Aching from the loss of her son, Michelle Reed of Fresno, CA, tries to focus on happy memories, taking solace in the messages she received from her son Dajon's friends, who remember him for his smile and kindness.

“He was always smiling, very happy, very kind-hearted,” Reed said. “He would give the shirt off his back.”

However, at age 16, Dajon started to show signs of mental health challenges. The boy who loved to sing, dance and read comic books lost his desire to do anything, often staying in his room all day and refusing to eat. Michelle was shocked by the sudden change of behavior from her son. She became even more surprised when Dajon revealed that he was molested by a female family member at age four.

“I didn't realize that he was dealing with his own battles," Michelle said.

As the years went by, Dajon went in and out of mental health facilities several times and continued to struggle with schizophrenia.

“He thought the TV was talking to him,” Michelle said. “He was decompensating completely.”

On July 27, 2019, when he was only 24, Dajon died by suicide in front of a train.

“He was kneeling, praying,” the train conductor told Michelle. “He would not move as they blew the horn.”

Michelle said Dajon’s death happened less than a year after he was released from a mental health facility. Now, she is left with questions for the mental health system. She wonders why did a Fresno judge go against psychiatrists' recommendations and released Dajon from a temporary Lanterman Petris Short (LPS) conservatorship before he was ready to be on his own.

Hoping to get answers from Congress and the president, Michelle created an online petition. Thus far, it has garnered more than 5,000 signatures.

“My son was considered homeless because he lost his housing after he became hospitalized, but he told the judge he would stay at the mission,” Michelle wrote in Change.org the petition. “No one ever contacted me to create a safety plan. Being that a psychiatrist recommended he stay in the hospital a year, one would think this warranted such actions at bare minimum.”

In Michelle's opinion, only treating psychiatrists should determine who needs hospitalization and who should be released for LPS temporary and permanent conservatorships, not a judge.

Although the County of Fresno Department of Behavioral Health said it can’t speak on specific cases pertaining to death via suicide, they did discuss the initiative known as Fresno County Suicide Prevention Collaborative (FCSPC).

“The FCSPC is a group made up of major local organizations representing different sectors ranging from health care, education, law enforcement, first responders, community organizations and suicide prevention experts," Brian Bishop, communication director at the Department of Behavioral Health, said. "The collaborative meets monthly to work on identifying trainings for the community, coordinate communication and other efforts for suicide prevention awareness.”

According to Bishop, the Fresno County Board of Supervisors adopted a suicide prevention plan in September, making Fresno the first county in California to formally adopt such an initiative. For Dajon, Michelle said there was never a plan, so he had no place to go after he was released.

“I have two little boys,” Reed said. “If I bring him to my house and he’s freaking out on the boys and decompensating, what am I supposed to do?’”

Michelle decided to put Dajon in a hotel temporarily. However, Dajon only lasted in the hotel for one night.

“The first night he just started flipping out,” she said. “The next day they called me and kicked him out of the hotel.”

Michelle then brought Dajon to her house and made him promise to take his medication.

“He would have his moments where he was combative, but I didn’t want my son on the streets,” she said. “What was I supposed to do?”

Michelle said Dajon qualified for section 8, then went to the SSA and made himself his own payee. When she went to talk to the social security supervisors, Michelle said she asked them why they would make him his own payee against the recommendation of a psychiatrist.

“I said, 'You do realize that he’s a mental health patient. He’s gonna get alcohol. He’s gonna get weed,'” Reed said. “They didn’t care, so he had his own money.”

With his rent amounting to about $300, Michelle said Dajon had plenty of money to buy other supplies he didn’t need.

“He would buy $300 worth of weed, and he would buy bottles and bottles of vodka,” Michelle said. “He would sit there and self-medicate because the medication apparently wasn’t doing what it needed to do.”

Michelle addresses her concern about SSI benefits in her petition.

“Judges and government agencies such as Social Security Administration making decisions that override psychiatrists, allowing clients with substance abuse and mental health diagnoses to be their own payee against psychiatric recommendations and releasing clients that are severe without safety plans in place at bare minimum is unacceptable,” she wrote.

She added that Dajon's psychiatrist sent SSI documentation asserting that because of his mental health and struggle with addiction, he should not have been the payee. She said that following an interview with a Social Security Administration representative, it was determined Dajon was in adequate condition to be the payee, despite the recommendation of his psychiatrist.

Michelle said she was unable to have any input on their decision and adds that Dajon's case manager Allen Cha reportedly seldom reached out to him.

"Since clients don't get proper treatment. Then there is a case overload and clients fall through the cracks," Reed said.

Cha declined to be interviewed for this story, saying he can't disclose information around Dajon's case.

Gidai Maaza, a Fresno-based mental health professional, said the mental health system must include community voice and engagement to hear the concerns of people like Michelle.

“They will tell you, ‘The families can go on our website or let the families call probation or call the courts,'” Maaza said. “The solution is real community engagement. Sitting with these families, bringing together focus groups that are really talking about, ‘Hey, what’s missing? What are your needs?'"

Maaza said there is a nationwide problem with the mental health system, but it’s especially a problem in places like Fresno, where the issue is overlooked by other problems.

“There are other issues in Fresno like poverty and crime. Those tend to be big red flags and the nation and the state will listen to that, but our city will hide behind those problems,” Maaza said. “Then they get away with whatever they want.”

Wobitu Gebresilassie, another Fresno resident, can also attest to having had difficulty ensuring her loved one received adequate health care through the county's behavioral health department. When a psychiatrist abruptly changed the medication routine of her brother, Gebresilassie claimed the condition of his mental health worsened.

“My brother was part of the behavioral health there,” Gebresilassie said. “Dealing with the psychiatrist himself was just hard. He didn't want to listen to anything that I had to say.”

Gebresilassie said her brother was making progress until the new psychiatrist prescribed him a different regiment of medications, which caused him to show irrational behavior and often disappear for days.

“I would go down there and I would ask [the doctor], ‘Hey, can you please put him back on the meds that he was taking?’” Gebresilassie said. “He would tell me, ‘I can't just change the medicine because you come in here. You would have to bring him in.’”

However, Gebresilassie said doing so was difficult because of how her brother was typically difficult to track down, and when she could find him, he wouldn't be in the right state of mind.

“It's just hard to see your family have to suffer, and no one wants to hear you,” Gebresilassie said. “No one really cares about the mentally ill. They're just another case number.”

When it comes to minority groups such as Gebresilassie’s family, experts say race usually plays a factor in how they are treated within the mental health system.

“Statistically speaking, African Americans, being a small minority in the country, tend to have the most significant mental health issues, and mainly lack access to resources to get the support they need,” Maaza said. “Hispanics fall under that category, as well.”

According to the National Alliance on Mental Illness (NAMI), "Approximately 30 [percent] of African American adults with mental illness receive treatment each year, compared to the U.S. average of 43 [percent]. […] Misdiagnoses, inadequate treatment and lack of cultural competence by health professionals cause distrust and prevent many African Americans from seeking or staying in treatment."

For Dajon, who is Black along with a mix of several other ethnicities, Michelle said she has spoken to an expert at NAMI, who recommended talking to an attorney because there are instances in which African Americans don’t always get the care they need due to stigmatization. Michelle still weighs many of the other events that happened before Dajon’s death in her mind, including her son’s encounter with the relative who he said molested him.

“That was very shocking for me because I had my own sexual abuse trauma, and I used to tell him all the time, ‘If somebody is trying to touch, you can tell me,'” Reed said. “But the perpetrators — they have their way. They were trying to keep him quiet. He told me they said they would kill him.”

Michelle also believes Dajon could have been impacted by his father’s absence. “His father was never in his life. He never cared to be in it,” Reed said. “He didn’t go to the funeral.”

Although she can’t change the past, Michelle said she is determined to keep fighting for mental health reform. “It has been very difficult to live my life without my son,” Michelle said. “What keeps me going is fighting for him."

Bishop said Fresno County recently adopted the use of an evidence-based screening tool called the Columbia Suicide Severity Rating Scale, which will enable more screenings and better care coordination. Furthermore, the county is looking to increase engagement with the local community, particularly students, to help them understand the signs of suicide and share supportive resources, on top of the work Fresno's Local Outreach to Suicide Survivors team does to provide counseling and resources for families experiencing the trauma of suicide.

If you or someone you know is contemplating suicide, please call the National Suicide Prevention Lifeline at 800-273-TALK (8255).

Mental Health Reform

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