Assembly Select Committee on California's Mental Health Crisis

We will bring this select committee on California's Mental Health crisis to order. I want to welcome everyone to our Nd of three scheduled hearings on the mental health crisis. Our third hearing will take place on Wednesday, June 7. For those who wish to participate in public comment via phone, you may do so by calling 877-692-8957 and the public access code is 131126. Public comment will be conducted at the end of the hearing. Of course, this is a busy day in Sacramento, but no day can be so busy that we do not continue to address the mental health crisis. So today we're focusing on learning the unique mental health needs of the rich and diverse populations of California. California is home to almost 40 million people who are Black, white, Latino, Asian and Pacific Islander. Native American. LGBTQIA are those with disabilities and, of course, also our senior population. Therefore, we must make sure that we do not have a cookie cutter approach when it comes to developing our mental health strategy. We learn quite forcefully when we try to do a cookie cutter approach and do the things that were most expedient when it came to COVID-19. We began to see gross disparities begin to form in various communities. And so we must make sure that we learn from those mistakes and making sure that we take our time to reach out to specific communities and meet their specific needs as well. We know that 25% of African Americans seek mental health treatment, compared to 40% of our white brothers and sisters. We know that they suffer unequal access to health care, which is a major contributor to this disparity. About one third of Asian Pacific Islander adults reported psychological distress. We also know that the odds of psychological distress were increased among adults who were female, trans, and nonbinary, and also those who were of the age 18 to 44. Approximately 8% of the LGBTQ plus individuals and nearly 27% of transgender individuals report being denied needed health care. Outright access to mental health services are severely limited by the rural, isolated locations, particularly those in the Native American communities, where 2% of females and 12% of males reported having attempted suicide, while 5% had serious thoughts of suicide in the past year. And then we know that adults with disabilities report experiencing frequent mental health distress almost five times as often as adults without disabilities. So this Select Committee was created to address those issues and help formulate policies that are effective in both the near term and long term and help California's live more meaningful and prosperous lives. It is indeed an honor to serve with my colleagues on this committee, and I'm looking forward to taking action in a bipartisan manner to meet this urgent need. I will now turn it over to my dear colleague on this committee, Assembly Member Gail Pellerin, serving as our Vice Chair. Thank you.

Thank you. I am very grateful to our chair of this committee for his leadership to pull these hearings together and his staff. I thank you so much for the time and effort to do this and thank you all for being here and those who are listening in. I just want to share a little story. I got a text from a friend yesterday, and his wife's good friend's husband had died by suicide. And his troubles were known, but they were not shared by his family, by his wife. And the family has been trying mightily since his death to mask how he died. I had the same experience in my family when my husband died by suicide in November of 2018. My kids did not want to tell anybody that their dad had taken his own life. The obituary that was going in the newspaper, his family insisted that we do not use the word suicide, that we use the phrase he died suddenly. And I remember feeling really suppressed by that because I wanted to share this. I wanted to connect with people. And it took many, many months before my kids were even able to admit the fact that their dad had died by suicide. And I wish I knew what to say or do in that moment of despair, of hopelessness, to stop someone from making this final decision. And one thing that I thought about is that we need to keep talking openly and honestly about mental health and suicide awareness until it is a normal thing for us to be talking about and removing this stigma. I wish my husband had the capability of reaching out to friends and family and saying, I'm not okay. I'm not well, I need help. But he was a successful attorney in Silicon Valley, and no one needs help when they're in those positions. And I thought about the fact that the shame you feel about who you are or what you are feeling is an extremely difficult way to live. So people choose the alternative. I'm really looking forward to today's hearing. I'm a member of our Santa Cruz County Nami board. I've worked a lot with Disability Rights California. I think the impact of mental health and the suicide rates among our LGBTQIA community is daunting. And I'm just here to continue to listen, to learn, to connect, and to do everything in my power to make sure that mental health is on parity with physical health, that we're talking about it, that it's accessible, it's affordable, and people get the help they need to thrive. So thank you.

Thank you very much, assembly member. We are going to just jump right into our first testimony on this panel, and we're going to bring up Disability Rights California. If you can, come on up. And I believe, Caris, you have been doing quite the travels right there. It's just fine. Yes. And we want to thank you for all the logistics in getting here. And you may begin when you're ready.

Okay, so the Mic is already on you.

You're all good.

Thank you. Yes. I don't think that I'm jet lagged yet, but I did come in last night from London, England. So the things that we're talking about are actually international as well.

Yeah.

Thank you. Okay, so thank you, Assembly Member Jackson and members of the Select Committee. My name is Keris Myrick and I'm a mental health advocate and newly appointed board member to Disability Rights California. Since we're providing testimony on defining mental health and addressing mental health stigma, I actually want to start with the stigma that occurs in these very hearing rooms of our state capitol, with our elected officials, and with legislation that sometimes is introduced and passed as recent as a week or two ago. During the hearing for SB 43 LPS Reform, a legislator stated they had never heard yet a person with lived experience state that they did not like involuntary treatment, though during that very hearing, a person identified as having lived experience and spoke about their trauma while under mandated care. And I understand that sometimes in these hearing rooms it can be very dramatic and very theatrical. I certainly understand that. But from our legislators to feed the beast of mental health stigma while trying to advance any type of legislation that we are to believe is in our best interest, erodes our trust, increases our trauma, and most importantly, defeats the goal of our legislators, policymakers, and advocates, which is to help people. We cannot continue to use derogatory, inflammatory language when speaking about mental health and those impacted by mental illness. So what does mental health look like for people living with psychiatric and other disabilities? So I'd like to start here to pick up from the legislator who had not heard from people who dislike involuntary treatment. I'm going to show you a pair of shoes. Not the ones on my feet, clearly. Cherry red, 1461. Doc martin Oxford's. I wanted these shoes forever. I saved up my pocket change until I could finally afford them, bought new outfits to match them, and wore them nearly every day. And I survived a life altering experience in them. My first encounter with the mental health system during a crisis occurred when I was in my late 30s in Los Angeles. The voices only I could hear were relentless calling me derogatory names, telling me I was stupid, worthless, useless, and ugly. Whenever this happens, I run inside myself, hiding the very essence of who I am inward in a deep and dark place. Outwardly, I'm withdrawn, silent, segregated from the world around me, never leaving my home, never eating, missing work, don't call in, and basically, I give up on life. Perhaps the voices are right. In times like this, my mom would remind me of the day that I was born as proof that I belonged in this world. But could I even trust her? Could I trust anyone? The voices are very powerful liars, and they easily cross over the invisible line between lies and the truth and I can't help but to believe them. I shrivel up in a ball in the back of my closet, enveloped in the dark, throwing clothes over myself in hopes of drowning out the incessant chatter, cursing at me. This is what it's like sometimes, even when in treatment, to live with a diagnosis of schizophrenia. The terrible night. The voices wouldn't relent. Terrified and too embarrassed to call my mom, I reached out to my doctor. Surely he was neutral and he would help me and give me some resources and I could trust him to get me out of this untenable situation. I was in trouble and needed help. My doctor quickly responded, saying you know what? I think I need to call 911. The police arrived at my apartment building where I was the only African American resident. The officer banged on the door, loudly announcing that he was from the police department. Yay for my neighbors who got to hear that and had been sent to do a welfare check. So many things ran through my mind. Will the neighbors think I'm some sort of stereotype about black folks being criminals? Would I be safe to open the door? Given the many horrific outcomes of African Americans and police interactions, my paranoia didn't stem as much from my illness as from the realities of what it's like to be black in America. I was fully dressed, wearing my very well broken in cherry red Doc Martins. I let the police in, fearing if I didn't comply they would break down my door. The police interpreted my ramblings to mean that I was suicidal and being deemed a danger to myself. I was handcuffed and taken to the police station where I was handcuffed to a chair. Later, back in the police car, my hands were still cuffed behind my back. I was transported to the psychiatric hospital that they called county. Didn't really have a name other than county. And upon arrival, the police escorted me to the ward where a nurse, I believe, asked to take my temperature. And I responded, no, thank you. I had no idea taking my temperature. I had no idea about what taking my temperature had to do with why I was there. No one bothered to explain it to me. No one asked why I even declined. Next thing I knew, I heard the word code. The police and others wrestled me to the ground and kept trying. And I kept trying to get free. My hands and feet were flailing around in the air like octopus's tentacles. Take her shoes, their weapons. Yelled one of the officers. And my well worn, perfectly broken in, beloved cherry red 1461 Doc Martin Oxford's were ripped from my feet. I found out that night what mental health care was all about asking for help and instead getting handcuffed and being harmed physically and emotionally as a result. And for many years I was unwilling to seek the care that I needed when I needed it most. My cherry red Dock Martins were relegated to the back of my closet, collecting dust in their beloved cracks and crevices. They were the embodiment of the trauma of that first hospitalization. I couldn't bear to wear them or even look at them. There were a reminder that I was so broken and so black in America that somehow the treatment I received was deserved. So clearly, I did not like that treatment I was subjected to at that time. So now we have it on record that a person with lived experience does not like involuntary treatment. And I want to note that this is not an individual or rare finding. One survey found that more than half of the respondents described their psychiatric ward experience as traumatic. 37% said they were physically abused in some way, including being subject to forced treatment. 7% said they were sexually abused and only 17% were satisfied with the quality of the psychiatric treatment they received. That's a pretty small number. When our peers and people with lived experience use terms such as surveillance, carceral systems and abolition, one should really pay attention. What happens, however, is that we suffer from the danger of a single story. A single story that does not include us. The single story is evident in Care Act legislation in which legislators assume that unhoused people are living with schizophrenia, don't think that they need help, and make clear that the purpose of Care Act is to take our streets back and help these people and that the individual should have an obligation to say yes. And if you don't, we're going to step in. And in stepping in, they're going to be the adult in the room. Okay, now I got to find out where I am. Hold on. Okay. Or from our families who are so disappointed, frustrated, scared, angry and traumatized for their loved ones for whom systems have repeatedly failed, make up the stories that are told and retold to support what is needed to address California's mental health crisis. And as a newly formed family advocacy group has said, carecourt is ours. It is the families. So it is the people singled out who have been given diagnosis of schizophrenia and or psychosis who will be adjudicated to this Care Act process without any benefit of input from people with the lived experience of being unhoused and living with schizophrenia of what might be helpful. So I'm grateful to be here today to talk about some of those things. So that is our single story. And what's the danger of a single story? Nigerian author Chimamanda Nagozo Adiche, whose name I probably butchered, shares in her writings and Ted Talks that stereotypical and reductive stories are harmful and argues that such stories rob people of dignity and make it harder for people to connect. And also, it makes it harder for us to understand each other. Never a truer statement as we continue to pit families and peers against each other about issues and people we all love, care about and want to help. Despite the statistics that point to disparities for black and brown folks under mandated orders, we persist to build things that may not work for us and hold us accountable to say yes. Because if we don't, a supposed adult will step in. A recent disability rights investigation in Alameda County revealed that 55% of individuals involuntary held over ten times in the county's psychiatric facilities were African Americans, even though African Americans make up less than 11% of the county's population. An analysis of discharge data from the California Department of Healthcare Access and Information showed that compared to their white counterparts, black and Latinx Californians were 57.2% and 154.5% respectively, more likely to be placed on a 51 50 hold. African Americans are also disproportionately diagnosed with schizophrenia, with estimates ranging from three to five times more likely in receiving such a diagnosis. So what is it that we're saying no to? So I've spoken to colleagues like Dr. Aaron Beck, who's recently passed away. He's a developer of cognitive behavioral therapy and his colleague Dr. Paul Grant, who is a co developer of recovery oriented cognitive therapy. And they cannot overstate the importance of attending to the no. What they say is while the no's and the headshakes of people who have been given a serious mental health condition diagnosis may strike healthcare providers, family members, law enforcement and many others as problematic, it's worth thinking about what might be driving the nays. The person may find themselves in an environment that does not offer a lot in terms of opportunity. It may not be culturally or linguistic relevant. They may find very little chance to direct their own life's course, and they may find many things that are asked of them, like accept this diagnosis, take this medication, attend this group, respond to this other prompt. They may see that their freedoms are seriously curtailed through hospitalization incarceration and mandated treatment. All of this might have been going on for many times for many years, and it might feel like being backed into a corner. It's very frustrating and very demeaning. How can you have a bit of self respect? How can you fight back? How can you feel a little better? You say no and it may seem like the only opportunity you have for control in a world devoid of choice. And they say it works every time. So where's the solution? We need a solution. Offering choice at every interaction, showing general interest in the person's interests and passions, building up trust with people and of all these things, increasing therapeutic alliance. Therapeutic alliance accounts for 70% of people's ability to participate in treatment. But we spend a lot of time breaking that therapeutic alliance or looking at a number of things in the 30%, not the 70%. So what are some of the solutions? So from a legislative standpoint, I'll just go there. I'll just go straight to policy. We know that peer support works. We have our recent peer support bill enacted and people moving forward. But what we need to understand is who are the peers? What do they look like? What languages do they speak? Are they LGBTQ? Soji and are they multiply disabled? We don't have that data yet, but we need to collect that data and understand that data. Our family support needs to be trauma informed. We talk a lot about psychoeducation, which is critically important, but we also need to support our families with the trauma they've experienced in trying to get their loved ones help. And not being able to do so is going to be also important. Many times I don't hear much about trauma in our legislation peer respite. So as recently in Oregon, they passed legislation to add four peer respites for the state of Oregon. In California, we have nine peer respites, with one opening up in Alameda County. But California is a country in itself, right, as big as it is. So it's really hard to brag about having nine peer respites. Two are in LA County. LA County is like a state. Two is not enough. Peer respites give people places to go, things to do, meaning, purpose, connection. It can be a place to enter in when they're fearful of entering into treatment. This may be a place where they can start and meet with a peer who's been through the very same experiences that they've been through to help them. We also need to measure what you treasure. So we talk a lot about recovery, but I don't know how well we actually measure recovery. We measure things like criminalization hospitalization. We want to decrease those things. But we really don't talk much about the domains of recovery, which are health, home, purpose and community. The reason that we all live is because we want to have a purpose in life and we want to be connected to others. So we need to move beyond some of these measures of homelessness and incarceration to meaning and purpose in life. Community inclusion, community participation, activation and therapeutic alliance. For our telehealth, we need to ensure that people just don't have access, but they have access to the technology. The technology is in the language and meets their disability needs and that if needed, they have access to digital health literacy. So I hope that my own journey could become part of someone else's survival guide, especially for folks who look like me. I've needed to tell my story for my own healing and the healing of others. With support from my family and my peers, I've learned how to reconnect with the fiercity and tenacity that lay dormant under the guise of mental illness. The fiercer I became, the less the illness defined me. I was finally careless with some voices on occasion, but I was me, an audacious black mental health advocate. I discovered over time that these shoes that I had wanted forever, these cherry red 1461 Doc Martins, they are a weapon for me. They're a weapon of power, pride and persistence and they give me the ability to be here today. So thank you and I'm able to take any questions from the committee at this time.

Members, any questions or comments? Can you tell me, tell us, particularly in the disability community, which is often not discussed when it comes to a whole host of issues, what are the most common needs? Do we find that those with disabilities need to help with their mental health?

So I think there are a couple of things for us to think about and some of the things have to do with our things accessible in the way that people need. I think we think of people not as intersectional, but actually you have a mental health condition, but you could have a mental health condition and also be hearing impaired or be deaf and hard of hearing. You can also have visual impairments, et cetera. So just last week, looking at, for example, the documents from the Judicial Council on the Care Court process, the ones that go to the respondents are not accessible. You have to ask for them to be accessible if you have a disability. But the respondents are going to already be disabled by default because they have a psychiatric disability and they're so ill if they need to be referred to care court, that the form should have already been just at a minimum to meet the threshold for people who have psychiatric disabilities. And then at the bottom of the form, at the very bottom of the form, it says if you need accommodations for a disability, well, that should be at the top of the form. So I think there are some really simple things that can really help meet our needs. Many times the facilities that people have to go to are not accessible. When I was running a peer run organization, I was told, oh yeah, well, they can go through the back door. Why would I make somebody in a wheelchair go through a back door? They're going to go in any door they want to go in and it's going to be accessible. But I don't know that that's the way most people think or approach their work. It might be the minimum standard of, well, we made it accessible in this way, but it really wasn't truly equitable in that accessibility. So I think those are some of the things. And then also to think about the intersection between LGBTQ, soji LGBTQ and the disability community with mental health needs also crosses a lot of other requirements that people may need to have attended to as well.

Thank you for that and thank you for your testimony. Appreciate it.

Also, thank you so much for sharing your story. It was really profound and inspiring. So thank you so much. And hopefully we'll be able to connect again because I'd like to learn more.

Thank you.

Thank you. Next up we will have the representative from the National Alliance of Mental Illness, California NAMI. Is NAMI in the house? Oh, she is on the phone. We will.

Yes, I am here.

Okay, go ahead and introduce yourself, and you may begin when you're ready.

Great. Thank you so much. Good afternoon and thank you again, assembly Member Jackson and all the other assembly members on this bill. My name is Anita Fisher, and first, I'm a family member, a mother of an individual who has lived with serious mental illness for 22 years. I'm a NAMI, California board member elect, and I also serve on the State Council on Criminal Justice and Behavioral Health. Just a little about NAMI. NAMi California is a statewide affiliate of the country's largest mental health advocacy organization, the National Alliance on Mental Illness. Our over 110,000 active advocates and 58 affiliates include many people living with serious mental illness, their families and supporters NAMI California advocates on their behalf, providing education, support to its family members and the broader community. And that is how I found Nami 18 years ago when my son was first diagnosed with a serious mental illness. A couple of years after taking the family to family course, I became one of those family to family teachers and family support group facilitators. So I've done this for over 16 years. So I'm also hearing the stories of other family members along with what has occurred with my own son over these 22 years. Many times. He did end up being one of those homeless individuals. He did end up being arrested and put in jail, in prison, all because he was unable to understand that he was in need of mental health services when he needed them. So now to address some of the questions that you posed for NAMI, California NAMI California Stakeholder Survey our respondents ranked a set of potential barriers that impact their loved ones ability to access treatment. The main barriers they cited were lack of available services, and I count this as a rapid pre-crisis in engagement.

Until they hit that crisis date of a 5150 of needing that police contact and coming in. I'm happy to say that in recent years in my county in San Diego, we do have a mobile crisis response team that doesn't involve law enforcement and can make that contact sooner pre crisis. Another is stigma and discrimination, the stigma and discrimination of having a mental illness. I believe that still as a society that we must understand that mental illnesses are a medical condition, treatable medical condition and then the cost of services. We know that mental health care, if it's done at the crisis state, is going to cost more. And just like with any other medical condition, when it's treated earlier and preventative, then we know that it will cost less. So this should be something that all the insurance companies should be wanting to see happen. We also want patient centered, clinically informed care versus funding based care. We need an integrated system that uses person centered care where people participate and engage in their treatment with their health care providers and those providers respect their wants, needs and preferences. So this reducing the fragmentation between behavioral health and physical health services can produce better outcomes for both physical and behavioral health diagnosis. I know again, that in speaking with my own loved one and all of the other individuals with lived experience that I worked with in my years at Nami San Diego, I know that their voice is important and that makes a difference in how they receive the care that they have. So we are definitely on point with that. What are the potential legislative reforms needed to support the California Department of Insurance and for future unintended consequences that may be exacerbated with current public policy? Well, mental illnesses should be treated again as the same as physical and all mental health appointments, services. Treatments should be easily accessible for those. As with physical illnesses, the legislature has done great work on parity. We now have some of the strongest parity policy in the nation, but we must follow through on parity enforcement. Mental health benefits should be provided in parity with medical and surgical benefits, ensuring that health plans and insurers are complying with regulations based on yearly investigation and reporting, rather than relying on a complaint based enforcement system. And here's why it reduces stigma. Enforcing parity in behavioral health treatment directly combats the stigma surrounding mental illness, which has historically been a barrier to effective care. Navigating life with a mental health condition is hard enough, and the isolation, blame and secrecy that are often encouraged by stigma can create huge challenges to reaching out, getting needed support, and living well. Stigma is toxic to a person's mental health because it creates an environment of shame, fear and silence that prevents many from seeking help and treatment. Enforcing Parity California sends a clear message that mental health conditions are as important as physical health condition, thus helping to reduce stigma. Two, it increases access to care. Parity enforced enforcement can help more people gain access to mental health care that they need. This is particularly important because many people with mental health conditions often go untreated due to the high cost of therapy, counseling and medication. By forcing insurers to cover these treatments to the same extent as physical health treatment, more people may be able to afford care. And lastly, it prevents further health complications. Many mental health conditions, if left untreated, can lead to severe complications, including increased risk for physical health conditions such as heart disease and diabetes. These conditions can be life threatening and costly to treat. By providing equal access to mental health care, we can prevent these complications, improving individuals quality of life and reducing overall health care costs. So I will stop here and ask if there are any questions.

Thank you very much. Any questions? Can you tell me the most recent data that Nami has received in regards to the mental health crisis and can you kind of briefly go over some of those points?

Well, I know that we fall in line with a lot of the national data. I was brought in at the very last minute, so I don't have those numbers in front of me. But I know that much of what I read and see in what is described in again the national data with the mental health crisis just across the country, we are very much in line with that.

And what do you see as some of the greatest barriers that are impeding people from accessing behavioral health in our health delivery system?

Well, one again is engagement with them prior to the crisis. We often know, especially as family members, where many times our family members do reside with us or we are very much connected to them even if they don't live in the home. And again, the hundreds and hundreds of family members that I've worked with over the years, this is what I hear constantly. There's an excellent report that was done by the National Association of Caregivers on family members who support their loved ones who live with mental illness. And it was over 110,000 individuals who have to care for their loved ones. So we do know, we see sometimes the crisis before the individual. So I think having we know that there is a shortage of a workforce and I know that one of the things that I always promote is workforce augmentation with peer staffing levels. I'm a big believer in peer support at every level of the behavior health system and that can begin some of that peer and family and that engagement prior to the crisis because again, it's normally identified by others sometimes before the individual. Some of the individuals do live with an added condition called anasagnosia or a lack of insight into their illness symptoms, their mental health illness symptoms. So being able to engage with that individual sooner can help prevent that big crisis that comes. I hope that kind of answered your question about that.

Yes, thank you. Assembly member Pellerin.

Hi. Thank you, Ms. Fisher. My name is Gail Pellerin and I'm a member of Nami Santa Cruz. And I was first introduced to Nami through participating in their Family to Family program before I joined the board. And I can't say enough how fabulous that program is. So anyone listening, do it. It's really worth your time. The peer to peer program is also fabulous. And as you and the previous person had testified, peer to peer is definitely essential. You had raised issues about insurance. I'm trying to understand this a little bit more, too. And I've been talking to some providers where they have to apply to each individual insurance company to get coverage for their services for mental health care. And it brings me back to those days when my kids were applying to college and there was one common app then it just went out to all the colleges and universities. Do you think that's possible? And is that something that NAMI's considered?

Well, it sounds like an option. I know that a lot of times we need to throw many tools and options out there, and I think that can definitely be one. And I'll have to look further. I just recently joined the board. It'll be official in July. That's why I said a Nami California board member elect. And that's something that we can definitely investigate.

Great.

Yeah, I'm just interested in pursuing that and seeing if we can make it more efficient for providers to get their services covered by insurance plans. So thank you.

Okay. Thank you so very much, Ms. Fisher. We will move on to our next person, Ms. Carolina Vaye. Is she also on the phone?

Thank you.

With the California Pan Ethnic Health Network.

Yes, I'm here.

Okay, you may begin when you're ready.

Thank you. Good afternoon, Chair and committee members. Carolina Valle. Senior Policy Director with the California Pan Ethnic Health Network. I'd first like to thank you all for holding this hearing on the important topic of California's mental health crisis, and specifically the role that plays in it. CPEN, we are a statewide multicultural advocacy organization that's dedicated to eliminating racial inequities and health outcomes. And over the last three years, we've convened over 1000 Californians of color in listening sessions to explore their perceptions of mental health, the role that stigma plays in it, and how they experience the mental health systems. And so I'd like to share some of those findings from those listening sessions with you today. So, first, mental health stigma is pervasive across all communities. It remains pervasive. It has been pervasive, and it continues to be so. While there is an acknowledgment among the communities of color that we talk to that mental health issues can happen to anyone, communities discuss the need to keep mental health struggles private and alone. For many communities of color, the stigmatization of mental health struggles is so pervasive that it actually hinders or impedes access to care. This stigma is also exacerbated by the absence of materials that are culturally and linguistically appropriate, both on consumer forms and public messaging materials, as well as not Ada compliant. As Karis mentioned earlier, in many instances communities talked about how diagnostic terms might be helpful for providers and pieces of legislation, but that they're being overused in consumer forms and public messaging materials in ways that actually have the opposite of an effect of what they intend to do, which is help people get into care. That is to say, they actually end up deterring people from seeking the care that they need. Many participants also talked about how most mental health materials aren't even translated into their primary language, let alone properly or accurately translate it. Communities also talked about their experiences with not seeking treatment for their depression, anxiety or other mental health struggles, really as a direct result of exposure and experience with discriminatory and disrespectful treatment. Many communities talked about and shared stories of disrespectful treatment by both the providers, officers and other systems, including hurt behavior from staff, gatekeeping of appointments, and even threats to terminate services altogether for running late to one appointment. Many also talked about traumatic interactions with the police as a result of sharing their mental health struggles. Communities talked about how implicit bias among providers and the lack of an integrated approach really discourages them from seeking care. One clinician in our listening session talked about how many communities of color actually have traditions of talking with their ancestors and how the mental health system without an appropriate cultural framework may diagnose this as a psychiatric symptom, when in reality, it is a cultural experience that should be viewed from within a cultural framework, not a diagnostic lens. And so this is really, I think, an example. One example of how stigma is not only a matter of perception or belief, but how a lack of understanding of mental health in communities of color has tangible consequences, such as unwanted interactions with the police or the well documented overdiagnosis of serious mental illness and Indigenous and African American communities. So in terms of solutions, I think to do some of this work to combat stigma, we first really need to ensure that conversations and the language that we're using around mental health are reframed from a deficit based treatment perspective to a cultural and health education framework. In our community listening sessions, participants share that using language like mental health and wellness instead of mental illness feels more positive and aligned to their experience. For example, in the Black community it might look like sharing stories and focusing on experiences rather than diagnostic labels or clinical language. For American Indian and Alaskan Native communities, it might providing context on generational trauma and traditional healing. As a foreground, before connecting to mental health conversations in Asian and Pacific Islander communities. Having cultural experts that are bilingual and bicultural and can talk to the issue of stigma with both an educational and cultural vantage point might be more relevant and accepting. We do have benefits and protections available for stigma elimination today. For example, the Mental Health Services Act currently fund stigma, discrimination and elimination campaigns. Many of the partnering community based organizations we work with in our statewide network, the Behavioral Health Equity Collaborative, have been working on mental health stigma and discrimination reduction campaigns in their communities for over a decade. Additionally, CPEN has passed successful legislation over the last couple of years that now requires medical to do a community review of translated medical beneficiary documents to ensure that they are properly translated into other languages and at a reading grade level, and that includes the medical mental health book that consumers use to navigate the system. And we have also passed successful legislation to require medical health plans to develop and implement more culturally appropriate outreach and education to inform consumers of their benefits and rights. So the state really should continue to invest in stigma, discrimination and elimination campaigns while also ensuring robust implementation of existing laws to improve access to mental health. Second thing, to combat stigma, we've got to scale up community based organizations, peers and community health workers. Romaturas as really a strategy and antiracist strategy and approach to mental health care. So this looks like partnering with cultural brokers and culturally specific community based organizations to understand how different communities of color define mental health, what language may deter them from connecting to mental health services, and then adjusting that language and approach to meet communities where they are. This looks like partnering with peers and peer run organizations that have trained peers who tell their stories of mental health recovery and resilience specifically to promote mental health awareness and decrease stigma. We should continue to ensure that peers match the cultural background of the consumer and collect that data. As was previously noted, this looks like partnering with community health workers in Prometoras who are really critical, culturally responsive, community based providers that support some of the most vulnerable members in our community. Both peers and community health workers in promotoras are really crucial for engaging racial and ethnic groups who are traditionally underserved or inappropriately served by our behavioral health system. Today, counties can opt into the pure mental health benefit while the community health worker benefit is available in medical managed care. Some benefits are available, but more can be done. For example, the state could consider categorizing, CHW promoters and peers as a required state benefit across all delivery systems, impacting mental health, and also prevent any future delays in funding for the education and training of this workforce that is necessary to meet the diverse needs of our state. Lastly, California needs to integrate and consider integrating more culturally responsive services into the primary set of medical mental health services into the primary interventions that are being provided. Our folks told us that diverse communities really need what's called a stealth mental health approach that integrates spiritual, emotional, and physical health to make the work and services more accessible. What we continue to see today, unfortunately, is policies with really deeply embedded racism that result in people of color living with mental health challenges being disproportionately impacted by involuntary detention and treatment, including jails, prisons, psychiatric hospitals, and conservatorships. But instead of involuntary treatment or incarceration, which further exacerbates stigmatization, we need culturally responsive services or a stealth mental health approach that should be integrated into the primary set of services for people who are experiencing the most significant suffering and stigmatization. Today we have a specialty mental health system or a specialty mental health benefit that is available, and many organizations across the state are integrating more culturally responsive services into those primary set of specialty services, including integrating traditional healing with medication management and integrating traditional healing with substance use treatment. So California should really think about how are these CBOs doing this work? What are the specific mechanisms that they're using to integrate holistic care into specialty mental health care? And we should add investments to build infrastructure for community rooted providers such that they have the capacity to bill for such services. Thank you for your time and leadership, and we continue to look forward to partnering with you on this issue.

Thank you very much. Any questions so far for members seeing none at this time, usually similar to the disability community, I think we don't hear enough of the needs of the Asian Pacific Islander community. Do you have any quantitative or qualitative information that you can share specifically for that community?

Yeah, so in general, I'll say when we look at national data Assemblymember Corey Jackson, we see that there's an estimate about 21%, about 20% of the population on a national level have a mental health issue, and about 5% have a serious mental health issue. And rates of access within the Asian and Pacific Islander community are much lower than the estimated rates of prevalence, and they're even lower than rates of their population within a given county. So there's very what we call underutilization or lack of access. Right. One thing to note, though, is that when we look at data prevalence or access, it's not grounded in a cultural framework, and it really underestimates the role that systemic racism could play in the presentation of mental health issues and the rate of mental health issues. So I can get you some more specific data on the API community as well, but that's a little bit of kind of a note in terms of what we consider when we're looking at.

Some of these data pieces.

Yes. Thank you very much. Yes, additional information for the API community would be very great. We want to thank you so much for your testimony. Next we will have the California Black Health Network. Dr. Shacunda Rodgers Please come on up, and you may begin when you're ready. Welcome.

Thank you so much. Glad to be here. Thank you for having me. Good afternoon, everyone. Before I begin, I would like to thank assembly member Dr. Corey Jackson, chair of the Select Committee on California's Mental Health Crisis and members for the opportunity to speak today on defining mental health and addressing the stigma. I would also like to thank Ms. Rhonda Smith, executive director of the California Black Health Network, for recommending me as an expert witness today to share some thoughts on the mental health and well being of the black community and how to find healing. It's a true honor and a privilege to be with all of you in this moment. So the questions I'm here to address today are as follows why has the black community struggled to define mental health? And what programmatic methods are needed to perform the necessary outreach to destigmatize mental health? What I offer all of you today is informed by three hats that I wear. One as a clinical psychologist in private practice, a second as a member of the California Board of Psychology, where I currently serve as the vice president and the third as a founder and executive director of a nonprofit dedicated to healing racial trauma in the black community. At the end of the day, though, I speak as a black woman who provides healing and actively pursues my own healing so that I can be a vessel to help others. And I'd like to begin with a quote that is near and dear to my heart, which is by Dr. Cornell west, a beloved son of Sacramento, which says, never forget that justice is what love looks like in public. This is at the heart of my talk today, which I have entitled A Meditation on Love and Trust. So when you think about love for one's fellow man, what comes to mind? For a brief moment, let's all take a collective pause and bring to mind a person in our lives who has loved us or loves us. Now, it could be someone alive today or an ancestor who once loved us. Whoever it is, bring them to your heart and to your mind's eye and really see their face. What is it about that person's actions that let you know that you are or were loved? Perhaps it was their kindness, their empathy, their compassion or tenderness. Or perhaps it was their ability to really, truly see you as you are, without judgment and with true, genuine acceptance. Perhaps it was their allowing you to be your authentic self and embracing you with warmth and care, making space for the totality of who you are. So who came to your mind and heart? For me, it's always my mother and my maternal grandmother who are now my ancestors. But more importantly, what does this have to do with health care, mental health and stigma? As a licensed psychologist I believe that one of the reasons that the black community is reluctant to seek out mental health care is due to the fact that our systems are not founded upon or rooted in the love in the ways that I just described. Historically, there's been a great deal of mistrust toward these systems as they have been rooted in oppression, marginalization and anti blackness. For example, in 1851, Dr. Samuel Cartwright developed a diagnostic term named Drapetomania to describe what he called a syndrome that caused enslaved Africans to run away, escape and be free. Imagine that the wish to be free from suffering and brutality was considered to be a mental disorder and a psychological condition. Although this category did not gain much traction in the medical community, it highlights the ways in which black people have either been over pathologized or have had the broader context of race related trauma either minimized or ignored altogether. When it comes to the challenges our people face over the last 18 years of being a licensed practitioner, I've seen the ways in which the lack of culturally competent care can harm the black community, which continues to perpetuate this cycle of mistrust. Broadly speaking, when clinicians do not have the training or do not embody cultural competence in the care they offer, it creates the potential for implicit bias to emerge. And as the panelists have already said today, when this happens, the clinician may misdiagnose the patient, which can lead to inaccurate case, conceptualization poor treatment planning and misaligned care. When care is offered that is misatuned and misinformed, it often results in patients not feeling heard and not feeling understood. This disrupts the capacity to build rapport in the therapeutic alliance, the context in which a patient feels safe with their provider and feels a sense of collaboration in working with their provider. If safety and trust are not present, treatment will often fail. Trust cannot be built when providers and the systems in which they are working cannot truly see their patients and honor the full scope of their humanity and the social context in which their suffering exists. And when trust is broken or cannot be built in the first place, people in the black community have their fears reinforced that these networks are unsafe at the very least or create major harm at the very worst. A professor of mine in graduate school used to always say it is the relationship, not the psychological interpretation, that is the curative factor in psychotherapy. All these years later, I still believe this it's the relationship that heals. In October 2021, the American Psychological Association issued an apology to people of color for APA's role in promoting perpetuating and failing to challenge racism, racial discrimination and human hierarchy in the US. Which can be found on their website. The apology begins with these words the American Psychological Association failed in its role leading the discipline of psychology, was complicit in contributing to systemic inequities and hurt many through racism, racial discrimination and denigration of people of color, thereby falling short on its mission to benefit society and improve lives. APA is profoundly sorry, accepts responsibility for and owns the actions and inactions of APA itself the discipline of psychology and individual psychologists who stood as leaders for the organization and field. If our own discipline has finally acknowledged the rampant harm it has caused by upholding racist principles and practices over the generations through its complicity, then this is an invitation for repair, reimagining and renewal so that healing can flourish where harm once roamed free. While this time asks for accountability for the years of oppression, we must not stay there. Rather, this time calls us to thoughtfully and carefully dismantle systems that no longer work and rebuild them with love, tenderness and compassion. This is what a just mental health system looks and feels like. It is a system that has a deep, abiding belief that all people, which includes black people, are worthy and deserving of being well healed, healthy and whole. I've been thinking about these issues for a long, long time now, recognizing that my private practice, which is always full, is limited in what I can offer my people who are hemorrhaging with the pain of present day racial trauma as well as the generational trauma that has been passed down through all of our respective lineages. This trauma is alive in our minds, our hearts, our bodies and spirits at all times. It makes it nearly impossible to find rest. It makes us weary. It makes us angry. It breaks our hearts. And it would destroy our souls if we didn't have the hope, the joy, the resilience and strength and the love of community to help keep us afloat and pull us through. The mere fact that any of us is standing upright today is a testament to the miraculousness of our people. We represent lineages of the African Diaspora who survived chattel slavery, Jim Crow and the presentday antiblackness that feels our news outlets and social media feeds. We are the ones who made it. Until we address the foundational pieces upon which our health care systems are built, we will be in continual conversations about what isn't working. Rather than approaching care through the lens of symptom reduction, the number of sessions that will be allotted by the regulators of insurance companies and the dismal reimbursement rates for literally going into the war zones of people's emotional interior. We should be asking the following how do we value the entirety of one's lived experience, including the pieces related to epigenetic and the transmission of generational trauma in the lives of our black brothers and sisters? More importantly, what will it take for people to find healing and stay rooted there? And as liberation psychology traumainformed practitioners teach us to ask, they teach us to ask not only what happened to you and your people and what continues to happen? But more importantly, how do we now honor your ancestral wisdom to heal ancestral and contemporary wounds so that you may go from surviving to thriving in this life. These questions keep me up at night, and after many years, I finally decided to do something about it. In 2019, I formed an organization dedicated to healing racial trauma in the Black community, which is called Holding Space. We became a nonprofit in April of 2020, just at the outset of the Pandemic, and our mission is to improve the emotional health and well being of people of African descent by providing a wide range of services and community offerings that are holistic, culturally competent, traumainformed and strength based. We cater our offerings to the mind, body and spirit for Black people, and our care is rooted in the abiding belief that living and being well in a Black body is our birthright. We also believe that our people already have everything they need to be well with our integrative racial trauma healing model. Our offerings incorporate holistic healing practices designed to help our members do a few things, develop tools to soothe the nervous system build awareness on how oppression impacts the mind and body identify historical, intergenerational, intersectional sources of trauma in order to defy the lies of inferiority and connect to ancestral wisdom and empower clients to transform oppressive narratives. Through strengthbased approach our heart centered healing practices. Recognize the need for tenderness and compassion in response to the wounds of racial trauma that have been passed down through the generations. Because we emphasize individual and collective healing, our holistic offerings allow members to do their own individual work while also being connected to a community that cares deeply about their well being. We see them, we love them, and we want them to be healed. While we are a relatively new organization, our healing practices are not. Our care is rooted in evidenced based mind body practices, mindfulness based approaches, as well as African centered psychotherapy access to movement practices such as yoga and African dance and other holistic practices such as sound healing for those who are so inclined, group therapy, psychoeducation ancestral wisdom traditions and contemplative practices for those who are seeking a spiritual component to their well being. Our model for healing racial trauma is integrative and holistic, and this seems to be a pathway toward radical healing from the inside out. In the African principle of Ubuntu, which means I am because you are, we acknowledge our interdependence and collective impact on one another. Holding Space is an agent of change on a journey toward racial healing, and we are a beacon of light charting the path toward Black healing, renewal, resilience and joy healing racial trauma requires loving, authentic and nurturing hands to help restore Black humanity. To fulfill our mission to offer soulfully attuned holistic healing, we need policy change, funding and a belief that our community is worth investing in, not continuing to subjugate and leave by the wayside the cost of mental health treatment, including race. Based mind body traumainformed therapy and other holistic wellness services can be a prohibitive barrier for many people. In particular, people marginalized by systemic oppression who may be most in need of care may be unable to access care because of being underinsured or not having health insurance at all. Additionally, by and large,insurance plans do not have structured reimbursement rates for care. Specifically, targeting race based trauma holding space is unique in that as a 501, we wish to provide healing services for the community in a way that is financially accessible to all persons of the African diaspora seeking services and is not cost prohibitive for those in need. We will need lots of support to help us accomplish our mission. I'm thankful to have been able to share our new vision of care with all of you today. Thank you, Assembly Member Dr. Corey Jackson and members of the Select Committee for this important and timely discussion. I look forward to further discussions in today's question and answer if you have them and in the future as we tackle this important issue. Thank you so much for being a champion of this often neglected topic. And if there's time, I'll still address the questions around programmatic methods of outreach to destigmatize mental health. But I'll pause for now if you have questions. Thank you.

Questions at this time.

Obviously.

Thank you very much for your thoroughness in terms of the entire triggers of various mental health issues affecting the African American community and particularly putting an Afrocentric perspective in terms of what healing means, how it's conducted. And I'm a trainee of emotional emancipation circles. I used to conduct them before I came up here and I still miss it. Absolutely. And what we're going to be asking for all of our panelists is to ensure that we also get your written testimony as well. Because we want to make sure that particularly those remedies that we may be able to legislate on. We want to make sure we have that physically in front of us so that we can make sure that as we go into the next year and the next round of legislation, we might be able to incorporate some of those things. So thank you so much for your.

Testimony, so much for your time and attention and presence. I really appreciate it. Absolutely.

Thank you.

Thank you.

Next we have the Friendship House Association of American Indians, mr. Anthony Guzman. Welcome. And you may begin when you're.

Good afternoon. Good afternoon. It's a pleasure to be here. And I want to say it's been wonderful to listen to all the experts and information that's been said before, because I have to say that I absolutely agree with everything that's been said. It's been fantastic to be here. My name is Anthony Guzman, and I am the Chief Cultural Director at the Friendship House Association of American Indian, Inc. In San Francisco, California. I'm so excited again to be here to speak on this very important topic. I'm an enrolled member of the Northern Ute Tribe and on my mother's side and on my father's side, Mexican American. He was born in Tijuana, Mexico, and moved to Watsonville, California when he was three years old. The Friendship House is an organization that utilizes an American Indian and Alaskan Native culturally based model built through the expertise of individuals with a similar and lived experience. Friendship House believes the acknowledgment of tribal traditions in traditional ways and distinguishes these ways from Western culture. It is important part of the recovery process. Friendship House believes that people facing crisis and recovery find strength in community in relating to those that have travel a similar road and finding purpose in reconnecting with culture as a source of identity and a pathway to better mental, emotional and physical health. We've talked about stigmatization of mental health in the community, and one of the things that we've touched on by our witnesses earlier and today is that this stigmatization of the mental health condition of our people began so very long ago. We could look back just recently, but oftentimes these issues that have faced Indigenous people begin when the lands were taken away. Federal policy we've seen in 1883 begin then when our Indigenous ceremonies for all people were taken away from us. Those were our methodologies for ensuring that we dealt with our trauma through our ceremonies. That was our trauma informed care. That was how we dealt not only with the grief and the loss, the things of happening as a human experience. So when those things were not only taken away from us, along with our land and the diet, it impacted the society of our people. So it wasn't just the stigmatization of a mental health condition then it was the stigma of being an Indigenous person. What did that do to the very fabric of the society of Native peoples? I think we can see that when we start looking at the statistics of suicide and mental health conditions across the country. Now, today, again, we've heard this through our testimonies earlier, understanding what historical trauma is, what intergenerational trauma is, and what it is that when we are looking at the lived experience and trauma that people are currently having now, how do we change that from community defined best practices and how do we destigmatize that as community organizations? And one of those things is taking back that narrative when we have people come into the Friendship House, they're coming into a ceremony, understanding that they are holy beings, they are sacred beings. They are not post traumatic stress disorder. They are not bipolar disorder. They are not depression or anxiety. They are experiencing these things. And by helping them understand that they are not their diagnosis through patient centered care, by providing them with unconditional positive regard and treating them as such, is something that the Friendship House has been doing for 50 years. And this model of care has now reached out to other treatment organizations across Indian country as a model that has been utilized by many nations. Quite honestly, the Friendship House doesn't just service only Native people, even though that's who our primary clientele are. Our non Native relatives who come through absolutely start to understand what this means to be a holy and spiritual sacred being. And when we start to treat them as such, something changes. There's a saying in indigenous and indigenous teaching is all my relations. And as you could hear today, our African American relatives and our Latinx relatives and all folks, when we start to treat each other through this all my relations ideology, we start to build the relationships. And as our relative said earlier, what determines the best outcome for mental health care oftentimes isn't always based upon paradigm, but it's based upon the relationship that the provider has with the individual sitting across from them. And at the Friendship House, we know that through that relationship building isn't just starting inside of the treatment center, but it also begins before people get there. Through outreach and prevention and early intervention. When you're a known provider in the community, when you show up before those crises happen, when you have a relationship, by engaging people through that social connection, you become a trusted agent. You become a trusted agent of the community. So when you say, you know what? I think you might need to talk to a therapist or a mental health provider, or you know what? It might be a good idea for you to check in and think about going to the Friendship hosting to address your substance use. It starts outside of that diagnosis or the mental health or the treatment center. So with looking at our preventative services as well, when we think about treating people with mental health, with mental health services, it's not new. Holistic health is something that we've all heard echoed again and again. But we know, and I'm so very proud of that our indigenous people, with the use of the medicine will and our ceremonial approach to wholeness and wellness. Understanding that our social connection is so critical in positive health outcomes. Our mental health, our physical health and our spiritual health. The feeling of safety that we need when we know that it takes a village to raise our children and to embrace each other. So today we're here to talk about mental health in our community and specifically how exactly has our community and culturally based model assisted the success of destigmatizing mental health within our community. And again, it's taking back that narrative and letting our relatives and our members know of the community that it's not just you, you are not your diagnosis. Understand that there is a long history that has impacted all of the people that when our folks were taken off the reservation and the land was taken, your food and your lifestyle was taken, your ceremonies were taken and that changed. You even see those federal policies that impacted it. Even up until 1953, the Indian Relocation Act, which took American Indian young folks off the reservation to send them into the cities across the country in order to eradicate the Indian and to dismiss the trust responsibility of the treaties that were fought for by the ancestors. That was an attempt to one, remove the identity of the Indian person with the fighting spirit that runs through the blood of all of my relatives. That just did not happen. And what we found was that all those folks coming together in these cities didn't lose their identity. It only strengthened their resolve. In places like the Friendship House emerged. The Native American Health Center emerged. American Indian Child Resource Center emerged. Intertribal Friendship House emerged with many others in in the Bay Area and across the country. And so in 1978, the Indian Religious Freedom Act happened. What does that mean? That means all the way from 1883 to 1978, american Indian ceremony and was still outlawed. And so today, when we are looking at how do we heal our people with the mental health services, it is the utilization of current western practices. But absolutely understanding that our ceremonies and our traditional ways of healing, our ancestral knowledge and wisdom is integrated into those practices. And that is when we see our relatives lean in closer and trust that mental health providers, when understanding having cultural competency and the cultural humility to provide that type of care, we see outcomes happening and we can see continuation of the fantastic work that the Friendship House has been providing for over 50 years. So I am so happy to be here and talking about mental health today as growing up on an Indian reservation. I'm in a rural in rural Utah. And now being in a city, I understand the challenges faced in the community in both sides. Being in the rural community, being here in the urban area, the things that work in the cities don't always work in the rural. And what works in the rural doesn't always work in the cities. But what I've seen by my professional experience is that ceremonial wisdom and integration into mental health providers and sound mental health cultural humility for those providers does work in both areas. So I'm glad to be here to share some of this today. And I would love to answer any questions that you might have for me at this time.

Assemblymember Pellerin.

Thank you for your testimony. So I know that suicide rates are very high in the Native American community. What more can we do to help in that area?

When we talk about suicides in Indian Country, I think it's such a massive issue that we have federal providers out there and tribal providers out there that we always need more resources, but we also need those professionals and licensed clinicians that have the cultural training not only just on the reservations, but also here in our urban settings too. One of the things that I know that would be so very helpful for our urban Indian organizations and particularly in such as Friendship House, is that oftentimes we do not have the mental health providers, american Indian mental health providers, which makes a massive difference when providing treatment to the community. That if we were able to have our treatment providers be able to transfer some of their licensures from different parts of the country, to be able to use their licensures in our urban Indian organizations would be really powerful. Because as you all know, trying to obtain licensed clinicians, even right now in the state is very difficult, let alone trying to find American Indian licensed clinicians is so very hard. So if those licenses were transferable into Indian organizations in the state would really be very powerful. And that, I believe would help tremendously when combating suicide and other mental health diagnoses and issues. And again, I think I had mentioned this before, but suicide also would be supported by an increase of outreach and prevention monies too. So that when folks are that relationship starts before the crises, it starts before the crises. And so to have those outreach and prevention funding and resources there so that we're out in the community doing that powerful work, that is, I think, another way that we can ensure that we can reduce some of the suicide in our communities.

Thank you so much for your testimony. In my doctoral studies, when I was truly trying to grasp the causes and remedies of historical trauma, intergenerational trauma, I found myself relying on the literature of Native American scholars who were so rich in understanding the protective factors that culture, language and history brings to healing. And how I began to make sure I translate that into the African American experience. And the African experience was so profound to me in helping me understand who I am and understanding where I need to go and where I need to help my people to go. Right. So I want to thank you for your testimony today. Appreciate you.

I want to say this California Reducing Disparities project has worked in many ways with some of our other sister partner organizations in the Bay Area. And one of those projects was Culture is Prevention, without a doubt. So thank you all so much for your time and appreciate you.

Thank you. And last, but certainly not least we have the California LGBTQ Health and Human Services Network by Danny's Sacina. Please come on up. Oh, we're going to have him on our screen here. Welcome. Are you there?

I am. Thank you so much, assembly member, and thank you so much for this opportunity to speak with you all. Next slide, please.

So, as mentioned, my name is Dannie Cesnena, and I am the director of the California LGBTQ Health and Human Services Network, and I am here to speak on LGBTQ mental health disparities across California. Next slide, please.

So we are funded by the MHS OAC. To do qualitative and quantitative research to identify what are the LGBTQ mental health disparities are. And every year, we take those results, and we compile it into our annual State of the Community report. Next slide, please.

So some of the ways that we conduct our research are in these specific steps. So the first thing that we do is that we conduct key informant interviews with LGBTQ leaders and researchers from across California. And this isn't just the Bay Area, La. Or San Diego. We're also speaking to leaders within the Central Valley, Northern California, Imperial Valley, as far east as, like, Blythe and such, and really ensuring as well that we are hitting the intersectionality of LGBTQ leaders. Myself, being a two spirit individual and Native, I'm really ensuring that we have our Native two spirit voices african American, Black, Latina, API, et cetera. The second thing that we do after the Cue form interviews is that we host listening sessions with members of the LGBTQ community with our partners across California. So we are very intentional with partnering with local LGBTQ organizations and really sitting down and asking questions regarding their access to mental health care, what are their challenges and barriers, what prevents them from seeking access to mental health, and what are some of the struggles that they have with Navigating insurances. We also will speak to folks after press conferences when we have town halls, and then we also engage with, on an even micro level, grassroots LGBTQ organizers through the various subcontracts that we provide. Next slide, please. So from there, what we do is we take that information and we develop a statewide public intercept survey, where, since we now collected the qualitative data, we now want to collect the quantitative data and really get the numbers. And percentages of what exactly the community is experiencing? And how do they see what advocacy should look like for us to really push the mental health narrative for the LGBTQ community? And then the last thing that we do, once we receive our survey results, we compile together all of the quotes and everything. We present all of our findings to LGBTQ leaders across California by hosting a gallery walk. And we do this gallery walk via webinar so that way everybody has a chance to participate and review the results and provide and identify systemic environmental and policy recommendations which all goes into our annual State of the Community report. So from start to finish, LGBTQ voices are at the forefront of everything that we do as we're conducting research.

Next slide, please. So where I really want to start off is I wanted to present to you all specific quotes and stories from the LGBTQ community. So that way you hear from them directly through me and this opportunity to speak to you all of what their experiences have been like in trying to access mental health care. So we have this individual from Imperial Valley who is unable to find any type of gender specialists or anyone who is knowledgeable in trans related health care. So these individuals have to drive 2 hours or more into San Diego one way in order to meet with a provider, whether it's medical or mental health. This means that many times our community members have to take an entire day off work to drive 4 hours or more round trip just to receive access to mental health care. Next slide, please.

This next community member from La County. Even though La County is extremely LGBTQ knowledgeable and has so many resources, it's still extremely difficult to find therapists who are not only LGBTQ affirming, but also culturally competent. And when we speak about culturally competent, it's not just the language, but also our intersecting identities. As I mentioned earlier, I'm two spirit native, I'm Latina, I'm LGBTQ, I'm somebody who lives with a disability and such. So even for myself, when I'm seeking a mental health provider, I want to know that I can speak with someone that's going to understand all of those different facets of my life that I need to talk through and navigate with. Next slide, please.

This next community member had a really hard time finding even a bisexual friendly therapist. And a lot of the quotes and information that we have received from our bisexual community members is the fact that many therapists will tell the bisexual community, well, you're halfway to straight. Why not just go the rest of the way? So when our bisexual community continues to seek out mental health services and keeps being dismissed for their sexual orientation, they start to give up on trying to find a therapist to help them navigate their mental health needs. And this is what we're seeing with not only the bisexual community, but the LGBTQ community as a whole, where they're just like, I give up. I'm not even going to look for a therapist. They're not taking insurance, or they dismiss my sexual orientation or gender identity. I'm just done. Next slide, please.

This next individual experienced extreme racism as well as violence. So when someone who is a queer or a member of the LGBTQ community and has that added layer, as I mentioned earlier, that intersectionality of being a person of color and experiencing racism again, it's really hard to find. A mental health provider or therapist that is able to understand and navigate all of those layers on top of layers when it comes to working through our mental health and what our needs are. Next slide, please.

So, for this one is another individual who is a queer person of color, and they barely found a person of color. Competent therapist. And mind you, this is someone who is a professional who is very well educated. However, when navigating their insurance and looking through resources and trying to find someone that was affordable that they can gain access to, it was still an extreme struggle where four years to find a mental health clinician should not be anyone's testimony or anyone's statement as we're talking to folks across the state. And I even know this to be personally true because it took myself over a year and a half to find my own therapist. And my own therapist isn't even near anywhere where I live. I live in Los Angeles County, and my therapist is based in Sacramento, and I have to zoom in with her all the time because she's the only one that I've been able to find that understands all of my intersectionalities. And now that I have her because it took me so long to find her, I really make sure that whatever insurance she accepts, that that's the insurance that I have because I don't want to go through the hassle and through the trauma of trying to find a therapist again. Next slide, please.

So, this is a member from Shasta County, the most northern part of California, and this individual really shared how they find basic safety to be lacking, which is one of the reasons why they want access to mental health care but have not been able to receive it. And their quote just really shows that by them just existing, wearing a Pride shirt or something with a rainbow on it, minding your own business, running errands and having people yell at you about who you love or how you identify. Is California one of the most affirming states in the nation when it comes to the LGBTQ community? Yes. Is there a lot of work to be done to educate the community, mental health providers, insurance agencies, et cetera? Absolutely, yes. If you do not live in Los Angeles, San Francisco, the Bay Area, or San Diego, and you go to more of the rural areas of the state, LGBTQ people still live there. And LGBTQ people have literally no access to mental health care. These are the folks that are driving 2 hours or more one way if they have the ability to do so. This is a major issue within our community where someone who lives all the way in Shasta does not have the means to drive to San Francisco or even down to Sacramento for care because they don't have a vehicle, they don't have someone that can drive them down. So they are unfortunately unable to access any type of therapy or psychiatric services. Next slide, please.

So another member from Shasta County really talked about how they did find a therapist that would say, yeah, come on in for evaluation. When they were called to the back, they outed. The person in front of everyone in the office outed as transgender in an area that is not safe or affirming for LGBTQ people to be visible. So it ended up putting additional negative views on that individual in the community's mind. And folks who live in Shasta County or in smaller rural areas, everybody knows everybody. So now, because that person was outed, it makes it very dangerous for them to even step outside because now they are a target. Next slide, please.

So this is from a member in Oakland who really shared that even if they are able to find a therapist, it's very hard to even pay to see or utilize that therapist because of the costs. And additionally, a lot of therapists and psychiatrists and other mental health providers that are available to the LGBTQ community don't accept medical. And even if they have a sliding scale fee, even the lower end of that fee is still out of reach in a financial sense. So many times our community members have to make the choice and decision of do I pay for a therapy appointment or do I save that money so I can pay rent or pay my cell phone bill or put food on the table or gas in my car? So when our community has to make those choices of do they save their money so they can survive or do they go to therapy, they're going to save their money to survive and forego the therapy, which then adds on that additional trauma onto their mental health. Next slide, please.

So again, in Oakland, this is an individual who talked about how therapy appointment times aren't even accessible, which is 100% true. Majority of therapists and psychiatrists only provide services Monday through Friday from nine to 05:00 p.m.. These are the times when people are working and so many folks are unable to take extended lunches or more time off work in order to see a mental health provider, but they are available in the evenings or on weekends. But again, this is not when mental health providers are available, so they're unable to access the services that they desperately need. Next slide, please.

So this is just another example, and again, this one's from Oakland of persons of color going through trauma every day. And unfortunately, they really have to turn down mental health care because again, of the costs. And when it comes to living as people of color, so many of us don't have access to resources or funding or high paying jobs that other people take for granted. And it really goes back to that whole making the choice of do I pay for what my needs are or do I pay for therapy? And really, no one in California regardless if they're a member of the LGBTQ community, if they're API African American, black, Native American, Caucasian, no one should have to worry about, can they afford access to mental health care. Next slide, please.

So coming a little bit closer to Sacramento, over to Amador County, this individual talked about whenever they were in crisis mode and talking about their relationship to their psychiatrist. Their psychiatrist would really dismiss their sexual orientation and what being a queer couple actually meant and really did a comparison of how heterosexual couples live their lives. Really putting that you're the wife, you need to have the wifely duties, she's the husband, she needs to do the husband thing, instead of understanding that this is a joint relationship where everyone is equal. And instead it really triggered and enhanced their bipolar issues that they were already struggling, navigating and controlling. So we have even had experiences of mental health providers adding on to the trauma that our community already faces. Next slide, please.

So also in Amador County, we had an individual call like 40 doctors in their area and the moment that they mentioned that they're transgender and that they're seeking access to medical care or mental health care, they were told basically that's too much effort for a physician and your kind is really hard to take care of. And we call this the LGBTQ broken arm where it's very much a we're only going to look at your sexual orientation and your gender identity and not look at anything else that you might need assistance with and just automatically reject care for you. And unfortunately, this is a very common narrative across California where it is extremely difficult to find physicians and mental health providers who are willing to learn with the LGBTQ community on how to take care of our health and our mental health. Next slide, please.

So I'm kind of going back down to Riverside County. This is from educator within the Riverside County School District who shared that they really try to teach their students and make their queer students feel normal at school and not feel like a minority. However, being the only queer teacher on campus, they're always educating their colleagues, their Admin staff and everything and constantly educating everyone around them just so that way the students would have someone that they can be comfortable with and living their true authentic lives and such. However, it really played on this educator's own mental health, because not only did they have to put out the time and energy to be a teacher and to really raise up and bring up the next generation of leaders, but they're also expelling additional energy on educating everyone around them about the LGBTQ community, so that way they could create that safe space. Next slide, please.

So kind of going now to Tulare. One of the things that was really talked about in the Central Valley was when it came to substance use and mental health, there are no rehabs or any facilities or recovery homes that are LGBTQ friendly. And this wasn't just in the Central Valley. We heard this. This was another one we heard all across California, including Los Angeles, San Francisco, Oakland, San Diego, where LGBTQ recovery homes really do not exist. And the recovery and rehabs that do say that they are LGBTQ affirming actually are not. And they actually cause additional trauma where LGBTQ patients leave the facility early because they do not feel safe, which then they fall back into substance abuse because of the way they were triggered in the rehab in the recovery home, in the different sober living situations. Next slide, please.

So, kind of going now over to our native and two spirit community members. This is what the previous speaker really spoke on previously on how. We don't just have our own trauma, but we carry the trauma of our ancestors and our parents. And it's really called historical trauma. So what we really need to see more of just across the board are those culturally responsive providers. Next slide, please.

So the last quote for the challenges that the community is experiencing is that there aren't any cultural sensitivity classes being offered to the various populations of folks, especially those that serve in terms of access to mental health care when it comes to insurance agencies, therapists, psychiatrists, other mental health professionals, pharmacists when they're dispensing medications and such. Really, having that cultural sensitivity with all of our intersecting identities is extremely important to not trigger our triggers and trauma but instead provide that healing that we're desperately seeking but are unable to attain. Next slide, please.

So, I just want to go over some quick conclusions with you all. Next slide. So, some of the common themes that we found was that there is a lack of LGBTQ competent providers and there's even a greater scarcity of those working with transgender clients. This really goes back to having those cultural sensitivity type classes or trainings for the providers. Additionally, BIPOC and LGBTQ members had difficulty finding and accessing culturally appropriate care. So this was something that was just really popped out at us over and over with both our qualitative and quantitative study. Next slide, please.

So, the other thing was that we really need therapists who have these intersecting identities and to be open about it so that way our community can find these therapists. As I mentioned, my therapist is 6 hours away in Sacramento and she is a native two spirit queer individual who completely understands my intersecting identities because we're able to relate to each other. Additionally, there is a lack of insurance coverage, providers not accepting insurance, and extremely high out of pocket costs. Next slide, please.

So, the other issue that we saw was, as mentioned throughout this presentation, the location travel time of traveling 2 hours or more one way and the time that appointments were available have been barriers. And then for our rural participants. The actual distance is the main problem. And with our urban participants, it's really the travel time due to traffic. If you've ever been to La, you know getting from one side of La. To the other side is easily 2 hours in itself fighting the traffic on the 405 or 101 freeway. Next slide, please.

Sorry, the other way. Thank you. So all of our respondents really endorse that a lack of Affirming nearby providers scheduling challenges, fears of discrimination on the basis of sexual orientation and gender identity are like the major barriers in accessing and receiving care. Next slide, please.

So what our participants really came up with and thought about when it came to policy changes, systemic changes, all of the different environmental changes is one we really need standardized, soji data collection and reporting. And we really need insurances and providers to even collect this data. So that way we can see who are those Affirming therapists or what types of trainings need to be done if folks aren't seeing LGBTQ patients. We really need LGBTQ affirming k through twelve as sex education. And not only for the students, but also for our own educators, teachers, Admins counselors to learn about the LGBTQ community and what our students are experiencing and facing in terms of bullying, racism, et cetera. So that way our schools can become an even safer place for our youth. So really, having that training for schools and daycare staff to support the students and families who are LGBTQ are really important. We also need gender inclusive reproductive and sexual health care. When we talk about mental health, we never think about inclusive reproductive or sexual health care. However, again, there is a lot of trauma our community experience when it comes to sexual assault and different situations that they need to talk to through with their therapists but are unable to because they are not knowledgeable in that arena. And then we also need LGBTQ program funding where LGBTQ centers can really build robust social and emotional support groups for our community. Because our community does not feel safe going into a medical provider's office or a therapist's office, they are flocking to our local LGBTQ centers looking for services. So we need to be able to fund those services so that way they can gain the access to social and emotional support that they fully need. Next slide, please.

The other thing is we need to create a listing of insurance on insurance websites that really identifies the culturally competent LGBTQ based medical providers and mental health providers. It is extremely difficult to identify who are able and understand our community unless we talk to each other word of mouth. And that's really how we find our therapists are by word of mouth, by sharing our experiences, by saying like, hey, I know this person is seeing this provider over here, let me give you their number and such. And then we also need to reduce and eliminate the barriers to mental health providers who accept medical while increasing that access to care. Next slide, please.

And then, as mentioned, we need to fund LGBTQ organizations to hire support group facilitators, but to also bring on mental health staff such as therapists and everything. So, so many LGBTQ organizations provide internships to future mental health providers, but they need permanent full time mental health staff to meet the needs of the community. Next slide, please.

So I really appreciate your time. I really appreciate your patience as I went through this presentation. All of our reports are on our website where you can see our very first report from 2018 all the way through 2021. Our 2022 report will be published this August. But I really do want to thank you all for your time and answer any questions you may have.

Thank you very much for your thoughtfulness and your thoroughness on your presentation. I believe you answered all the questions and then some for us, but most importantly, of course, making sure that we get a copy of your information so that we can ensure that other committee members also have access to it. And so as we begin to think about possible legislative solutions for next year. But thank you so much for especially the qualitative data that you were able to provide to us on real experiences throughout the state of California, both rural and urban areas. And so thank you so much for that information.

Thank you so much for the opportunity.

We want to thank everyone for being here. We want to thank all of our panelists. And please note before we go to public comments, that our last session again is going to be June 7. And at that hearing, we will be highlighting more mental health issues affecting the Asian Pacific Islander community, our seniors as well as our veterans as well. And then we will cap it off with solutions moving forward as we begin to continue to find both common sense solutions to this mental health crisis and then also some mountains we need to move and some systems we need to make sure shift and conform to making sure that we're meeting this moment in this crisis. So we will now go into our public comment period. Are there any public comments on our phone lines?

Thank you. For any public comment, you may press. One and then zero. We do have one that comes from line eight.

One and then zero.

Your line is open. Good afternoon, Assembly Member Jackson and honorable members of the Select Committee on the Mental Health Crisis. I'm Adrian Shelton with the California Alliance of Child and Family Services. We are a statewide association of nationally accredited nonprofits that are serving children, youth and families in our safety net programs in all of the 58 counties in California. So we really want to thank the committee again for bringing attention to the urgent issues of our state as it relates to mental health care in California and how we can improve services and save lives. Just wanted to reiterate here that we have a youth behavioral health crisis. When you look at suicide rates for children and youth, the rates are skyrocketing. And this is even before the full brunt of the pandemic. We also have significant disparities among demographic groups which are further caused for alarm. So, for example, our California Department of Public Health notes that youth ages ten to 24 who are black experience the largest increase in suicide rates. And as we know, this is just one measure of mental health. So these struggles are playing out in classrooms, in our homes, and in communities. So we just would love to explore with this committee and the leadership here about how we can dig into the issues that our vulnerable youth are facing, what the innovative programs that are serving them look like, and what we can do to ensure that we continue to meet youth where they are at the right place and with the right intervention. So please consider us at the California Alliance and our providers a resource to all of you and thank you so much again for this amazing hearing.

Thank you, Mr. Chair. We have no further comments in queue.

Thank you very much. Thank you for those who provided testimony. Again, and this hearing was just about making sure that all communities know that we see you, we hear you, and it's important to make sure that you all have the space to tell your stories, to tell your experiences, and to be able to inform the legislative process as we try to meet this moment. So I want to thank again, our Vice Chair, Assembly Member Pellerin, for being here and being a fantastic partner as we go on this journey together. And again, thank you to everyone, including thank you to my staff who might need some mental health support dealing with me, but I love them nonetheless. So thank you very much and we will adjourn this hearing.