After 36 years at the helm of Pacific Clinics, local mental health legend, Dr. Susan Mandel is stepping down.
BY: Cuyler Gibbons
Nearly 1 in 6 California adults has a mental health need and perhaps as many as 1 in 20 suffer from an illness serious enough to make basic life difficult if not impossible to navigate. More troubling, about half of the adults and as many as two-thirds of the adolescents so afflicted do not get treatment, with both the prevalence of illness and lack of treatment access exacerbated in low income communities. For 36 years, Susan Mandel has remained singularly focused on improving mental health access and outcomes for the indigent and needy of Pasadena and the surrounding area.
Dr. Mandel is gracious, with a dry wit and easy to smile manner that belies a dogged prize-fighter mentality, iron will and a certainty in the righteousness of her mission. While she’s anxious to spend some new found time honing her golf game, she remains obviously committed to the mental health needs of the poor and underserved. Her no holds barred willingness to speak plainly about what she sees as right…and often wrong, with today’s health care system was as refreshing as it is rare. When Dr. Susan Mandel arrived, Pacific Clinics had an operating budget of $800,000. As she steps down, that budget has grown to nearly $100 million, with facilities in Los Angeles, Orange and Riverside counties. I met with Dr. Mandel at the Arcadia headquarter offices. James Balla, President and CEO of Pacific Clinics, joined us for the conversation. We started at the beginning.
Tell me about the origins of Pacific Clinics. I understand it goes back to the ’20s.
Pacific Clinics started as Pasadena Child Guidance Clinic, one of the first services for children west of the Mississippi. Prior to that time all services were adult only really and they were in large state hospitals…As people became concerned there were not services, they decided to model [facilities east of the Mississippi] and the clinic started in the basement of the Pasadena Unified School District, serving children and families, first come first serve. Over the years…[there was a desire] to bring adult care back to the community, and they needed providers who would serve adults in the community as well as children and families. So Pacific Clinics became one of those, then known as Pasadena Guidance Clinic. Which is how it was known when I arrived. At the time, one of my board members, Hugh McNeil, said he thought it sounded like a dog obedience school…so we had a contest. We went with “Pacific Clinics” not only because people didn’t know what Pasadena Guidance meant but because “Pasadena” connoted, in those days, an image of a very wealthy community that didn’t need support and we didn’t want to be known as part of a rich community that didn’t need anything when we were serving poor people who were terribly needy.
Was the facility state supported at that point?
No. No, it was actually United Community Chest, those were the days of Community Chest even before United Way. Community Chest and patient fees if they could pay for it. In those days, there wasn’t much recognition about the fact that children and adolescents had problems that could be treated successfully with counseling. So we weren’t flooded with clients, but by the time I came there was this tremendous need for services for adults and [seniors] because the state hospitals were being closed.
That was when Regan was Governor and they emptied the state hospitals?
Well, if you recall the reason for closing the state hospitals was not Ronald Regan was mad and he didn’t like mental health services and he wanted to punish mentally ill people, the state hospitals were falling apart. They weren’t earthquake safe and he was under pressure from the federal government to do something to make them safe. The cost for that was something like three billion dollars in the early ‘70s and ‘80s. Well, nobody wanted to spend three billion dollars to recreate buildings and there was also this feeling that maybe it wasn’t best to send people away, isolated from their families, locked up, how are you going to get reintegrated out of there, ever…
But there must have been some thought as to what would happen to this formerly institutionalized population?
When they decided to close the state hospitals, they needed providers in the community to take care of the people that they had to let go. The plan was to do double funding, to build some facilities in the community and close the state hospital, let people out. Well, they never let enough money go out of the state treasury to build enough facilities to take care of the people who were released. We’re talking originally 30,000 or 40,000 people in the state hospitals and we’re down to maybe 2,500 now, almost all of them are from the Penal Code, they’re not really mentally ill. So that’s why you see so many homeless people on the street because there was never a plan put in place to make up for 8 or 10 state hospitals.
That seems like madness, but perhaps not atypical of government policy, or lack of it.
Well, even looking back on it now I wouldn’t say it would have been a good investment to put $3 billion into doing earthquake reinforcements for state hospitals because again how would you ever get people from Napa and Mendocino, Atascadero, back into the community? You needed community placements. But the biggest problem with California’s mental health system is its lack of planning and standards. There was no planning for every community…[how to provide] X, Y and Z services per hundred thousand population. It’s just hit and miss, whatever a county wanted to do, whatever they wanted to do, they did it and then, as money dried up, they look around and go, “Wow.”
How does the state allocate funds in this regard?
There’s nothing by formula built in that says as the population changes the money needs to change. So Riverside’s population has gone up like 40 percent, they still have the same money they had 30 years ago. In Southern California, you’ve got San Bernardino and Riverside and San Diego and L.A. and there’s not a lot of services down here, all of the services are up north. Part of it was Willie Brown was the Speaker of the Assembly, he was a very powerful speaker, a very good politician, and very community minded and he got all the money he could for the Bay Area counties…[But] I don’t know any rational system in the world that doesn’t have a way of reallocating resources based on need.
And there has been no plan put forth to improve the allocation process?
There is no plan. I mean the Mental Health Services Act, which is the famous Millionaire Tax, that adds certain kinds of services which is great for seriously and persistently mentally ill people across their lifespan. It encourages support of housing and wellness and all kinds of great things but it doesn’t give county X that’s underfunded more money than county Y that may be overfunded. It’s just the same old, same old because in politics if you don’t get it right the first time you never get another chance. I mean it’s really ludicrous.
Yet in the midst of all that, you’ve achieved a tremendous, some would say a miraculous, amount in your 36-year tenure. What was it like when you arrived?
I found volunteers running programs, there wasn’t enough money to pay staff, there’s samples in the doctor’s offices because there’s not enough money for prescriptions and a pharmacy. So if you’re lucky enough to need the kind of sample the doctor has in his office you get it, if not, you don’t. There’s no residential programs of any kind, there’s no services. This is the time of the “little old lady from Pasadena,” and there’s no services for older adults. You drive down Valley Boulevard and all the signs are in Asian languages and there’s no services for Asians or Pacific Islanders and there’s no services for older people at all.
Sounds pretty daunting. How did you prioritize?
I went to the board and said, “My goodness, there’s a lot to do here. The most obvious things that I think we could do would be to try to develop some older adult services because there is nothing in Pasadena, absolutely nothing, no geriatricians, no services at the hospital…”
And we went for a federal grant to provide for some mobile services to older adults so we could go to them, not have them come to us. The dearth of mental health talent in Southern California was so severe at that time…we had to pay for somebody to move from Virginia to come out here to head the program but we did, and we still have a small older adult program because, speaking as an older adult, there’s very little interest in serving older adults!
The other thing was it was obvious that Asians and Pacific Islanders were coming into the Valley in huge numbers and there were no services [for them] so we worked together with the Department of Mental Health locally to build a community collaborative with the schools and police departments, ministers, parents, mental health advocates, and we were able after a couple of years to secure sufficient money to open the first Asian/Pacific Family Center on Rosemead and provide services in about six languages. That’s now grown, it’s 30 years old and we have services here in Rosemead and services in the east as well.
It was clear from your website as I was preparing for our interview that outreach across numerous ethnicities is central to your mission.
I think for two reasons. One, is it’s obvious that our community is diverse and ethnic and continuing to be so and the second reason is that almost all ethnic communities are historically and traditionally underserved and under represented. In Medi-Cal, they call it penetration rate, the lack of ability to get in the system and get care is not just due to (cultural) stigma.
But do you find the stigma around seeking mental health care to be a problem?
Yeah, I mean there’s no word for crazy in certain languages, forgive the expression, but I think what happens is families tend to try, and this is true of Latino families, Asian, Pacific Islands, they’ll keep their relative in the back bedroom and try to manage that themselves. But the stigma is as bad I think, in the general community as it is in ethnic communities. Yet [even though] people said, “Oh, you opened that agency for families, nobody will come,” let me tell you, we haven’t had a day when we didn’t have enough clients to see.
Regarding ethnic communities, when we first met you spoke to me about your efforts to help immigrant parents relate to their rapidly Americanized kids, and your program to help both generations work through those tensions. Can you elaborate?
We’re doing a lot now and have been forever in working with immigrant families, Latino as well as Asian and Pacific Islander to help them deal with the culture shock of what happens when their adolescent comes to the United States and becomes acculturated or Americanized, that’s quite a shock. We work a lot on what kids need to become successful and how to help them make good choices and how to help parents deal with some of these things that they find so alien and so foreign and these groups are led by parents themselves who graduated through our programs.
So from the beginning outreach has been central to your mission, but to pay for outreach, and the resulting treatment needs uncovered you need funding. What has been your strategy there?
We actually do have a lot of government support, it’s just not enough to meet the need. We actually, as an organization, were very sorry to see Supervisor Antonovich retire. Pete Chavar and Mick Antonovich, Don Knabe and Deane Dana did [tremendous work] for the residents of this Pasadena Valley area that we serve…we also get grants, and about 1-3 percent of the budget is covered by charitable donations. We also do a lot of advocating, making people more aware of the need and I think that’s where we were successful both with board members and staff members and members of the community. Our clients, the National Alliance for the Mentally Ill, are really educating the Supervisor and his staff about what it is we needed.
Where exactly in the mental health ecosystem does Pacific Health reside?
We’re sort of at the far end. There’s a continuum of services. There’s general counseling services and family services and things for people, ordinary problems in living, divorce, and then there’s Pacific Clinics at the other end where you have a biologically based mental illness if you’re an adult, or a seriously mentally disturbed child.
Mental health and homelessness are obviously integrally intertwined, and what comes first is often something of a chicken and egg question. Despite what seems a lot of money and political will directed toward the problem of homelessness it remains seemingly intractable. How do you see the relationship? James Balla, President and CEO of Pacific Clinics answers:
What we’re describing is a psycho-social model of care which means let’s get to those issues of basic need and at the same time treat the mental illness. But you can’t just prescribe medicine and just expect an individual to survive. You’ve got to get them off the street, get them adequate housing, teach them how to live independently again and connected with resources so that you can proceed with location, education, work and you can sustain a person. We have evidence of folks then completely being removed from going back to the street; if you do it correctly you have very low recidivism and if you have recidivism then the drop often time doesn’t go all the way back to homelessness.
What exactly do those services look like? James Balla responds:
It may go to maybe a different level of care like a need to have more residential treatment than independent living type facilities…so, a community of friends. Other housing developers have done a good job of placing housing for the special needs population, homeless and mentally ill primarily, in communities and our goal has been to get people back in communities. They shouldn’t be in state hospitals because that’s the building where all the mentally ill live, because that’s not what you want to achieve. In a residential treatment facility yeah, because that’s part of the treatment and rehabilitation, but once you get more individualized, you’re able to live more independently, then they should be able to live in communities of their choice.
Yet you are a mental health facility, not a homeless shelter. I assume these are two very different things from a regulatory and financial perspective. How do you navigate that? James Balla, again:
I’d say that’s the biggest challenge. We have done partnership with Union Station Salvation Army, we do Homeless Connect Day and it’s a large outreach to the homeless population of Pasadena. It’s a very successful event and basically we provide the homeless individuals with contact, we provide health, psychiatric, we provide them with linkages into care, there’s physical health, optometry, there’s food provisions, showers, etc. and it’s an attempt to help to get homeless folks connected to services, that’s all it is. But how do you sustain that? And that is the problem. People say, “Do you treat homelessness?” We do, but in order for us to be reimbursed for that service they’ve got to be diagnosed with a primary mental illness. Susan and I worked in the system years ago, where you had COS, Community Outreach Services and non-Medi-Cal tied dollars that you could do a lot of things with. Well, those have all evaporated and what’s happening now is that everything is tied to Medi-Cal match. So you’re homeless, you’re probably not connected with Medi-Cal and if you did have Medi-Cal you probably lost it. So now the goal is to get them reinstituted with Medi-Cal.
Disturbed as many of these people are however, you’re asking them to come in voluntarily, correct?
That’s right but if you’re there often enough people will come in. One of my big bugaboos is that involuntary treatment is necessary for certain people. I think no. I think if there’s enough outreach and engagement with people, people want treatment. You don’t need to say, “If you don’t come, I’m going to lock you up,” that’s just not the case, but most politicians are very impatient. So doing the kind of outreach and engagement that it takes, I mean if you’ve been mentally ill for 20 years, you’ve been on the street for 10, I mean you don’t just all of the sudden say, “Oh gee, Susan I’d be happy to come with you and move into this motel.” We don’t need to lock people up, we need outreach and proper funding.
Can you elaborate?
Almost all of our clients have either themselves been involved with addiction or their parents, or family members, but the system doesn’t pay for those integrated services. You have addiction services over here and mental health services over here. I mean that was part of what Jim was getting at, all these rules we have now. Everybody talks about integrated care, no one talks about integrated funding. You can’t do integrated care until you do integrated funding.
So if you have a patient and you’re treating them for schizophrenia but he’s also an alcoholic you don’t get reimbursed for the alcoholism part of his treatment?
Only if you have a separate contract with another department to do that, and you’ll only get paid from the mental health department if you put the primary diagnosis as schizophrenia but as secondary drinking, alcoholism. If you don’t demonstrate that you’re treating the alcoholism because it’s related to the schizophrenia, they won’t pay attention to schizophrenia either and…oh, and then suppose in addition to being schizophrenic with alcoholism you have diabetes and heart disease, well, God forbid you try to help them with their diabetes diet or an exercise program for their heart disease. So it’s all chopped up in little funding buckets and makes no sense.
That’s seems like an inordinate amount of complexity to impose on an indigent population, particularly when data supports a more integrated model.
Well, the idea of one door where you can really get all your needs met has not been accomplished. I think if anything the funding system made it worse. We’ve made so many diverse pockets of funding that are available for people and the worst part of it all is that we have to bill by the minute. So imagine if you’re dealing in a counseling session and you have to worry about billing by the minute. No one is concerned with the outcome.
So, I think the real problem is needing to switch away from this counting by the minute and moving towards what are some of the agreed upon outcomes that we’d like to see. You want to see no jail recidivism, hospital recidivism, back to work, in school, less fights with family. I mean they’re very real outcomes you want to see as a taxpayer saving money. If you’re not going to jail, you’re not going into the hospital or the emergency room. That saves all of us much less the grief. It saves a family from going through that up and down, up and down, up and down, and that’s what we should be measuring.
Well, you’ve described a litany of challenges, challenges that bely the tremendous success you’ve achieved. As you look back at your experience here, and then toward the future, what is your hope for the community?
When I’m out and about, I don’t generally hear people saying, “Gee, I wish we were doing a better job with the homeless.” I think it becomes an issue when it’s prevalent, when it impacts you directly then there’s an issue. I think people are sensitive to the homeless plight, but I don’t think they understand it. I think when you mix homelessness with mental illness or substance use and the fact that we’ve let a lot of folks out of institutions and institutions now being the jails, some of the early release programs from those offenders that don’t have serious convictions, it just adds to the issue. Where are they going to go without some type of reach to services, housing, treatment if they need treatment to stabilize their behavior and their mental illness, and then certainly the opportunity to become productive—that’s what I think is the full approach. That’s what we need to achieve. If you don’t offer that continuum I’m not sure how you really get your arms around this.
Any parting words?
Yes. The message is that people get better. I mean, this is not hopeless…people get better, they get better with a roof over their heads, with treatment, with family support, with medication, with employment. People want to get better and they do get better.