Law Gives Calif. Counties Commitment Authority

California Gov. Gray Davis signed legislation in September to permit county mental health department officials to order outpatient treatment for people with serious mental illness who cannot take care of themselves or are likely to harm themselves or others.

The legislation, which goes into effect on January 1, 2003, for a five-year period, will be enacted on a county-by-county basis dependent on whether each county is able to offer services required by the measure.

The new law gives courts an additional, less-restrictive option for helping seriously mentally ill people. The current law governing commitment, called the Lanterman-Petris-Short (LPS) Act, provides only for inpatient commitment and stipulates that individuals can be involuntarily hospitalized only if they pose an immediate danger to themselves or others or are judged by the court to be “gravely disabled,” a legal term meaning they do not have the ability to care for themselves. The law gives physicians a 72-hour period to evaluate such individuals and begin treatment.

Efforts have long been under way in California to reform the LPS law. Opponents of LPS have noted that, as written, the meaning of “danger” is subject to a vast degree of interpretation by law enforcement officers or health professionals who commit people with mental illness to involuntary treatment. As such, some people are committed only after they have attempted suicide or physically injured another. Those who fought to reform the LPS law maintained that court-ordered treatment fell under the category of “too little, too late.”

The new legislation would trigger the Outpatient Treatment Demonstration Act of 2002 (AB 1421), under which a community-based, multidisciplinary treatment team can provide intensive outpatient treatment to people with serious mental illness for a 180-day period.

The law includes a clause that requires participating counties to provide data to the California Department of Mental Health on a number of variables. They include but are not limited to the number of clients receiving the court-ordered outpatient treatment who have contacts with local law enforcement, the number involved in employment services programs, the number abusing substances, and the hospitalization days that have been reduced or avoided for persons in the program.

If the state can show that the outpatient treatment program is reducing hospitalization days and contacts with law enforcement, for instance, the legislation is likely to be extended past 2008, according to supporters of the measure. Similar data are now being collected under New York’s assisted outpatient treatment program, known as Kendra’s Law. Preliminary data in New York show that among those receiving intensive outpatient treatment, there has been a 129 percent increase in medication compliance and a 100 percent decrease in homelessness since the law went into effect.

The typical person who qualifies for treatment under AB 1421 is unlikely to survive safely in the community without supervision and has a history of refusing treatment, which has resulted in the following: the person has been hospitalized at least twice in the previous three years or has made one or more acts, attempts, or threats to cause serious physical harm to himself or herself or others in the previous four years.

Those who qualify for the court-ordered outpatient treatment may receive a wide range of services, including psychiatric and substance abuse treatment, housing assistance, and vocational rehabilitation. A mental health services coordinator is assigned to each patient and ensures that all care is individualized for that patient.

The counties that adopt the legislation must either already provide these services or be able to fund them with new money that does not take away from existing voluntary mental health treatment.

AB 1421 represents a hard-won victory for California Assemblywoman Helen Thomson (D-Davis), who wrote the bill. She renamed it Laura’s Law after 19-year-old Laura Wilcox, a Nevada County, Calif., mental health worker who was shot to death by a person with mental illness who had refused treatment.

Thomson tried for five years to reform the longstanding LPS law, under which as many as 30,000 institutionalized psychiatric patients were released into the community beginning in the late 1960s. Many ended up in state prisons and on the streets. In 2000 she wrote a bill similar to AB 1421 involving assisted outpatient treatment, but it met with opposition from Senate President Pro-Tem John Burton (D-San Francisco), who sent the bill to a research committee where it died (Psychiatric News, May 4, 2001).

Supporters of the measure expect that it will reduce unending cycles of relapse and recovery. In a press release dated September 28, Davis said, “This is a critical step in helping the seriously mentally ill as well as their families. This legislation will help end the cycle of hospitalization, quitting treatment, and relapse.”

The new law’s value lies in its preventative focus, Thomson told Psychiatric News. “Laura’s Law provides California counties with the option to intervene with court-ordered outpatient treatment before a person suffering from severe mental illness who refuses voluntary treatment becomes so ill that he or she requires inpatient treatment in a locked facility,” she said.

Thomson is optimistic about the willingness of California counties to support and adopt her legislation, even in the face of providing the intensive outpatient services that will call for a 10-to-1 patient-staff ratio. “Where there’s a will, there’s a way,” she said.

Thomson acknowledged that there has never been enough money allotted to mental health services in the state and noted that counties do the best they can with the resources available.

“I think that adding a court-ordered outpatient option to existing voluntary mental health programs will provide a more cost-effective continuum of mental health care. In the long run, it will save money through the avoided costs of repeated hospitalizations, jails, and prisons for the severely mentally ill.”

Thomson’s efforts were backed—and even preceded—by a phalanx of supporters in her fight to get court-ordered outpatient treatment to people with serious mental illness in California.

In 1995 Elizabeth Galton, M.D., president-elect of the California Psychiatric Association and then president of the Southern California Psychiatric Society, formed and cochaired the LPS Reform Task Force with Carla Jacobs, a board member of the Los Angeles chapter of the National Alliance for the Mentally Ill (NAMI) and now co-coordinator of the California Treatment Advocacy Coalition (CTAC), based in Orange County.

Out of the task force’s work came the report, “A New Vision for Mental Health Treatment Laws,” which listed 12 recommendations for LPS reform. The report was the basis for Thomson’s proposed legislation.

“We were fortunate to find Helen Thomson to champion our cause,” Galton told Psychiatric News. “She is a hero.”

While Thomson strove to push AB 1421 through the state legislature, Jacobs worked with the Arlington, Va.–based Treatment Advocacy Center, CTAC, and NAMI to rally the support of law enforcement, mental health professionals, and people with mental illness and their families. They worked on a letter-writing campaign that resulted in more than 1,000 letters being sent to state legislators in support of AB 1421.

“The legislation passed because of a massive outcry from California citizens,” Jacobs said. “We like to believe this law gives people the right to be free of psychosis.”

Under the LPS law, Jacobs asserted, “we’ve basically thrown these people into the streets and said, ‘We’ll help you when you become dangerous.’ If someone was delirious with a high fever, we would not leave him lying on the sidewalk until he lashed out. That is discrimination, and Laura’s Law is a step toward eliminating that discrimination.”

The text of AB 1421 can be accessed on the Web at www.leginfo.ca.gov by searching on the bill number. Additional information can be found on the Treatment Advocacy Center Web site at www.psychlaws.org. ▪