto the streets. We agree. But expanding involuntary commitment criteria will only make things worse by forcing resources to expensive locked institutions. Sufficient community-based supportive services are less-expensive than locked institutions and key to providing people with severe mental illness the assistance they need to live and thrive. 

Counties are required to provide Full Service Partnership (FSP) programs for adults with severe and persistent mental illness.5 FSP principles utilize a “whatever it takes” approach to help people reach their recovery goals.6 However, FSP requirements are vague and programs often fall well-short of “whatever it takes.”7 Examples of services that FSP programs should provide include: reminding participants of appointments, being available in case of emergency, providing assistance with employment, providing assistance with applications, and ensuring the individual stays housed. Services and capacity for FSP programs vary considerably from county to county. Caseloads for FSP case managers have skyrocketed, resulting in many individuals not receiving the level of support they need from these programs. 

Assertive Community Treatment (ACT) generally provides a more engaged level of service than the standard FSP. ACT is an evidence-based practice that utilizes a multidisciplinary team approach to provide a wide range of community-based intensive services to people living with severe mental health disabilities.8 ACT teams operate 24 hours a day, seven days a week, and services are available for as long as needed and wherever they are needed.9 ACT is a highly integrated, team-based service delivery model, not a case management program, and is proven to be effective for people who have not been adequately served by traditional service delivery approaches.10 A recent behavioral health needs assessment published by DHCS found that ACT is not yet available on the scale necessary to support optimal care for people who could benefit from the level of engagement that it offers.11 

Requiring counties to provide ACT throughout the state would strengthen standards for FSP programs, ensuring individuals with severe mental illness have the support they need to remain housed. The state should ensure counties have funding to provide ACT to all who have need. 5 

3. Crisis Services 

The author of SB 43 writes that people with mental health disabilities are being sent to jails rather than receiving appropriate treatment before they get there. We agree this practice is abhorrent and needs to stop. However, forcing people into institutions is not the solution. Both of these outcomes discourage individuals from seeking help and can traumatize all involved. We need to ensure people have the immediate crisis services they need to resolve their behavioral health crisis in the community, and that our crisis service systems encourage people to seek help. 

Counties are required to provide crisis services, but there are significant gaps in many behavioral health crisis systems. Provision of sufficient crisis services allows individuals to get the help they need immediately on a voluntary-basis. Fidelity with recovery-oriented principles would ensure that crisis services are not just another entry point to involuntary commitment. Recovery-oriented principles include: hope, self-determination, empowerment, equity, and peer & community support. Alignment with these principles encourages people to seek help and engages more individuals in treatment. 

Many counties lack important elements of crisis services. Specifically, counties lack community-based, resolution-focused crisis intervention services, such as calls centers, mobile crisis teams, peer respite, and voluntary drop-in mental health urgent care. Additional funding is needed to build out county crisis systems and ensure adequate capacity to resolve crises in the community, without resorting to institutionalization. Services should be trauma-informed, peer-rich, culturally aligned, and linguistically relevant. Need can vary regionally, thus funding increases should allow communities flexibility to decide what services are needed. 

A. Community-Based Crisis Intervention Services 

Crisis systems must include community-based crisis intervention services that offer unplanned emergency brief assessment, treatment and support. These services are designed to resolve mental-health crises in community settings without transfer to another location. 

At minimum, these services must include (1) 24/7 call centers that serve as an alternative to 911 and law enforcement response, with capacity to de-escalate crises through calls, texts, or online chat and dispatch Mobile Crisis Teams; and (2) Mobile Crisis Teams that can respond to a person’s home, school, workplace, or other location in the community without law enforcement assistance. Mobile Crisis Teams should include Peer Specialists and mental health professionals who are available 24/7 to respond face-to-face and to stay with the person until the crisis subsides and to arrange further services when indicated. 

With proper funding and coordination with the housing and ACT services discussed above, crisis intervention can resolve crises in the community and prevent cycling through institutions and houselessness. The State should continue to fund and monitor these services, including through 988 initiatives and implementation of the Medi-Cal mobile crisis service. 

B. Peer Respite 

SAMHSA recognizes that “[p]eer support services can effectively extend the reach of treatment beyond the clinical setting into the everyday environment of those seeking a successful, sustained recovery process.”12 Peer respite is a voluntary, short-term, overnight program that provides community-based, non-clinical crisis support to help people find new understanding and ways to move forward. Peer respites operate 24 hours per day in a homelike environment. Peer respites are staffed and operated by people with psychiatric histories or who have experienced trauma and/or extreme states. Peer respite programs are very effective, with research suggesting a 70 percent reduction in the use of emergency and in-patient services.13 Despite these findings, peer respite programs are underutilized, with California having only nine programs in the entire state.14 

C. Voluntary Behavioral Health Drop-In Centers 

All too often, a person with an urgent mental health need must wait weeks for an out-patient appointment. Accessible, timely, and voluntary behavioral health drop in centers allow individuals to get the immediate help they need and prevent unnecessary hospitalizations. 

Robust behavioral health crisis service systems are critical to providing people the immediate support they need to reduce negative outcomes. Counties need additional funding to ensure their crisis service systems have adequate breadth and capacity. Alignment with recovery-oriented principles encourages people to utilize services. 

CONCLUSION 

We welcome the opportunity to discuss our proposal in greater detail. 

Sincerely, 

Samuel Jain
Senior Policy Attorney
Disability Rights California

Deb Roth 
Senior Legislative Advocate 
Disability Rights California 

Cc: The Honorable Senator Susan Talamantes Eggman 

• 1. Senate Bill 43 expands the definition of “grave disability” in California Welfare & Institutions Code § 5008(h), making it significantly easier to involuntary commit individuals for behavioral health reasons.
• 2. See, e.g., Collins, S., et al. Project-based Housing First for Chronically Homeless Individuals with Alcohol Problems: Within-Subjects Analyses of 2-Year Alcohol Trajectories, (2012), American Journal of Public Health, 102 (3), 511-519; Greenwood,R.M., Schaefer-McDaniel, N.J., Winkel, G., & Tsemberis, S.J., Decreasing Psychiatric Symptoms by Increasing Choice in Services for Adults with Histories of Homelessness, (2005), American Journal of Community Psychology, 36 (3/4), 223-238; Seidman et al., The Effect of Housing Interventions on Neuropsychological Functioning Among Homeless Persons with Mental Illness, (2003), Psychiatric Services, 54(6), 905-908.
• 3. See, e.g., Flaming, D., Lee, S., Burns, P., & Sumner, G., Getting Home: Outcomes from Housing High Cost Homeless Hospital Patients, (2013), Los Angeles: Economic Roundtable; Culhane, D.P., Metraux, S., & Hadley, T., Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental illness in Supportive Housing, (2002), Housing Policy Debate, 13(1), 107-163.
• 4. See Welf. & Inst. Code § 8255, et seq.
• 5. Welf. & Inst. Code § 5600.3(b); Cal. Code of Regulations § 3620.05.
• 6. Mental Health Services Act,§ 3200.130.
• 7. See Cal. Code of Regulations § 3620.
• 8. State of California, Department of Health Care Services, Assessing the Continuum of Care for Behavioral Health Services in California: Data, Stakeholder Perspectives, and Implications (January 10, 2022) at 60 (https://www.dhcs.ca.gov/Documents/Assessing-the-Continuum-of-Care-for-BH-Services-in- California.pdf).
• 9. Id.
• 10. Substance Abuse and Mental Health Services Administration (SAMHSA), Assertive Community Treatment Evidence-Based Practice Kit: Building Your Program at 5 (https://store.samhsa.gov/sites/default/files/d7/priv/buildingyourprogram-act_1.pdf).
• 11. State of California, Department of Health Care Services, Assessing the Continuum of Care for Behavioral Health Services in California: Data, Stakeholder Perspectives, and Implications (January 10, 2022) at 14 (https://www.dhcs.ca.gov/Documents/Assessing-the-Continuum-of-Care-for-BH-Services-in- California.pdf).
• 12. SAMHSA, Peer Support Workers for those in Recovery (https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers).
• 13. Croft,B, & Isvan, N, Impact of the 2nd Story Peer Respite Program and Use of Inpatient and Emergency Services (2015), Psychiatric Services, 66(6), 632-637.
• 14. National Empowerment Center, Directory of Peer Respites (https://power2u.org/directory-of-peer-respites/).