Category: Mental Health

Introduction

The Marchman Act, officially the “Hal S. Marchman Alcohol and Other Drug Services Act of 1993”, is a Florida law that provides a means of involuntary and voluntary assessment and stabilisation and treatment of a person allegedly abusing alcohol or drugs.

Refer to the Baker Act 1971, Lanterman-Petris-Short Act 1967, Laura’s Law 2002, and Kendra’s Law 1999.

Text of the Act

INVOLUNTARY CATEGORIES AND CRITERIA

The involuntary assessment and treatment has two categories non-court and court involved admissions. The criteria for involuntary admission is:

“There is good faith reason to believe the person is substance abuse impaired and, because of such impairment:

1. Has lost the power of self-control with respect to substance use; AND EITHER

2a. Has inflicted, or threatened or attempted to inflict, or unless admitted is likely to inflict, physical harm on himself or herself or another; OR

b. Is in need of substance abuse services and, by reason of substance abuse impairment, his or her judgment has been so impaired that the person is incapable of appreciating his or her need for such services and of making a rational decision in regard thereto; however, mere refusal to receive such services does not constitute evidence of lack of judgment with respect to his or her need for such services. “

It is under Title XXIX – PUBLIC HEALTH Chapter 397 -SUBSTANCE ABUSE SERVICES of the Florida Statutes. The links to these paragraphs are listed below:

PART IV

VOLUNTARY ADMISSIONS PROCEDURES

‘397.601 Voluntary admissions.

PART V

INVOLUNTARY ADMISSIONS PROCEDURES

397.675-397.6977

A. General Provisions

B. Non-court Involved Admissions: Protective Custody

C. Non-court Involved Admissions; Emergency

D. Non-court Involved Admissions; Alternative Involuntary Assessment for Minors

E. Court Involved Admissions, Civil Involuntary Proceedings; Generally

F. Court Involved Admissions; Involuntary Assessment; Stabilization

G. Court Involved Admissions; Involuntary Treatment

PART VII

OFFENDER REFERRALS

397.705 Referral of substance abuse impaired offenders to service providers.

397.706 Screening, assessment, and disposition of juvenile offenders.

PART VIII

INMATE SUBSTANCE ABUSE PROGRAMS

397.752 Scope of part.

397.753 Definitions.

397.754 Duties and responsibilities of the Department of Corrections.

Criteria

Criteria for involuntary admission is listed under the 397.675.

Timeframes

• 3-5 days for assessment under special conditions (minors or emergency admissions).
• Non-Court protective custody is limited to 3 days (72 hours). The court can order involuntary treatment at a licensed service provider for a period not to exceed 60 days.

Procedure

• A sworn affidavit is signed at the local county courthouse or clerk’s office.
• A hearing is set before the court after a Petition for Involuntary Assessment and Stabilisation is filed.
• Following the hearing, the individual is held for up to five days for medical stabilisation and assessment.
• A Petition for Treatment must be filed with the court and a second hearing is held for the court to review the assessment.
• Based on the assessment and the recommendation that the individual needs extended help, the judge can then order a 60-day treatment period with a possible 90-day extension, if necessary.
• If the addict exits treatment in violation of the judge’s order, the addict must return to court and answer to the court as to why they did not comply with treatment. Then the individual is returned immediately for involuntary care.
• If the addict refuses, they are held in civil contempt of court for not following treatment order and are ordered to either return to treatment or be incarcerated.

Costs

It is an unfunded state requirement and each community must allocate funds for it.

Additionally, there are filing fees with the court.

Introduction

Kendra’s Law, effective since November 1999, is a New York State law concerning involuntary outpatient commitment also known as assisted outpatient treatment.

It grants judges the authority to issue orders that require people who meet certain criteria to regularly undergo psychiatric treatment. Failure to comply could result in commitment for up to 72 hours. Kendra’s Law does not mandate that patients be forced to take medication.

It was originally proposed by members of the National Alliance on Mental Illness, the Alliance on Mental Illness of New York State, and many local NAMI chapters throughout the state. They were concerned that laws were preventing individuals with serious mental illness from receiving care until after they became “dangerous to self or others”. They viewed outpatient commitment as a less expensive, less restrictive and more humane alternative to inpatient commitment.

The members of NAMI, working with NYS Assemblywoman Elizabeth Connelly, NYC Department of Mental Health Commissioner Doctor Luis Marcos, and Doctor Howard Telson were successful in getting a three-year pilot commitment program started at Bellevue Hospital. When the Bellevue outpatient commitment programme came to an end, Attorney General Eliot Spitzer, the Treatment Advocacy Centre and DJ Jaffe put together a coalition to pass a statewide law. It was based on the same concept as the Bellevue Outpatient Commitment Programme but with important differences.

Refer to Baker Act 1971, Lanterman-Petris-Short Act 1967, Laura’s Law 2002, and the Marchman Act 1993.

Background

In 1999, there was a series of incidents involving individuals with untreated mental illness becoming violent. In one assault in the New York City Subway, Andrew Goldstein, then 29 and diagnosed with schizophrenia but off medication, pushed Kendra Webdale into the path of an oncoming N train at the 23rd Street station. Goldstein had recently attempted to get treatment but had been turned away. Kendra’s family joined a coalition led by Governor Pataki, the Treatment Advocacy Centre and DJ Jaffe, and the family played a significant role in getting the law passed. Subsequently, in a similar incident, Julio Perez, age 43, pushed Edgar Rivera in front of an uptown 6 train at 51st Street. Rivera lost his legs and became a strong supporter of the law. Kendra’s Law, introduced by Governor George E. Pataki, was created as a response to these incidents. In 2005, the law was extended for 5 years.

As a result of these incidents, involuntary outpatient commitment moved from being seen as a program to help people with mental illness to a program that could increase public safety. Public safety advocates joined advocates in trying to take the Bellevue Pilot Program statewide. What was formerly known as involuntary outpatient commitment was re-named euphemistically as “assisted outpatient treatment”, in an attempt to imply a positive intent of the law.

Criteria

Kendra’s Law allows courts to order certain people diagnosed with mental illness to attend treatment as a condition for living in the community. The law is aimed at those who have a pattern of not following treatment recommendations which has resulted in re-hospitalisation, and/or violent behaviour placing the patient or others as serious risk of physical harm.

In order to be admitted to Kendra’s Law, individuals must meet the following criteria established in Section 9.60 of NYS Mental Health Law. A patient may be ordered to obtain assisted outpatient treatment if the court finds by clear and convincing evidence that:

• The patient is eighteen years of age or older; and
• The patient is suffering from a mental illness; and
• The patient is unlikely to survive safely in the community without supervision, based on a clinical determination; and
• The patient has a history of lack of compliance with treatment for mental illness that has:
  • At least twice within the last thirty-six months been a significant factor in necessitating hospitalisation in a hospital, or receipt of services in a forensic or other mental health unit of a correctional facility or a local correctional facility, not including any period during which the person was hospitalised or incarcerated immediately preceding the filing of the petition or;
  • Resulted in one or more acts of serious violent behaviour toward self or others or threats of, or attempts at, serious physical harm to self or others within the last forty-eight months, not including any period in which the person was hospitalised or incarcerated immediately preceding the filing of the petition; and
• The patient is, as a result of his or her mental illness, unlikely to voluntarily participate in the recommended treatment pursuant to the treatment plan; and
• In view of the patient’s treatment history and current behaviour, the patient is in need of assisted outpatient treatment in order to prevent a relapse or deterioration which would be likely to result in serious harm to the patient or others as defined in section 9.01 of this article; and
• It is likely that the patient will benefit from assisted outpatient treatment; and
• If the patient has executed a health care proxy as defined in article 29-C of the public health law, that any directions included in such proxy shall be taken into account by the court in determining the written treatment plan; and
• The treatment plan set forth is the least restrictive plan that is most likely to benefit the patient.

A patient can only be ordered to Assisted Outpatient Treatment for a maximum 12-month period. The Assisted Outpatient Treatment may be renewed by petition filed prior to the current order’s expiration. Where the petition is for a renewal, the 36-month limit for re-hospitalisations and the 48-month limit for violent behaviour do not apply.

Support

The New York Times reported:

“a study has found that a controversial program that orders these patients to receive treatment when they are not hospitalized has had positive results. Patients were much less likely to end up back in psychiatric hospitals and were arrested less often. Use of outpatient treatment significantly increased, as did refills of medication. Costs to the mental health system and Medicaid of caring for these patients dropped by half or more.”

According to the Treatment Advocacy Centre, the following organisations (in part or in full) support the law:

• National:
  • Treatment Advocacy Center (TAC).
  • American Psychiatric Nurses Association.
  • American Psychiatric Association.
  • National Alliance on Mental Illness (NAMI).
  • National Sheriffs Association.
  • National Crime Prevention Council.
• Statewide:
  • National Alliance on Mental Illness New York State (NAMI NYS).
  • NYS Association of Chiefs of Police (NYSCOP).
• Regional/local:
  • AMI-Friends of NYS Psychiatric Institute, NYC.
  • NAMI/Familya of Rockland County.
  • NAMI Schenectady.
  • NAMI Chautauqua County.
  • NAMI of Buffalo and Erie County.
  • NAMI of NYC/Staten Island.
  • NAMI Orange County.
  • NAMI Champlain Valley.
  • Harlem Alliance for the Mentally Ill.
  • NAMI of Montgomery, Fulton, Hamilton Counties.
  • NAMI/Albany Relatives.
  • NAMI North Country.
  • Albany County Forensic Task Force.
  • Westchester County Chiefs of Police Association.
  • Orange County Police Chiefs Association.
  • Town of New Windsor, Police Department.
  • Town of Chester, NY Police Department.
  • Town of Mechanicville, Police Department.
  • West Seneca, NY Police Department.
  • Broome County District Attorney.
• Selected individual supporters:
  • Dr. Xavier Amador – author, I am Not Sick, I Don’t Need Help!
  • Pete Early – author, Crazy: A Father’s Search Through America’s Mental Health Madness.
  • Rael Jean Isaac – co-author, Madness in the Streets.
  • Dr. Richard Lamb – Dept. of Psychiatry, USC.
  • Edgar Rivera – lost legs in subway pushing.
  • E. Fuller Torrey – author, Surviving Schizophrenia.
  • Pat Webdale – mother of Kendra Webdale.
  • Dr. Robert Yolken – Director of Developmental Neurovirology Johns Hopkins Univ.
  • DJ Jaffe, Executive Dir. Mental Illness Policy Org.
• Media editorial supporters:
  • New York Times.
  • Newsday.
  • New York Post.
  • Daily News.
  • Albany Times Union.
  • Buffalo News.
  • Troy News.
  • Office of the Attorney General.
  • NYS Public Employees Federation.
  • Greater NY Hospital Association.
  • Citizens Crime Commission.
  • Victim Services Agency.
  • Visiting Nurses Service.
  • Justice for All.
  • St. Francis Residence.

Moreover, research (outlined in the “Studies” section below) specifically on Kendra’s Law in New York State shows lower rates of violence, homelessness, arrest, incarceration, and cost. It shows that shows those who support Kendra’s Law say it helps them get well and stay well. Research in other states that have Assisted Outpatient Treatment programs have also shown positive results.

Courts have ruled that Assisted Outpatient Treatment (Kendra’s Law) does not violate rights citing the narrow criteria, the fact that the law does not provide for medication over objection (“force”) and the government interest in reducing violence.

Supporters note that the system in the United States is so different from that in the UK that studies that aggregate community treatment orders (CTOs) used in the UK and elsewhere overseas with Kendra’s Law as practiced in the US do not give as accurate a picture as studies exclusively on Kendra’s Law. They note that the Cochrane Study quoted by opponents of Assisted Outpatient Treatment did not include any of the studies on Kendra’s Law, or Assisted Outpatient Treatment as practiced in other states, and only included a pilot program, the Bellevue Outpatient Commitment Program, that was never taken statewide.

In addition, the New York Times reported on Kendra’s Law:

The “program that orders these patients to receive treatment when they are not hospitalized has had positive results. Patients were much less likely to end up back in psychiatric hospitals and were arrested less often. Use of outpatient treatment significantly increased, as did refills of medication. Costs to the mental health system and Medicaid of caring for these patients dropped by half or more.”

Opposition

Kendra’s Law is opposed for different reasons by many groups, most notably the anti-psychiatry movement and the New York Civil Liberties Union. Opponents say that the law has harmed the mental health system, because it can deter people from seeking treatment. The implementation of the law is also criticised as being racially and socioeconomically biased.

Studies

A 2017 Cochrane systematic review of the literature, that included three relatively small randomized controlled trials, did not find significant differences in the use of services, social functioning, or quality of life when comparing compulsory community treatment with standard voluntary care or brief supervised discharge. The systematic review did report that people who receive compulsory community treatment may be less likely to be victims of crime, both violent and non-violent.

A randomised, controlled trial published in The Lancet concluded, “the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients’ personal liberty.”

Of 442 patients assessed, 336 patients were randomly assigned to be discharged from hospital either on CTO (167 patients) or Section 17 leave (169 patients). One patient withdrew directly after randomisation and two were ineligible, giving a total sample of 333 patients (166 in the CTO group and 167 in the Section 17 group). At 12 months, despite the fact that the length of initial compulsory outpatient treatment differed significantly between the two groups (median 183 days CTO group vs 8 days Section 17 group, p<0·001) the number of patients readmitted did not differ between groups (59 [36%] of 166 patients in the CTO group vs 60 [36%] of 167 patients in the Section 17 group; adjusted relative risk 1·0 [95% CI 0·75—1·33]).

A 2005 study, “Kendra’s Law: A Final Report on the Status of Assisted Outpatient Treatment”, done by New York State’s Office of Mental Health, concluded, “Over a three year period prior to their AOT order, almost all (97%) had been hospitalised (with an average of three hospitalisations per recipient), and many experienced homelessness, arrest, and incarceration. During participation in the AOT programme, rates for hospitalisations, homelessness, arrests, and incarcerations have declined significantly, and programme participants have experienced a lessening of the stress associated with these events.”

The same study found 55% fewer recipients engaged in suicide attempts or physical harm to self; 47% fewer physically harmed others; 46% fewer damaged or destroyed property; 43% fewer threatened physical harm to others and the average decrease in harmful behaviour was 44%. 74% fewer participants experienced homelessness; 77% fewer experienced psychiatric hospitalisation; there was a 56% reduction in length of hospitalization; 83% fewer experienced arrest; 87% fewer experienced incarceration; 49% fewer abused alcohol and 48% fewer abused drugs. The number of individuals exhibiting good adherence to meds increased 51%; The number of individuals exhibiting good service engagement increased 103%.

The study found that of those subjects included in the sample, 75% reported that AOT helped them gain control over their lives; 81% said AOT helped them get and stay well; 90% said AOT made them more likely to keep appointments and take medications; 87% of participants said they were confident in their case manager’s ability, and 88% said they and their case manager agreed on the issues to be addressed.

The study reported the following effects on the mental health system. “Improved access to services. AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers.” “Improved treatment plan development, discharge planning, and coordination of service planning. Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past.” “Improved collaboration between mental health and court systems. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources.” “There is now an organized process to prioritize and monitor individuals with the greatest need …” AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve. …” “There is now increased collaboration between inpatient and community-based providers.”

A 2009 study, New York State Assisted Outpatient Treatment Evaluation done by Duke University, Policy Research Associates, University of Virginia, concluded that New York State’s programme had the following effects on the mental health system:

…improves a range of important outcomes for its recipients, apparently without feared negative consequences to recipients. The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order, itself, and its monitoring do appear to offer additional benefits in improving outcomes. It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.

The authors said that the evaluation reflected not just the compulsory aspects of the programme, but the additional resources provided for recipients, particularly in New York City.

The same study found “No evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings.” “AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.” “After 12 months or more on AOT, service engagement increased such that AOT recipients were judged to be more engaged than voluntary patients. This suggests that after 12 months or more, when combined with intensive services, AOT increases service engagement compared to voluntary treatment alone.” “Despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their treatment experiences than comparable individuals who are not under AOT.”

One study found Kendra’s Law has lowered risk of violent behaviour, reduced thoughts about suicide, and enhanced capacity to function despite problems with mental illness. Patients given mandatory outpatient treatment were four times less likely than members of the control group to perpetrate serious violence after undergoing treatment. Patients who underwent mandatory treatment reported higher social functioning and slightly less stigma, rebutting claims that mandatory outpatient care is a threat to self-esteem.

Another study found, “For those who received AOT, the odds of any arrest were 2.66 times greater (p<.01) and the odds of arrest for a violent offense 8.61 times greater (p<.05) before AOT than they were in the period during and shortly after AOT. The group never receiving AOT had nearly double the odds (1.91, p<.05) of arrest compared with the AOT group in the period during and shortly after assignment.”

Another study found, “The odds of arrest for participants currently receiving AOT were nearly two-thirds lower (OR=.39, p<.01) than for individuals who had not yet initiated AOT or signed a voluntary service agreement.”

A study previously cited also found, “The likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order … and by over one-third during a subsequent six-month renewal of the order…. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals…. Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services.”

A peer-reviewed study that included an analysis on the costs of Assisted Outpatient Treatment found that in New York City net costs declined 50% in the first year after Assisted Outpatient Treatment began and an additional 13% in the second year. In non-NYC counties, costs declined 62% in the first year and an additional 27% in the second year. This was in spite of the fact that psychotropic drug costs increased during the first year after initiation of Assisted Outpatient Treatment, by 40 percent and 44 percent in the city and five-county samples, respectively. The increased community-based mental health costs were more than offset by the reduction in inpatient and incarceration costs. Cost declines associated with Assisted Outpatient Treatment were about twice as large as those seen for voluntary services.

Another study found that “In all three regions, for all three groups, the predicted probability of a M(edication) P(ossession) R(atio) ≥80% improved over time (AOT improved by 31–40 percentage points, followed by enhanced services, which improved by 15–22 points, and ‘neither treatment,’ improving 8–19 points).”

Another peer review study on the effect of AOT on the mental health system found that “In tandem with New York’s AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.”

Finally, a study found individuals in AOT stay in treatment after AOT ends. “When the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services.”

Current Status

On 15 January 2013, then New York Governor Andrew Cuomo signed into law a new measure that extended Kendra’s Law through 2017.

47 states have adopted laws allowing for assisted outpatient treatment.

In February 2021, Governor Cuomo suggested that state lawmakers should revisit or expand Kendra’s law, after New York City experienced a spate of violent attacks committed by people with untreated mental illness.

Introduction

Laura’s Law is a California state law that allows for court-ordered assisted outpatient treatment. To qualify for the program, the person must have a serious mental illness plus a recent history of psychiatric hospitalisations, jailing or acts, threats or attempts of serious violent behaviour towards self or others. A complete functional outline of the legal procedures and safeguards within Laura’s Law has been prepared by NAMI San Mateo.

The law was named after Laura Wilcox, a receptionist who was killed by a man who had refused psychiatric treatment. Modelled on Kendra’s Law (1999), a similar statute enacted in New York, the bill was introduced as Assembly Bill 1421 by Assemblywoman Helen Thomson, a Democrat from Davis. The measure passed the California Legislature in 2002 and was signed into law by Governor Gray Davis. The statute can only be used in counties that choose to enact outpatient commitment programs based on the measure. As of 2010, Nevada County has fully implemented the law and Los Angeles County has a pilot project. In 2010 the California State Association of Counties chose Nevada County to receive its Challenge Award for implementing Laura’s Law. Subsequently, in 2011, a National Association of Counties Achievement Award in Health was awarded to Nevada County for the Assisted Outpatient Treatment Programme.

Refer to Baker Act 1971, Lanterman-Petris-Short Act 1967, Kendra’s Law 1999, and the Marchman Act 1993.

Background

Laura Wilcox was a 19-year-old college sophomore who had been valedictorian of her high school before going on to study at Haverford College. While working at Nevada County’s public mental health clinic during her winter break from college, on 10 January 2001, she and two other people were shot to death by Scott Harlan Thorpe, a 40-year-old man who resisted his family’s and a social worker’s attempt to have him hospitalised when he became increasingly delusional and paranoid. Thorpe was found incompetent to stand trial and was sent to Atascadero State Hospital and was later transferred to California’s Napa State Hospital. After the incident Laura’s parents chose to advocate for assisted outpatient treatment of individuals considered to have mental illness.

Implementation at County Discretion

The law is only operative in those counties in which the county board of supervisors, by resolution, authorizes its application and makes a finding that no voluntary mental health programme serving adults, and no children’s mental health program, was reduced in order to implement the law.

In 2004, Los Angeles County implemented Laura’s Law on a limited basis. Since the passage of the MHSA, Kern County, Los Angeles County, Nevada County, Orange County, Placer County, San Diego County, San Mateo County, Yolo County, Contra Costa County, the City and County of San Francisco, Ventura County, San Luis Obispo County, Alameda County and Mendocino County have approved implementation of Laura’s Law. Marin County launched a two-year pilot programme for Laura’s Law on 04 September 2018. Santa Clara County adopted it 25 May 2021, with 23 out of 58 counties having opted in before the 30 June deadline.

In those counties that adopt outpatient commitment, an AB 1421 programme will ensure individuals are provided the services and medical treatment (including medication) that will enable the person to have a good chance to recover. Nevada County Director Michael Heggarty bests describes it as part of the recovery movement.

Proposition 63 Impact

In November 2004, California voters passed Proposition 63. When the California Department of Mental Health (DMH) released its draft plan requirements for county mental health administrators on 15 February 2005, they contained a provision that would allow MHSA funds to be used for “involuntary services” if certain criteria were met. Nevada County’s Laura’s Law programme and Los Angeles County’s AOT pilot project are utilising MHSA funding for services.

Assisted outpatient treatment eligibility criteria
As stated above, the patient must have a serious mental illness plus a recent history of psychiatric hospitalizations, jailings or acts, threats or attempts of serious violent behavior towards self or others. The recipient must also have been offered an opportunity to voluntarily participate in a treatment plan by the local mental health department, yet fails to the point that, without a Laura’s Law program, he or she will likely relapse or deteriorate to the point of being dangerous to self or others. “Participation in the assisted outpatient program is the least restrictive placement necessary to ensure the person’s recovery and stability.” While a specified group of individuals may request an investigation to determine if a person qualifies for a Laura’s Law program, only the County mental health director, or his or her designee, may file a petition with the superior court for a hearing to determine if the person should be court ordered to receive the services specified under the law.

A person may be placed in an assisted outpatient treatment if, after a hearing, a court finds that the following criteria[19] have been met. The patient must:

• Be eighteen years of age or older.
• Be suffering from a mental illness.
• Be unlikely to survive safely in the community without supervision, based on a clinical determination.
• Have a history of non-compliance with treatment that has either:
  • Been a significant factor in his or her being in a hospital, prison or jail at least twice within the last thirty-six months; or
  • Resulted in one or more acts, attempts or threats of serious violent behaviour toward self or others within the last forty-eight months.
• Have been offered an opportunity to voluntarily participate in a treatment plan by the local mental health department but continue to fail to engage in treatment.
• Be substantially deteriorating.
• Be, in view of his or her treatment history and current behaviour, in need of assisted outpatient treatment in order to prevent a relapse or deterioration that would likely result in the person meeting California’s inpatient commitment standard, which is being:
  • A serious risk of harm to himself or herself or others; or
  • Gravely disabled (in immediate physical danger due to being unable to meet basic needs for food, clothing, or shelter).
• Be likely to benefit from assisted outpatient treatment.
• Participation in the assisted outpatient programme is the least restrictive placement necessary to ensure the person’s recovery and stability.

If the court finds that the individual meets the statutory criteria, the recipient will be provided intensive community treatment services and supervision by multidisciplinary teams of highly trained mental health professionals with staff-to-client ratios of not more than 1 to 10, and additional services, as specified, for persons with the most persistent and severe mental illness. The law specifies various rights of the person who is the subject of a Laura’s Law petition as well as due process hearing rights. The bill also provides for voluntary settlement agreements as an alternative to the hearing process.

Debate over Bill’s Efficacy and Propriety

Supporters

Passage of the bill was supported by organisations such as the California Treatment Advocacy Coalition (an affiliate of the Treatment Advocacy Centre), the California Psychiatric Association, the Police Chiefs Association, Mental Illness Policy Org. and the National Alliance on Mental Illness (NAMI). In an editorial endorsement of the law, the Los Angeles Times touted then-Governor Gray Davis’s support, while limiting its comments on opponents to mentioning that the Citizens Commission on Human Rights which opposes virtually all psychiatric treatments, sponsored a rally at the Capitol against Laura’s law. The San Francisco Chronicle and The San Francisco Examiner have published positive articles on the topic. The Los Angeles Times won a Pulitzer Prize, in part for its coverage of Laura’s Law.

Opposition

MindFreedom International and the California Network of Mental Health Clients (CNMHC), along with allies in the psychiatric survivors movement, also fought the measure and its earlier versions, accusing such legislation as a regressive and reprehensible scheme to enforce coerced drug treatment regimens against the will of patients. The Church of Scientology and the Citizens Commission on Human Rights have also gained attention as an opponent of the new law.

Outpatient commitment opponents make several varied arguments. Some dispute the positive effects of compulsory treatment, questioning the methodology of studies that show effectiveness. Others highlight negative effects of treatment. Still others point to disparities in the way these laws are applied. The psychiatric survivors movement opposes compulsory treatment on the basis that the ordered drugs often have serious or unpleasant side-effects such as anhedonia, tardive dyskinesia, neuroleptic malignant syndrome, excessive weight gain leading to diabetes, addiction, sexual side effects, and increased risk of suicide.

John M. Grohol, Psy.D., in his article “The Double Standard of Forced Treatment”, says:

“Forced treatment for people with mental illness has had a long and abusive history, both here in the United States and throughout the world. No other medical specialty has the rights psychiatry and psychology do to take away a person’s freedom in order to help “treat” that person. Historically, the profession has suffered from abusing this right — so much so that reform laws in the 1970s and 1980s took the profession’s right away from them to confine people against their will. Such forced treatment now requires a judge’s signature. But over time, that judicial oversight — which is supposed to be the check in our checks-and-balance system — has largely become a rubber stamp to whatever the doctor thinks is best. The patient’s voice once again threatens to become silenced, now under the guise of “assisted outpatient treatment” (just a modern, different term for forced treatment).”

The New Mexico Court of Appeals declared an Albuquerque ordinance, modelled after Kendra’s Law, requiring treatment for some mentally ill people conflicts with state law and can’t be enforced.

Tom Burns

Tom Burns, the psychiatrist who originally advised the United Kingdom’s government on laws that are similar to Laura’s Law, has also come to the conclusion they are ineffective and unnecessary. Professor Burns, once a strong supporter of the new powers, said he has been forced to change his mind after a study he conducted proved the orders “don’t work”.

However, Burns’ opinion was based heavily on his (very different) circumstances in the United Kingdom. The study he conducted found that coerced treatment was no better than regular/competent un-coerced treatment (the standard in the United Kingdom, which has public healthcare). As a result, the bulk of his argument does not apply to California, where the alternative to coerced treatment in most cases is no treatment at all. Professor Burns himself admitted that: “We were careful in our Lancet article to say that in well-coordinated mental health services, compulsory treatment has nothing to offer”.

Burns went on to highlight another critical difference between the two systems, and even mentioned that as a psychiatrist under a European system he would be willing to order coercive treatment under circumstances similar to the ones described by Laura’s Law:

“There’s a profound conceptual difference in the approach to mental health care between America and Europe. European laws often state “danger to self or others,” but danger in Europe is almost always interpreted very broadly — and you might think paternalistically — to include the patient’s mental health. If I have a seriously ill schizophrenic patient who is neglecting himself, not taking his medicine, and I know he’s going to get worse, I can say that’s a “danger” to his health. My understanding is that in many states in America, it’s got to be an imminent physical risk.”

Introduction

The Lanterman-Petris-Short (LPS) Act (Chapter 1667 of the 1967 California Statutes, codified as Cal. Welf & Inst. Code, sec. 5000 et seq.) regulates involuntary civil commitment to a mental health institution in the state of California.

Refer to the Baker Act 1971, Laura’s Law (2002), Kendra’s Law (1999), and the Marchman Act 1993.

Background

The act set the precedent for modern mental health commitment procedures in the United States. The bipartisan bill was co-authored by California State Assemblyman Frank D. Lanterman (R) and California State Senators Nicholas C. Petris (D) and Alan Short (D), and signed into law in 1967 by Governor Ronald Reagan. The Act went into full effect on 01 July 1972. It cited seven articles of intent:

• To end the inappropriate, indefinite, and involuntary commitment of mentally disordered persons, people with developmental disabilities, and persons impaired by chronic alcoholism, and to eliminate legal disabilities;
• To provide prompt evaluation and treatment of persons with serious mental disorders or impaired by chronic alcoholism;
• To guarantee and protect public safety;
• To safeguard individual rights through judicial review;
• To provide individualised treatment, supervision, and placement services by a conservatorship program for gravely disabled persons;
• To encourage the full use of all existing agencies, professional personnel and public funds to accomplish these objectives and to prevent duplication of services and unnecessary expenditures; and
• To protect mentally disordered persons and developmentally disabled persons from criminal acts.

The Act in effect ended all hospital commitments by the judiciary system, except in the case of criminal sentencing, e.g. convicted sexual offenders, and those who were “gravely disabled”, defined as unable to obtain food, clothing, or housing. It did not, however, impede the right of voluntary commitments. It expanded the evaluative power of psychiatrists and created provisions and criteria for holds.

Prior to 1987 it was assumed that the Act allowed involuntary treatment for those who were detained under an initial three-day hold (for evaluation and treatment) and a subsequent fourteen-day hospitalisation (for those people declared after the three-day hold to be dangerous to themselves or others or gravely disabled). However, in the 1987 case of Riese v. St. Mary’s Hospital and Medical Centre, the California Court of Appeal declared that these people had the right to exercise informed consent regarding the use of antipsychotic drugs, except in an emergency, and if they rejected medication “a judicial determination of their incapacity to make treatment decisions” was required before they could be involuntarily treated. This case was a class action suit brought in the name of person Eleanor Riese by the California ACLU. Eleanor Riese’s story is depicted in the movie 55 Steps.

LPS Evaluation, Detention and Conservatorship Process

Under the LPS Act, individuals can be detained into a locked psychiatric facility in the following process.

5150 Hold

Under California Welfare and Institutions Code (WIC) 5150, an individual can be placed (involuntarily) to a locked psychiatric facility, for an evaluation for up to 72 hours. Any peace officer or specific individuals authorized by a county government may place the hold. Three criteria apply – the individual is assessed to be: a danger to themselves, a danger to others, or “gravely disabled”. Per WIC 5008, grave disability is defined as an individual’s lack of ability, due to their mental illness, to provide for their food, clothing, or shelter. In the case of children, it is the inability to use food, clothing, or shelter even if it is supplied.

As the individual in question is likely in a state of distress (highly symptomatic), and likely also causing a disturbance in the community, it is not uncommon for police to be the party who places them on the 5150 hold and then takes the individual to the hospital for further assessment. Over the next 72 hours, the hospital/psychiatrist must determine the individuals need for further locked psychiatric detainment. If the individual’s condition clears up and they are no longer a danger to others or themselves or gravely disabled, they are released from the hospital. If, however, they remain a danger to others or themselves or continue to be gravely disabled, the hospital/psychiatrist may then request a 5250 hold to thereby keep the individual in the hospital beyond the 72-hour limit of the 5150 hold.

In Popular Culture

Largely because the production of many American movies and television programs are based in California, usage of the term “5150” has spread beyond its original location and user population. An album of the same name by the California hard rock band Van Halen was named directly for the code section, and several derivative uses followed.

5250 Hold

If, after a 72-hour hold, an individual is deemed to still be a danger to others or themselves, or is gravely disabled, WIC 5250 permits for an individual to be involuntarily held (in a locked psychiatric hospital) for another 14 days.

Unlike a 5150 hold a 5250 hold requires that the individual served receive a court hearing within 4 days of being served to ascertain the validity of the hold. Court hearings are often held in the hospital. Individuals are provided an attorney and a county court officer reviews the evidence for the hold presented by the hospital, hears the argument of the client and their attorney, and decides whether or not to uphold the 5250.

Just as with the 5150 hold, during the 5250 hold, the individual is continually being assessed by psychiatric staff. Again, if the individual is (at any time) deemed to be no longer a danger or gravely disabled, they are then released from the hospital.

According to section 5257 of the act, the individual must be released after 14 days, unless, they agree to further treatment on a voluntary basis; they are certified for an additional 14 days of intensive treatment; they are certified for an additional 30 days of intensive treatment; they are the subject of a conservatorship (commonly known as a Temporary LPS Conservatorship) petition or they are the subject of a petition for post-certification treatment of a dangerous person.

5350 Hold/Temporary LPS Conservatorship

A 5350 hold, otherwise known as a Temporary LPS Conservatorship (under W&I Code § 5352.1), is initiated at the end of 5250/14-day hold. Such is initiated by the individual’s treating psychiatrist and co-signed by the medical director of the psychiatric facility to the Public Guardian Office in the individuals county of residence. The basis for the LPS Temporary Conservatorship is that the individual (due to their mental illness, even after ~17 days of involuntary psychiatric detention) remains “gravely disabled.”

There are 58 counties in California, each with its own independent Public Guardian Offices. Unlike other conservatorship processes in California (Probate / Older adult or Limited / Developmentally disabled) – a LPS Conservatorship cannot be initiated by the public at large. Codified in the WIC – the individual must go through the 5150 – 5250 process and from there the county Public Guardian is the only authorised party to be able to request for a LPS Conservatorship. The legislative intent for such was that prior to the LPS act, it was felt individuals were often psychiatrically committed for subjective (if not outright punitive) reasons. To combat such potential abuses, the county Public Guardian, seen as an impartial, third party was designated as sole party.

Once the individual is on a LPS Temporary Conservatorship, they are no longer legally on a “hold,” but now, legal consent to treat and continue to detain the individual (now known as the “conservatee”) lies with the Public Guardian office.

A Temporary LPS Conservatorship can last a maximum of 180 days. As the county superior court has direct oversight of LPS Conservatorship matters, typically the conservatee is afforded court hearings (for status) every 30 days. Unlike other conservatorship hearing, LPS Conservatorship matters / records are NOT open to the public.

With 58 counties, the Public Guardian Office and Superior Courts may interpret and practice differing ways legal administration of LPS Conservatorship. In general, all conservatees are appointed legal counsel (typically the public defender office) and during the course of their LPS Conservatorship they can ask for a series of writs and hearing or even a full jury trial to contest their detention and overall LPS Conservatorship. It is not uncommon for a psychiatrist to conversely declare the conservatee is no longer gravely disabled. During the course of the LPS Conservatorship if the conservatee stabilises and can thereby be discharged to the community, a psychiatrist can request that the LPS Conservatorship be dismissed (for lack of legal support).

As of the Public Guardian office, during a Temporary LPS Conservatorship, it is their general duty to ensure the conservatee is properly cared for and that all reason efforts are ruled out, that the conservatee continues to require locked psychiatric care.

During the LPS Temporary Conservatorship, it is indeed the Public Guardian, not the conservatee, who consents to treatment and placement. A common way to understand such is parent to child – in that a minor child cannot consent to medical care. The same goes for the conservatee – in that the Public Guardian consents to their psychiatric treatment and placement.

If during the LPS Temporary Conservatorship, the Public Guardian feels the conservatee will (for the foreseeable future) need to remain in locked psychiatric care – they can then seek to have the LPS Conservatorship changed from Temporary to General (also referred to a “Permanent” but this can be a misnomer as it is not permanent / indefinite). With the appointment of a Permanent LPS Conservatorship (approved by the court) – the conservatee is now under the auspice / authority of the LPS Conservator for exactly 1 year. It is with a Permanent LPS Conservatorship that then the public (family / friends) can now become involved. If family / friends request and with court approval, (unlike the Temporary LPS Conservatorship) they can be appointed as the General / Permanent LPS Conservator for the conservatee.

The 1-year duration for a General / Permanent LPS Conservatorship was again codified into the LPS act as to combat past abuses. This ensures that no individual is indefinitely detained in locked psychiatric care and that every year justification to continue the LPS Conservatorship is brought before the court. This too is another difference between LPS conservatorship and Probate or Limited Conservatorship – both which have no implicit expiration date. Indeed, if the LPS Conservator does not submit a request (to the court) to renew the LPS Conservatorship, by default it expires. Renewal of the LPS Conservatorship requires that 2 MD / Psychiatrists / Psychologist formally declare that the LPS Conservatorship still remains appropriate.

During the course of a General / Permanent LPS Conservatorship, the conservatee is most likely held in long-term, locked psychiatric care. Although California State Hospital still exist and are in use, a most LPS Conservatees are placed at local (county level) locked psychiatric hospitals. Nothing though in the LPS act precludes a conservatee being under a LPS Conservatorship and living in the community. No time frame is quantified in the LPS act (as matters vary from conservatee to conservatee), but it is generally practiced (amongst the 58 county Public Guardian Offices) that if a conservatee has been living in the community for an extended period of time – the legal justification to thereby continue the LPS equally diminishes and from there they are bound to dismiss the LPS Conservatorship. As such there is no common duration for a LPS Conservatorship. It can indeed vary from a conservatee being under a single LPS conservatorship continuously for 30 years to others undergoing multiple Temporary LPS Conservatorship over the course of a single year.

Some family of mentally ill individuals believe that the LPS act favors the individual’s civil rights too much when weighed against their self-evident need for treatment. It can be very difficult for their family member to be placed on a 5150 hold or on a LPS Conservatorship. Again per the LPS act – “grave disability” is primarily codified with food, clothing, or shelter. Thus an individual may indeed be highly symptomatic – displaying paranoia, delusions, mania, etc. but if they can present a cogent plan to care for their food, clothing, or shelter – they may very well be released from psychiatric care. Many have argued that revisions should be made to thereby make it easier for individuals to be detained, lessening the restrictions made under the LPS act. In 2018 SB 1045 was signed into CA Law – establishing a pilot program in San Francisco, Los Angeles, and San Diego counties if the counties approve, creating a conservatorship for a person who is unable to care for their own health and well-being due to serious mental illness and substance use disorder. SB 1045 would provide the least restrictive and most clinically appropriate alternative needed for the protection of the person who is incapable of caring for the person’s own health.