In the struggle to fix its broken mental hospital system, California has placed its fate in the hands of two out-of-state experts.
One, Nirbhay Singh, is a psychologist who has already been working to reform the system for nearly four years, but was unable to push through enough changes to avert a federal consent decree.
The other, Dr. Mohamed El-Sabaawi, is a psychiatrist who served as the U.S. Department of Justice's chief investigator of California's hospitals over the same four-year period and found them deeply troubled.
Singh's contract will be renewed for at least one more year -- at $1.1 million -- say state Department of Mental Health officials, who credit him with steering the system on the right course.
El-Sabaawi last week took off his Justice Department hat to become the court-appointed monitor who will oversee the extensive reforms mandated in the consent decree.
The two men, who know each other well and are both based in Virginia, are among a small stable of consultants who have worked for both the Justice Department and for dozens of state mental health institutions struggling with federal demands for improvement.
Both declined to be interviewed. But their histories shed light on the challenges that lie ahead as California works under threat of federal sanction over the next five years to improve care for nearly 5,000 gravely mentally ill patients.
State officials hired Singh after federal investigators in 2002 found severe problems at Norwalk's Metropolitan State Hospital involving misdiagnoses, unsafe conditions and improper medications and restraints.
First retained by the state attorney general's office as part of a broader team of experts, Singh became the Department of Mental Health's key architect of reform in 2004. Rather than wait for federal officials to finish their investigation, the state reasoned, California would get a jump on needed changes.
Singh has not worked as a clinician since 1981, in New Zealand, where he completed his education, according to his resume. His research and consulting has focused most intensively on patients with developmental disabilities -- not the severely mentally ill channeled through the criminal justice system who largely fill California's hospitals.
Yet his consulting record is ample: Since 1989, he has worked for the Justice Department to help correct problems at facilities in several states. He has promoted a holistic approach to healing, encouraging his college students to meditate and conducting paid research for an herbal anti-anxiety supplement.
Working to implement a model of care in California that individualizes treatment and involves patients in their recovery, Singh is the "eyes and ears" of administrators at the four mental hospitals under federal scrutiny. In addition to Metropolitan, those include San Bernardino's Patton State Hospital, and Atascadero and Napa state hospitals.
"Dr. Singh was the guy who started educating me," said John Rodriguez, deputy director of the state Department of Mental Health. "Having been a [Department of Justice] guy, he also knew where they were going. So that was helpful."
But his efforts have met with deep resistance and a growing lack of confidence among some of the hospital system's 9,000 staff members, who believe the changes implemented so far have done little to help patients.
The Department of Justice appears to agree. Last week, the civil rights division released findings noting that attempts to bring Patton State Hospital in line with the latest trends in care had disregarded "actual treatment needs" and in some cases "may aggravate the condition of patients already in distress."
Current and former staff at several of the hospitals described Singh's style as "arrogant" and "haphazard." At Patton and Metropolitan, they say, his push to implement "treatment malls," where hundreds of patients mingle and attend classes, has led to depersonalized care -- the opposite of federal goals.
"They actually distanced the clinicians from their patients," said former Patton social worker Kathy Kelly, who after 11 years resigned in frustration two months ago. "It became more dangerous, definitely less rewarding, and less effective.... I believe the medium for change is the relationship. They took that away from us."
Many psychiatrists have been fiercely critical of Singh and the recovery model, which has pressed them to share authority over diagnosing and treatment decisions with psychologists and other nonmedical staff. Psychiatrists have also chafed at being told by non-clinicians what to teach patients in "mall" classes.
Rodriguez dismisses such criticism as byproducts of a professional turf war. But four years after Singh began implementing changes at Metropolitan, even some psychologists have lost faith in his abilities, in part because of his limited experience with severe mental illness.