Editor’s note: This is the fourth in a series of stories on how law enforcement and the mental health system failed the Steichen family.

What happened to the Steichen family two years ago was a disaster, but the family’s story isn’t unique.

In March 2020, a 27-year-old Massachusetts man with untreated schizophrenia fatally stabbed his mother and stabbed his stepfather, later telling police that his “alleged mother” had kidnapped and tried to poison him.

In January 2015, a 21-year-old New York man with schizophrenia fatally stabbed his aunt, uncle and sister, placing a glass nativity set on his uncle’s stomach, among other bizarre behaviors, because he thought it would get rid of the devil.

In October 2019, a 24-year-old Louisiana woman with untreated bipolar disorder and schizophrenia committed suicide after having violent outbursts and saying she was hearing voices.

The national nonprofit Treatment Advocacy Center has a database of preventable tragedies with almost 4,000 news articles from across the country related to people with schizophrenia getting arrested for committing a crime, getting killed by police or committing suicide, usually as the result of not receiving treatment.

“There are many tragic outcomes and some preventable outcomes as a result of untreated severe mental illness, including violent behavior,” Elizabeth Hancq, research director with the Treatment Advocacy Center, told The Times-Standard.

There were 14.2 million adults with a serious mental illness, like schizophrenia or severe bipolar disorder in 2020, and 35% of them, about 5.1 million, were going without treatment, according to the National Institute of Mental Health.

Going without treatment has a lot of negative outcomes for people with severe mental illness, Hancq said, pointing to how they are overrepresented in jails and prisons, more likely to be victimized by sexual and other violent assaults, more likely to experience homelessness, and 16 times more likely to be shot and killed by law enforcement, along with having high rates of suicidal behavior.

But she said one part that goes overlooked because of the stigma around mental illness is that, while most people with mental illness are not dangerous, people with untreated severe mental illness have higher rates of violent behavior than people with treated severe mental illnesses and the general population.

“The recognition that untreated severe mental illness can lead to more violent behavior is an important one when we’re discussing and trying to create policies and solutions to help,” Hancq said.

Schizophrenia and its treatments

Most of the time when people think of schizophrenia, they think of the hallucinations and delusions that people experience, said Katherine Jonas, an assistant professor of psychiatry and behavioral health at Stony Brook University and an expert in schizophrenia. Those are known as positive symptoms.

“That’s one symptom dimension out of, I would say, three,” Jonas said.

The other two dimensions are negative symptoms, where people have a lack of motivation to do things and have difficulty perceiving and expressing emotions, and cognitive decline that is associated with difficulty going to school and work, as well as maintaining independent functioning.

How an individual’s schizophrenia progresses varies, but in general, Jonas said symptoms get worse over time even if a person responds well initially to treatment. That treatment tends to come in the form of antipsychotic medications, which really only impact the positive symptoms like hallucinations, Jonas said.

“They don’t really do much for the negative symptoms or the cognitive deficits,” Jonas said. “There are a lot of researchers working right now to develop treatments for those, but there are certainly no pharmacological treatments right now.”

There are some psychosocial therapies for the negative symptoms, but Jonas said it’s hard to get access to those since there aren’t many people trained to provide them on top of the fact that it can be hard to find a therapist in general.

“It’s more expensive than medication,” Jonas said. “So it’s just less accessible and fewer people get those. Vocational rehabilitation is also really helpful, again, if you can get it. So oftentimes people just receive antipsychotic medication, it’s kind of the standard.”

Sometimes people with a severe mental illness have a neurological condition called anosognosia, or a lack of insight into the fact that a person has a mental illness in need of treatment, leading them to refuse treatment.

But people may also decline if the primary treatment a person is being offered is antipsychotic medication, which have serious side effects, with no therapy or vocational rehabilitation, Jonas said.

“People tend to gain a significant amount of weight and there’s a high rate of metabolic syndrome among people with schizophrenia,” Jonas said. “That’s just one of the side effects of antipsychotic drugs and there are many others.”

Broken continuums of care

A hundred years ago, people with severe mental illness would be committed to state hospitals, but that changed with the deinstitutionalization movement half a century ago. State hospitals were closed as the state began prioritizing the autonomy of people with these illnesses.

“The idea behind the deinstitutionalization movement was fundamentally sound,” Hancq said. “Most people with severe mental illness can live successfully in the community with adequate supports, however, the adequate supports weren’t necessarily realized.”

The Community Mental Health Act of 1963, which was signed by President John F. Kennedy, didn’t recognize inpatient psychiatric care as an essential component of the continuum of care for people with psychiatric illnesses, but Hancq said that’s just as necessary as outpatient treatment.

“Severe mental illness, such as schizophrenia and severe bipolar disorder, like any other chronic illness, have symptoms that wax and wane over time,” Hancq said. “So someone with severe mental illness, when their symptoms are at their peak, may need inpatient psychiatric care at some point over the course of their illness and should have access to those inpatient beds.”

People don’t have access to those beds because of a federal rule called the Medicaid Institutions for Mental Diseases exclusion, which states inpatient psychiatric services in a psychiatric hospital that has more than 16 beds cannot be reimbursed through Medicaid funds.

But there’s also the added issue that “the treatment system is not built for those that do not understand that they are ill,” Hancq said.

Changes being made

In line with the rest of the deinstitutionalization movement, the state Legislature passed the Lanterman-Petris-Short Act in 1967 to limit the involuntary detention of all but the most gravely mentally ill, but that quickly led to psychiatrists in jails seeing an increased number of people with severe mental illnesses.

“We’ve been trying to figure out ever since then how we deal with the fact that people who need a lot of structure and support in the community are not getting it,” said Randall Hagar, director of government relations for the California Psychiatric Association and a board member of the Treatment Advocacy Center. “So there’s been various things that have been crafted to help us try to deal with what’s been called transinstitutionalization — people going from state hospitals to jails and prisons.”

Hagar worked for years to get the “grave disability” added to the involuntary treatment standard in the state, but the implementation of that standard ends up impacting whether or not a person actually receives treatment.

About 20 years ago, the state also passed Laura’s Law, named after Laura Wilcox, a 19-year-old woman who was fatally shot by a man with untreated severe mental illness. The law provides community-based, assisted outpatient treatment to people who are unable to voluntarily access treatment as a result of their mental illness.

Hagar was one of the primary drafters of that law, as well as the state’s Mental Health Parity Act.

That program did not have funding for a long time, but Hagar said he worked with State Sen. Darrell Steinberg to pass a bill that clarified Mental Health Service Act funds could be used for the program.

“That was a great boost,” Hagar said. “At that point, we only had a couple of counties implementing it and when that clarification became law, we had Orange County, San Francisco and 20 other counties implementing.”

Humboldt County implemented its assisted outpatient treatment recently, too.

Sonia Waraich can be reached at 707-441-0504.