What is O’Connor vs. Donaldson (1975)?

Introduction

O’Connor v. Donaldson, 422 U.S. 563 (1975), was a landmark decision of the US Supreme Court in mental health law ruling that a state cannot constitutionally confine a non-dangerous individual who is capable of surviving safely in freedom by themselves or with the help of willing and responsible family members or friends.

Since the trial court jury found, upon ample evidence, that petitioner did so confine respondent, the Supreme Court upheld the trial court’s conclusion that petitioner had violated respondent’s right to liberty.

Refer to Involuntary Commitment.

Overview

Kenneth Donaldson (confined patient) had been held for 15 years in Florida State Hospital at Chattahoochee, due to needs of “care, maintenance, and treatment.” He filed a lawsuit against the hospital and staff members claiming they had robbed him of his constitutional rights, by confining him against his will. Donaldson won his case (including monetary damages) in United States District Court, which was affirmed by the United States Court of Appeals for the Fifth Circuit. In 1975, the United States Supreme Court agreed that Donaldson had been improperly confined but vacated the award of damages. On remand, the Fifth Circuit ordered that a new trial on damages be held.

A finding of “mental illness” alone cannot justify a State’s locking a person up against his will and keeping him indefinitely in simple custodial confinement. Assuming that that term can be given a reasonably precise content and that the “mentally ill” can be identified with reasonable accuracy, there is still no constitutional basis for confining such persons involuntarily if they are dangerous to no one and can live safely in freedom.

May the State confine the mentally ill merely to ensure them a living standard superior to that they enjoy in the private community? That the State has a proper interest in providing care and assistance to the unfortunate goes without saying. But the mere presence of mental illness does not disqualify a person from preferring his home to the comforts of an institution. Moreover, while the State may arguably confine a person to save him from harm, incarceration is rarely if ever a necessary condition for raising the living standards of those capable of surviving safely in freedom, on their own or with the help of family or friends. May the State fence in the harmless mentally ill solely to save its citizens from exposure to those whose ways are different? One might as well ask if the State, to avoid public unease, could incarcerate all who are physically unattractive or socially eccentric. Mere public intolerance or animosity cannot constitutionally justify the deprivation of a person’s physical liberty. In short, a State cannot constitutionally confine without more a non-dangerous individual who is capable of surviving safely in freedom by himself or with the help of willing and responsible family members or friends.

Kenneth Donaldson

The origins of Donaldson’s institutionalisation began in 1943, at age 34, when he suffered a traumatic episode. He was hospitalized and received treatment, before resuming life with his family.

In 1956 Donaldson travelled to Florida to visit his elderly parents. While there, Donaldson reported that he believed one of his neighbours in Philadelphia might be poisoning his food. His father, worried that his son suffered from paranoid delusions, petitioned the court for a sanity hearing. Donaldson was evaluated, diagnosed with “paranoid schizophrenia,” and civilly committed to the Florida State mental health system. At his commitment trial, Donaldson did not have legal counsel present to represent his case. Once he entered the Florida hospital, Donaldson was placed with dangerous criminals, even though he had never been proved to be dangerous to himself or others. His ward was understaffed, with only one doctor (who happened to be an obstetrician) for over 1,000 male patients. There were no psychiatrists or counsellors, and the only nurse on site worked in the infirmary.

He spent 15 years as a patient; he did not receive any treatment, actively refusing it, and attempting to secure his release. Throughout his stay he denied he was ever mentally ill, and refused to be put into a halfway house.

Donaldson later wrote a book about his experience as a mental patient titled Insanity Inside Out.

What is the California Mental Health Services Act (2005)?

Introduction

On November 2004, voters in the US state of California passed Proposition 63, the Mental Health Services Act (MHSA), which has been designed to expand and transform California’s county mental health service systems.

The MHSA is funded by imposing an additional one percent (1%) tax on individual, but not corporate, taxable income in excess of one million dollars. In becoming law on January 2005, the MHSA represents the latest in a Californian legislative movement, begun in the 1990s, to provide better coordinated and more comprehensive care to those with serious mental illness, particularly in underserved populations. Its claim of successes thus far, such as with the development of innovative and integrated Full Service Partnerships (FSPs), are not without detractors who highlight many problems but especially a lack of oversight, large amount of unspent funds, poor transparency, lack of engagement in some communities, and a lack of adherence to required reporting as challenges MHSA implementation must overcome to fulfil the law’s widely touted potential.

Background

At one time, California was known for having a strong mental health system. Treatment was available for Medi-Cal recipients with few limitations on care. Legislators and voters have acknowledged the inadequacy of California’s historically underfunded mental health system to care for the state’s residents, especially those with serious mental illness, over the past few decades. In 1991, to build a more community- and county-based system of care, the California legislature instituted realignment, a delegation of the control over mental health funds and care delivery from state to county. This was followed by a succession of legislation targeted towards marginalised populations with high documented rates of mental illness, such as the homeless (AB 2034, in 1999) and the potentially violent mentally ill (Laura’s Law, in 2002). However, with the passage of Proposition 63 in 2004, California voters acted upon a widespread perception that state and county mental health systems were still in disrepair, underfunded, and requiring a systematic, organizational overhaul. This perception echoed a nationwide perspective, with the President’s New Freedom Commission on Mental Health in 2003 calling for fundamental transformation of the historically fragmented mental health system. The MHSA is California’s attempt to lead the way in accomplishing such systemic reform.

In the end, voter consciences were pricked by the well-organised and -funded campaign that displayed both the need (50,000 mentally ill homeless people, according to the National Alliance on Mental Illness) and the promise (successes of past mental health initiatives) of increased funding for the mental health system. Then-Assemblyman Darrell Steinberg and Rusty Selix, executive director of the Mental Health Association in California, led the initiative by collecting at minimum 373,816 signatures, along with financial ($4.3 million) and vocal support from stakeholders. Though Governor Arnold Schwarzenegger and the business community were opposed to Proposition 63 because of the tax it would impose on millionaires, the opposition raised only $17,500. On 02 November 2004, Proposition 63 passed with 53.8% of the vote, with 6,183,119 voting for and 5,330,052 voting against the bill.

Overview

The voter-approved MHSA initiative provides for developing, through an extensive stakeholder process, a comprehensive approach to providing community based mental health services and supports for California residents. Approximately 51,000 taxpayers in California will be helping to fund the MHSA through an estimated $750 million in tax revenue during fiscal year 2005-2006.

The MHSA was an unprecedented piece of legislation in California for several reasons:

  • Its funding source, quantity, and allocation is dedicated for mental health services, including times of budget cuts to many other public programmes
  • It was intended to engage communities in prioritising which service elements would be funded.
  • It was focused on developing preventive and innovative programmes to help transform the mental health care system in California.

To accomplish its objectives, the MHSA applies a specific portion of its funds to each of six system-building components:

  • Community programme planning and administration (10%).
  • Community services and supports (45%).
  • Capital (buildings) and information technology (IT) (10%).
  • Education and training (human resources) (10%).
  • Prevention and early intervention (20%).
  • Innovation (5%).

Notably, none of the funds were to be used for programmes with existing fund allocations, unless it was for a new element or expansion in those existing programmes. 51% of the funds have to be spent on children’s service.

The MHSA stipulates that the California State Department of Mental Health (DMH) will contract with county mental health departments (plus two cities) to develop and manage the implementation of its provisions. Oversight responsibility for MHSA implementation was handed over to the sixteen member Mental Health Services Oversight and Accountability Commission (MHSOAC) on July 7, 2005, when the commission first met.

The MHSA specifies requirements for service delivery and supports for children, youths, adults and older adults with serious emotional disturbances and/or severe mental illnesses. MHSA funding will be made annually to counties to:

  • Define serious mental illness among children, adults and seniors as a condition deserving priority attention, including prevention and early intervention services and medical and supportive care
  • Reduce the long-term adverse impact on individuals, families and State and local budgets resulting from untreated serious mental illness.
  • Expand the kinds of successful, innovative service programs for children, adults and seniors already established in California, including culturally and linguistically competent approaches for underserved population.
  • Provide State and local funds to adequately meet the needs of all children and adults who can be identified and enrolled in programmes under this measure.
  • Ensure all funds are expended in the most cost-effective manner and services are provided in accordance with recommended best practices, subject to local and State oversight to ensure accountability to taxpayers and to the public.

Implementation

Starting from enactment, implementation of the MHSA was intended to take six months; in reality, the process of obtaining stakeholder input for administrative rules extended this period by several months. By August 2005, 12 meetings and 13 conference calls involving stakeholders across the state resulted in the final draft of rules by which counties would submit their three-year plans for approval.

Counties are required to develop their own three-year plan, consistent with the requirements outlined in the act, in order to receive funding under the MHSA. Counties are obliged to collaborate with citizens and stakeholders to develop plans that will accomplish desired results through the meaningful use of time and capabilities, including things such as employment, vocational training, education, and social and community activities. Also required will be annual updates by the counties, along with a public review process. County proposals will be evaluated for their contribution to achieving the following goals:

  • Safe and adequate housing, including safe living environments, with family for children and youths.
  • Reduction in homelessness.
  • A network of supportive relationships.
  • Timely access to needed help, including times of crisis.
  • Reduction in incarceration in jails and juvenile halls.
  • Reduction in involuntary services, including reduction in institutionalisation and out-of-home placements.

MHSA specifies three stages of local funding, to fulfil initial plans, three year plans, and long term strategies. No services would be funded in the first year of implementation. The DMH approved the first county plan in January 2006. Allocations for each category of funding were planned to be granted annually, based upon detailed plans with prior approval. However, an amendment to the MHSA, AB 100, which passed in March 2011, serves to streamline the DMH approval and feedback process to the counties, ostensibly to relieve the DMH of some of its administrative burden.

Roles & Responsibilities

While the county mental health departments are involved in the actual implementation of MHSA programmes, the MHSA mandates that several entities support or oversee the counties. These include the State Department of Mental Health (DMH) and the Mental Health Services Oversight and Accountability Commission (MHSOAC).

California State Department of Mental Health (DMH)

In accordance with realignment, the DMH approves county three-year implementation plans, upon comment from the MHSOAC, and passes programmatic responsibilities to the counties. In the first few months immediately following its passage, the DMH has:

  • Obtained federal approvals and Medi-Cal waivers, State authority, additional resources and technical assistance in areas related to implementation.
  • Established detailed requirements for the content of local three year expenditure plans.
  • Developed criteria and procedures for reporting of county and state performance outcomes.
  • Defined requirements for the maintenance of current State and local efforts to protect against supplanting existing programmes and their funding streams.
  • Developed formulas for how funding will be divided or distributed among counties.
  • Determined how funding will flow to counties and set up the mechanics of distribution.
  • Established a 16-member Mental Health Services Oversight and Accountability Commission (MHSOAC), composed of elected State officials and Governor appointees, along with procedures for MHSOAC review of county planning efforts and oversight of DMH implementation.
  • Developed and published regulations and provide preliminary training to all counties on plan development and implementation requirements.

The DMH has directed all counties to develop plans incorporating five essential concepts:

  • Community collaboration.
  • Cultural competence.
  • Client/family-driven mental health system for older adults, adults and transition age youth and family-driven system of care for children and youth.
  • Wellness focus, which includes the concepts of recovery and resilience.
  • Integrated service experiences for clients and their families throughout their interactions with the mental health system.

The DMH, in assuming and asserting its primacy over MHSA implementation, has dictated requirements for service delivery and supports as follows:

  • Full Service Partnership (FSP) Funds: Funds to provide necessary services and supports for initial populations.
  • General System Development Funds: Funds to improve services and infrastructure.
  • Outreach and Engagement Funding: Funds for those populations that are currently receiving little or no service.

Mental Health Services Oversight and Accountability Commission (MHSOAC)

The authors of the MHSA created the MHSOAC to reflect the consumer-oriented focus of the law, mandating at least two appointees with severe mental illness, two other family members of individuals with severe mental illness, and various other community representatives. This diverse commission holds the responsibility of approving county implementation plans, helping develop mental illness stigma-relieving strategies, and recommending service delivery improvements to the state on an as-needed basis. Whenever the commission identifies a critical issue related to the performance of a county mental health programme, it may refer the issue to the DMH.

The first meeting of the MHSOAC was held July 7, 2005, at which time Proposition 63 author Darrell Steinberg was selected unanimously by fellow commissioners as chairman, without comment or discussion. After accepting the gavel, Steinberg was roundly praised for devising Proposition 63’s ‘creative financing’ scheme. Steinberg then said, “We must focus on the big picture,” and stated his priorities with regard to the implementation of the MHSA:

  • Prioritise prevention and early intervention, without falling into the trap of fail first service provision;
  • Address “the plight of those at risk of falling off the edge,”; and
  • Advocate for mental health services from his “bully pulpit.”

MHSOAC Commissioners

In accordance with MHSA requirements, the Commission shall consist of 16 voting members as follows:

  • The Attorney General or his or her designee.
  • The Superintendent of Public Instruction or his or her designee.
  • The Chairperson of the Senate Health and Human Services Committee or another member of the Senate selected by the President pro Tempore of the Senate.
  • The Chairperson of the Assembly Health Committee or another member of the Assembly selected by the Speaker of the Assembly.
  • Twelve appointees of the Governor, who shall seek individuals who have had personal or family experience with mental illness, to include:
    • Two persons with a severe mental illness.
    • A family member of an adult or senior with a severe mental illness.
    • A family member of a child who has or has had a severe mental illness.
    • A physician specialising in alcohol and drug treatment.
    • A mental health professional.
    • A county Sheriff.
    • A Superintendent of a school district.
    • A representative of a labour organisation.
    • A representative of an employer with less than 500 employees.
    • A representative of an employer with more than 500 employees.
    • A representative of a health care services plan or insurer.

State Government Appointees

The initial government officials and designee appointed:

  • Senator Wesley Chesbro (Democrat), of Arcata, chair of the Senate Budget and Fiscal Review Committee and the Senate Select Committee on Developmental Disabilities and Mental Health.
  • Assemblyman Mark Ridley-Thomas (Dem), of Los Angeles, a member of the Assembly Health committee and former L.A. city councilman.
  • Attorney General Bill Lockyer, of Hayward, a former State Senator and Assemblyman.
  • Darrell Steinberg (Dem), of Sacramento, an attorney, the author of Proposition 63, former Assemblyman. Steinberg is the appointee of the Superintendent of Public Instruction.

Governor’s Appointees

On 21 June 2005, then Governor Schwarzenegger announced his appointment of twelve appointees to the MHSOAC:

  • MHOAC Vice Chairman Linford Gayle (declined to state party), 46, of Pacifica, a mental health program specialist at San Mateo County Mental Health Services.
  • Karen Henry (Republican), 61, of Granite Bay, a labour attorney and a board member of California National Alliance for the Mentally Ill (NAMI). Henry is afflicted by ‘rapid cycling’ bipolar disorder, has a son who has autism, and another son with a mental illness.
  • William Kolender (Rep), 70, of San Diego, the San Diego County Sheriff and president of the State Sheriffs Association, a member of the State Board of Corrections, and was for three years the director of the California Youth Authority (CYA). Kolender’s wife died as a result of mental illness, and he has a son with a mental disorder.
  • Kelvin Lee, Ed.D. (Rep), 58, of Roseville, a superintendent of the Dry Creek Joint Elementary School District.
  • Andrew Poat (Rep), 45, of San Diego, former director of the government relations department for the City of San Diego, a member of the public policy committee for the San Diego Gay and Lesbian Centre, and a former deputy director of the United States Office of Consumer Affairs. Poat represented employers of more than 500 workers on the commission, and says he will use his experience building multimillion-dollar programs to bring together mental health advocates.
  • Darlene Prettyman (Rep), 71, of Bakersfield, is a psychiatric nurse, a board member and past president of NAMI California, and a past chairman and a member of the California Mental Health Planning Council. Her son has schizophrenia, and her stated priority is to enhance provision of housing for mental health service clients.
  • Carmen Diaz (Dem), 53, of Los Angeles, a family advocate coordinator with the L.A. County Department of Mental Health and a board member of United Advocates for Children of California. Diaz has a family member with a severe mental illness.
  • F. Jerome Doyle (Dem), 64, of Los Gatos, is chief executive officer of EMQ (a provider of mental health services for children and youth), a board member and past president of the California Council of Community Mental Health Agencies, and a board member of California Mental Health Advocates for Children.
  • Saul Feldman DPA, (Dem), 75, of San Francisco, is chairman and CEO of United Behavioural Health, a member of the American Psychological Association, the founder and former president of the American College of Mental Health Administration, and a former president and CEO of Health America Corporation of California. Feldman was appointed as a health care plan insurer.
  • Gary Jaeger, M.D. (Dem), 62, of Harbour City, is currently the chief of addiction medicine at Kaiser Foundation Hospital, South Bay, a member and former chair of the Behavioural Health Advisory Board of the California Healthcare Association, and former medical director of family recovery services at St. Joseph Hospital in Eureka. He says members of his family have an “80 percent rate of drug and alcohol abuse.”
  • Mary Hayashi (Dem), 38, of Castro Valley, president of the Iris Alliance Fund and a board member for Planned Parenthood Golden Gate and member of the Board of Registered Nursing. Hayashi’s concerns include transportation access for clients and paratransit services, and represents employers with 500 or fewer workers.
  • Patrick Henning (Dem), 32, of West Sacramento, is the legislative advocate for the California Council of Laborers. He was previously the Assistant Secretary at the Labour and Workforce Development Agency (An Agency that he helped create), deputy director for the Department of Industrial Relations and Prior to his State service Special Advisor and Congressional Liaison to President Bill Clinton. Henning is a member of the Career Technical Education Standards and Framework Advisory Group and the California Assembly Speaker’s Commission on Labour Education. He represents labour.

Current Progress

One unqualified success story from the MHSA thus far involves the implementation of Full Service Partnerships (FSPs) demonstrating the “whatever it takes” commitment to assist in individualised recovery – whether it is housing, “integrated services, flexible funding [such as for childcare], intensive case management, [or] 24 h access to care.” FSP interventions are based upon evidence from such programs as Assertive community treatment (ACT), which has effectively reduced homelessness and hospitalisations while bettering outcomes. But the FSP model looks more like that of the also-popular MHA Village in Long Beach, which is a centre that offers more comprehensive services besides those specifically mental health-related. Beyond these guiding principles, however, there has not been much consensus over unifying strategies to define and implement an FSP – resulting in varying FSP structures across counties.

Overall, though, the Petris Centre, funded by the DMH and California HealthCare Foundation to evaluate the MHSA, has reported quantifiable improvements in many areas:

  • Homelessness rates.
  • Entry rates into the criminal justice system.
  • Suffering from illness.
  • Daily functioning.
  • Education rates.
  • Employment rates.
  • General satisfaction with FSPs.

Continued Challenges

According to the UCLA Centre for Health Policy Research, the 2007 and 2009 California Health Interview Surveys (CHIS) demonstrate continued mental health needs of almost two million Californians, about half of which were unmet in 2011. In spite of steady tax revenue ($7.4 billion raised as of September 2011) earmarked for the MHSA, the unremittingly high numbers of mentally ill who lack treatment contrast starkly with the implementation of new programs like the FSPs, which may cost tens of thousands of dollars annually per person. The MHA Village programme, for example, averages around $18,000 annually per person. One of the major growing concerns regarding MHSA implementation is its unintentional but worrying tendency to create silos of care. As directed by the DMH, counties search for “unserved” mentally ill or at-risk individuals to enrol in their new programmes, while keeping existing and perhaps underserved clients in old programs that are usually underfunded, but cannot take MHSA funds. Ironically, while the MHSA was established in part to address racial/ethnic disparities in health care, it may be perpetuating the disparity in services delivery between underfunded and well-funded, new programmes.

A possible solution to this issue highlights another challenge for the MHSA: the need for more comprehensive evaluation, oversight, and advisory mechanisms. Though there is an accountability commission, the MHSOAC, its oversight and regulatory responsibilities are not well-defined. However, it is a relatively new entity, having been created by the MHSA in 2004, and has yet to fully delineate its role in the MHSA. With time, the MHSOAC will hopefully continue to develop towards its stated function. Objective and expert evaluation of the MHSA will also be necessary to achieve the kind of longstanding system-wide improvement that then becomes a model for others.

What is the Marchman Act (1993)?

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.

What is Kendra’s Law (1999)?

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.

What is Laura’s Law (2002)

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.”

What is the Lanterman-Petris-Short Act 1967?

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.

What is the Florida Mental Health Act of 1971?

Introduction

The Florida Mental Health Act of 1971 (Florida Statute 394.451-394.47891 [2009 rev.]), commonly known as the “Baker Act,” allows the involuntary institutionalisation and examination of an individual.

Refer to Lanterman-Petris-Short Act 1967, Laura’s Law 2002, Kendra’s Law 1999, and the Marchman Act 1993.

Background

The Baker Act allows for involuntary examination (what some call emergency or involuntary commitment), which can be initiated by judges, law enforcement officials, physicians, or mental health professionals. There must be evidence that the person:

  • Possibly has a mental illness.
  • Is in danger of becoming a harm to self, harm to others, or is self neglectful.

Both of these are defined in the Baker Act.

Examinations may last up to 72 hours after a person is deemed medically stable and occur in over 100 Florida Department of Children and Families-designated receiving facilities statewide.

There are many possible outcomes following examination of the patient. These include the release of the individual to the community (or other community placement), a petition for involuntary inpatient placement (often called civil commitment), involuntary outpatient placement (what some call outpatient commitment or assisted treatment orders), or voluntary treatment (if the person is competent to consent to voluntary treatment and consents to voluntary treatment). The involuntary outpatient placement language in the Baker Act took effect as part of the Baker Act reform in 2005.

The legislation was nicknamed the “Baker Act” after Florida Democratic state representative from Miami, Maxine Baker, who served from 1963 to 1972. She had a strong interest in mental health issues, served as chair of the House Committee on Mental Health, and was the sponsor of the bill.

The nickname has led to the term “Baker Act” as a transitive verb, and “Baker Acted” as a passive-voice verb, for invoking the Act to force an individual’s commitment. Although the Baker Act is a statute only for the state of Florida, use of “Baker Acting” as a verb has become prevalent as a slang term for involuntary commitment in other regions of the United States.

Criteria for Involuntary Examination

Specific criteria must be met in order to initiate involuntary examination. Among those criteria are the following elements, which do not individually qualify an individual as meeting the criteria:

  • Reason to believe that the person has a mental illness;
  • The person refuses voluntary examination; and
  • The person is unable to determine whether examination is necessary.

The decisive criterion, as stated in the statute, mentions a substantial likelihood that without care or treatment the person will cause serious bodily harm in the near future. Criteria are not met simply because a person has a mental illness, appears to have mental problems, takes psychiatric medication, has an emotional outburst, or refuses voluntary examination. Furthermore, if there are family members or friends that will help prevent any potential and present threat of substantial harm, the criteria for involuntary examination are also not met.

The following are not included under this act:

  • Developmental disability.
  • Intoxication.
  • Conditions manifested only by antisocial behaviour.
  • Conditions manifested only by substance abuse impairment.

“Substantial likelihood” must involve evidence of recent behaviour to justify the substantial likelihood of serious bodily harm in the near future. Moments in the past, when an individual may have considered harming themselves or another, do not qualify the individual as meeting the criteria.

Reception

An editorial in the Tampa Bay Times wrote “that crisis stabilization is a Band-Aid solution to emotional problems” and the Act should be reformed to allow public defenders to have access to the patient’s medical records and ongoing counselling and outpatient mental health treatment should be provided to the patient.

What is the Family and Medical Leave Act of 1993?

Introduction

The Family and Medical Leave Act of 1993 (FMLA) is a United States labour law requiring covered employers to provide employees with job-protected and unpaid leave for qualified medical and family reasons.

The FMLA was a major part of President Bill Clinton’s first-term domestic agenda, and he signed it into law on 05 February 1993. The FMLA is administered by the Wage and Hour Division of the United States Department of Labour.

The FMLA allows eligible employees to take up to 12 work weeks of unpaid leave during any 12-month period to care for a new child, care for a seriously ill family member, or recover from a serious illness. The FMLA covers both public- and private-sector employees, but certain categories of employees, including elected officials and highly compensated employees, are excluded from the law or face certain limitations. In order to be eligible for FMLA leave, an employee must have worked for the employer for at least 12 months, have worked at least 1,250 hours over the past 12 months, and work for an employer with at least 50 employees within a 75-mile radius. Several states have passed laws providing additional family and medical leave protections for workers.

Background

Prior to the 1992 presidential election, a family medical leave act had been vetoed twice by President George H. W. Bush. After Bill Clinton won the 1992 election, a law protecting family medical leave became one of his major first-term domestic priorities. Rapid growth in the workforce, including a large number of women joining, suggested a necessary federal regulation that would support the working class who desired to raise a family and/or required time off for illness related situations. President Clinton signed the bill into law on 05 February 1993 (Pub.L. 103–3; 29 U.S.C. sec. 2601; 29 CFR 825) to take effect on 05 August 1993.

The United States Congress passed the Act with the understanding that “it is important for the development of children and the family unit that fathers and mothers be able to participate in early childrearing … [and] the lack of employment policies to accommodate working parents can force individuals to choose between job security and parenting”. It also stressed the Act was intended to provide leave protection for individuals “in a manner that accommodates the legitimate interests of employers”.

On 20 December 2019, as part of the National Defence Authorisation Act (NDAA) for Fiscal Year 2020, the Federal Employee Paid Leave Act (FEPLA) amended the Family and Medical Leave Act (FMLA) to grant federal government employees up to 12 weeks of paid time off for the birth, adoption or foster of a new child. The law applies to births or placements occurring on or after 01 October 2020.

Contents

Scope of Rights

The Family and Medical Leave Act of 1993 generally applies to employers of 50 or more employees in 20 weeks of the last year. Employees must have worked over 12 months and 1250 hours in the last year (around 25 hours a week). However, employees are not eligible if they work at a work site where the total number of employees employed by the employer within 75 miles of that work site is less than 50. A worksite includes a public agency, including schools and state, local, and federal employers. The 50 employee threshold does not apply to public agency employees and local educational agencies. There are special hours rules for certain airline employees.

Employees must give notice of 30 days to employers if birth or adoption is “foreseeable”, and for serious health conditions if practicable. Treatments should be arranged “so as not to disrupt unduly the operations of the employer” according to medical advice.

Along with the 30 day notice, there are also other requirements to be made when seeking the FMLA rights. If an employee wants to leave the first time using ones FMLA rights, the person must first claim the Family and Medical Leave Act. In the case that an employee were to leave again under the FMLA act, the same process must proceed.

With the release of employees, there is a certification as well. The absence of an employee due to the conditions he or she may have may require a certification as proof of the verification of absence. In order to certify the leave of an employee, the employer may ask for other requirements. An example of these requirements are requiring multiple medical opinions. All of these prerequisites are at the employer’s expense. There are also certain rules that may apply to those who work at local education agencies.

Rights During Leave

Employees can have up to 12 weeks of unpaid leave for child birth, adoption, to care for a close relative in poor health, or because of an employee’s own poor health. In full, the purposes for leave are:

  • To care for a new child, whether for the birth, the adoption, or placement of a child in foster care;
  • To care for a seriously ill family member (spouse, son, daughter, or parent) (Note: Son/daughter has been clarified by the Department of Labour to mean a child under the age of 18 or a child over the age of 18 with a mental or physical disability as defined by the Americans With Disabilities Act, which excludes, among other conditions, pregnancy and post-partum recovery from childbirth);
  • To recover from a worker’s own serious illness;
  • To care for an injured service member in the family; or
  • To address qualifying exigencies arising out of a family member’s deployment.
  • Twenty-six workweeks of leave during a single 12-month period to care for a covered servicemember with a serious injury or illness if the eligible employee is the servicemember’s spouse, son, daughter, parent, or next of kin (military caregiver leave).

Child care leave should be taken in one lump, unless an employer agrees otherwise. If a father and mother have the same employer, they must share their leave, in effect halving each person’s rights, if the employer so chooses.

Employers must provide benefits during the unpaid leave. Under §2652(b) states are empowered to provide “greater family or medical leave rights”.

Since 2008, the Department of Labour has allowed the spouse, child, or parent of an active duty military member who is deployed overseas for 12 or more months to take up to 12 weeks of leave. Also, a military caregiver provision was added that would allow a caregiver to take up to 26 weeks of leave in order to actively care for a military member who requires medical attention for acute or ongoing conditions.

Substitute Leave

Under §2612(2)(A) an employer can make an employee substitute the right to 12 unpaid weeks of leave for “accrued paid vacation leave, personal leave or family leave” in an employer’s personnel policy. Originally the Department of Labour had a penalty to make employers notify employees that this might happen. However, five judges in the US Supreme Court in Ragsdale v Wolverine World Wide, Inc held that the statute precluded the right of the Department of Labour to do so. Four dissenting judges would have held that nothing prevented the rule, and it was the Department of Labour’s job to enforce the law.

Right to Return to Job

After unpaid leave, an employee generally has the right to return to their job, except for employees who are in the top 10% of highest paid and the employer can argue refusal “is necessary to prevent substantial and grievous economic injury to the operations of the employer.” In full, the rights during and after unpaid leave are to:

  • The same group health insurance benefits, including employer contributions to premiums, that would exist if the employee were not on leave.
  • Restoration to the same position upon return to work. If the same position is unavailable, the employer must provide the worker with a position that is substantially equal in pay, benefits, and responsibility.
  • Protection of employee benefits while on leave. An employee is entitled to reinstatement of all benefits to which the employee was entitled before going on leave.
  • Protection of the employee to not have their rights under the Act interfered with or denied by an employer.
  • Protection of the employee from retaliation by an employer for exercising rights under the Act.
  • Intermittent FMLA leave for their own serious health condition, or the serious health condition of a family member. This includes occasional leave for doctors’ appointments for a chronic condition, treatment (e.g. physical therapy, psychological counselling, chemotherapy), or temporary periods of incapacity (e.g. severe morning sickness, asthma attack).

“Highly compensated employees” have limited rights to return to their jobs. They are defined as “a salaried eligible employee who is among the highest paid 10 percent of the employees employed by the employer within 75 miles of the facility at which the employee is employed”. Their employers are not required to restore them to their original position (or an equivalent position with equivalent pay and benefits, as is guaranteed to other employees) if the employer determines that denying the employee their position is “necessary to prevent substantial and grievous economic injury to the operations of the employer” and the employer provides the worker with notice of this decision, though no time frame for providing this notice is established.

Enforcement

Employees or the Secretary of Labour can bring enforcement actions, but there is no right to a jury for reinstatement claims. Employees can seek damages for lost wages and benefits, or the cost of child care, plus an equal amount of liquidated damages unless an employer can show it acted in good faith and reasonable cause to believe it was not breaking the law. There is a two-year limit on bringing claims, or three years for wilful violations.

Non-Eligible Workers and Types of Leave

The federal FMLA does not apply to:

  • Workers in businesses with fewer than 50 employees (this threshold does not apply to public agency employers and local educational agencies as they are covered employers by name but there still must be at least 50 employees with a 75-mile radius for the employee to be eligible for FMLA leave);
  • Part-time workers who have worked fewer than 1,250 hours within the 12 months preceding the leave and a paid vacation;
  • Workers who need time off to care for seriously ill elderly relatives (other than parents), unless the relative was acting in loco parentis at the time the worker turned 18;
  • Workers who need time off to care for pets;
  • Workers who need time off to recover from short-term or common illness like a cold, or to care for a family member with a short-term illness;
  • Elected officials; and
  • Workers who need time off for routine medical care, such as check-ups.

State Family Leave

Some states have enacted laws that mandate additional family and medical leave for workers in a variety of ways. By 2016 four states had laws for paid family leave: California since 2002, New Jersey since 2008, Rhode Island since 2013, and New York since 2016. Washington state passed a paid family and medical leave law in 2007, but the law has not taken effect due to a lack of funding mechanism.

Dropping the Employer Threshold

The federal FMLA only applies to employers with 50 or more employees, within 75 miles. Some states have enacted their own FMLAs that have a lower threshold for employer coverage:

  • Maine: 15 or more employees (private employers) and 25 or more (city or town employers).
  • Maryland: 15 or more employees (private employers)Up to seven days for bone marrow donation. Up to 30 days for organ donation.
  • Minnesota: 21 or more employees (parental leave only).
  • Oregon: 25 or more employees. An employee must have worked at least 180 days, and averaged 25 hours per week at the time medical leave is requested
  • Rhode Island: 50 or more employees (private employers) and 30 or more employees (public employers).
  • Vermont: 10 or more employees (parental leave only) and 15 or more employees (family and medical leave).
  • Washington: 50 or more employees (FMLA reasons besides insured parental leave); all employers are required to provide insured parental leave.
  • District of Columbia: 20 or more employees.

Expanded Coverage

The federal FMLA only applies to immediate family – parent, spouse, and child. The 2008 amendments to the FMLA for military family members extend the FMLA’s protection to next of kin and to adult children. The Department of Labour on 22 June 2010 clarified the definition of “son and daughter” under the FMLA “to ensure that an employee who assumes the role of caring for a child receives parental rights to family leave regardless of the legal or biological relationship” and specifying that “an employee who intends to share in the parenting of a child with their same sex partner will be able to exercise the right to FMLA leave to bond with that child.”

In February 2015, the Department of Labour issued its final rule amending the definition of spouse under the FMLA in response to the decision in United States v. Windsor, effective 27 March 2015. The revised definition of “spouse” extends FMLA leave rights and job protections to eligible employees in a same-sex marriage or a common-law marriage entered into in a state where those statuses are legally recognised, regardless of the state in which the employee works or resides. Even if an employee works where same-sex or common law marriage is not recognized, that employee’s spouse triggers FMLA coverage if the employee married in a state that recognized same-sex marriage or common law marriage. Some states had already expanded the definition of family in their own FMLAs:

  • California: Domestic partner and domestic partner’s child.
  • Connecticut: Civil union partner, parent-in-law.
  • Hawaii: Grandparent, parent-in-law, grandparent-in-law or an employee’s reciprocal beneficiary.
  • Maine: Domestic partner and domestic partner’s child, siblings.
  • Maryland: Allows the employee to use time for immediate family under the same rules if taking it for themselves. Includes step, adopted and even people who were primary caregivers even if not related.
  • New Jersey: Civil union partner and child of civil union partner, parent-in-law, step parent.
  • Oregon: Domestic partner, grandparent, grandchild or parent-in-law.
  • Rhode Island: Domestic partners of state employees, parent-in-law.
  • Vermont: Civil union partner, parent-in-law.
  • Wisconsin: Parent-in-law.
  • District of Columbia: Related to the worker by blood, legal custody, or marriage; person with whom the employee lives and has a committed relationship; child who lives with employee and for whom employee permanently assumes and discharges parental responsibility.

Increasing the Uses for FMLA Leave

FMLA leave can be used for a worker’s serious health condition, the serious health condition of a family member, or upon the arrival of a new child. State FMLA laws and the new military family provisions of the FMLA have broadened these categories:

  • Connecticut: Organ or bone marrow donor.
  • Maine: Organ donor; death of employee’s family member if that family member is a servicemember killed while on active duty.
  • Maryland: Maryland Family Leave Act (MFLA) – Organ donor, Person Standing in Loco Parentis, For Service Leave, and added a specific anti-retaliation penalty on top of FMLA recovery. Runs parallel to FMLA.
  • Oregon: Care for the non-serious injury or illness of a child requiring home care.

Unpaid Leave for Other Related Purposes

Several states have passed FMLA-type statutes to give parents unpaid leave for other related purposes, including:

  • Attending child’s school or educational activities. Examples include California, District of Columbia, Massachusetts, Minnesota, Rhode Island, Vermont, and others.
  • Taking family members to routine medical visits. Massachusetts and Vermont.
  • Addressing the effects of domestic violence, stalking, or sexual assault. Examples include Colorado, Florida, Hawaii, and Illinois.

Significance

In 2003, Han and Waldfogel found that “only about 60% of private sector workers are covered” due to the clause stipulating a minimum number of employees, and once the clause stipulating a minimum number of hours worked is added, only 46% of private sector workers are eligible for leave under the FMLA. In June 2007, the Department of Labour estimated that of 141.7 million workers in the United States, 94.4 million worked at FMLA-covered worksites, and 76.1 million were eligible for FMLA leave. Only eight to 17.1% of covered, eligible workers (or between 6.1 million and 13.0 million workers) took FMLA leave in 2005. The 2008 National Survey of Employers found no statistically significant difference between the proportion of small employers (79%) and large employers (82%) that offer full FMLA coverage.

Although much of the research has been conducted on populations in other countries, Berger and colleagues found that children in the United States whose mothers return to work within the first 3 months after giving birth are less likely to be breastfed, have all of their immunisations up to date (by 18 months), and receive all of their regular medical checkups; they are also more likely to exhibit behavioural problems by four years of age. Chatterji and Markowitz also found an association between longer lengths of maternity leave and lesser incidence of depression among mothers.

Despite the lack of rights to leave, there is no right to free child care or day care. This has encouraged several proposals to create a public system of free child care, or for the government to subsidise parents’ costs.

Controversy

The act was controversial at its passage. Much of the controversy focused on its impact on the business community, and on whether the law should be gender neutral or not. In order to make the law more acceptable, it was argued that the law would reduce abortions. Proponents of the law focused on its benefit to men and children, in order to counter the claim that it was giving women “special treatment”. Other controversies focused on whether the leave should be paid or not.

The law was finally approved, mandating unpaid gender-neutral leave; nevertheless it was still criticised. Critics of the act have suggested that by mandating various forms of leave that are used more often by female than male employees, the Act, like the Pregnancy Discrimination Act of 1978, makes women more expensive to employ than men. They argue that employers will engage in subtle discrimination against women in the hiring process, discrimination which is much less obvious to detect than pregnancy discrimination against the already hired. Throughout history, gender discrimination towards women was common; certain laws were placed that would restrict a woman’s option in choosing a working position, as well as, how many hours she could work, i.e. Employers Supporters counter that the act, in contrast to the Pregnancy Discrimination Act of 1978, is aimed at both women and men, and is part of an overall strategy to encourage both men and women to take family-related leave. However, this is based on the assumption that men will take advantage of the opportunity of unpaid leave at comparable rates to women. According to Grossman, there is no basis for this assumption upon the inception of the legislation and no evidence has been found today to support this assumption. Therefore, the employer incentive to prefer male employees is preserved despite the equal opportunity for both sexes to take leave.

Moreover, the FMLA is much less comprehensive than Western European leave policies. Namely, the United States is the only industrialised country without paid leave for parents. This illustrates the lack of provisions offered in the United States as compared to that of other industrialised countries. For instance, all Western European nations have maternity paid leave and over half have paternity and sick child care paid leave, while the United States has no paid leave.

Additionally, workplace fairness has been questioned under the Act. For instance, any woman-specific benefits provided by the legislation were considered special treatment and thus unacceptable, and ignoring the idea that women may have a greater share of burden of caregiving in reality. In retort, supporters may argue that creating such legislation that recognises the female’s greater role in child care, stereotype would be reinforced.

The success of the implementation of the policy is also controversial because it is questioned whether the policy is actually going to those who need the benefits. For instance, since the leave offered is unpaid, majorities of eligible employees can not take time off because they can not afford to do so. And according to Pyle and Pelletier, eligible workers may not even know about this policy and the benefits allotted to them.

Under law, women are protected from sex discrimination in the workplace but a large stigma against women still exists in terms of them being equally skilled as their male co-workers, and ultimately testing the federal protection of rights in a work environment. Like any other federal regulation, it is strictly prohibited for an employer to discriminate towards an employee (especially if the employee is using their FMLA rights), and to strain from providing accurate information for all employees to access.

Signing Ceremony

Vicki Yandle, a receptionist who was fired after asking for a few weeks of time off to care for a daughter with cancer, was on stage with President Clinton when the law was signed.

What is the Americans with Disabilities Act of 1990?

Introduction

The Americans with Disabilities Act of 1990 or ADA (42 U.S.C. § 12101) is a civil rights law that prohibits discrimination based on disability.

It affords similar protections against discrimination to Americans with disabilities as the Civil Rights Act of 1964, which made discrimination based on race, religion, sex, national origin, and other characteristics illegal, and later sexual orientation. In addition, unlike the Civil Rights Act, the ADA also requires covered employers to provide reasonable accommodations to employees with disabilities, and imposes accessibility requirements on public accommodations.

In 1986, the National Council on Disability had recommended the enactment of an Americans with Disabilities Act (ADA) and drafted the first version of the bill which was introduced in the House and Senate in 1988. The final version of the bill was signed into law on 26 July 1990, by President George H. W. Bush. It was later amended in 2008 and signed by President George W. Bush with changes effective as of 01 January 2009.

Brief History

The ADA has roots in Section 504 of the Rehabilitation Act of 1973.

Drafting

In 1986, the National Council on Disability (NCD), an independent federal agency, issued a report, Towards Independence, in which the Council examined incentives and disincentives in federal laws towards increasing the independence and full integration of people with disabilities into our society. Among the disincentives to independence the Council identified was the existence of large remaining gaps in our nation’s civil rights coverage for people with disabilities. A principal conclusion of the report was to recommend the adoption of comprehensive civil rights legislation, which became the ADA.

The idea of federal legislation enhancing and extending civil rights legislation to millions of Americans with disabilities gained bipartisan support in late 1988 and early 1989. In early 1989 both Congress and the newly inaugurated Bush White House worked separately, then jointly, to write legislation capable of expanding civil rights without imposing undue harm or costs on those already in compliance with existing rules and laws.

Lobbying

Over the years, key activists and advocates played an important role in lobbying members of the US Congress to develop and pass the ADA, including Justin Whitlock Dart Jr., Patrisha Wright and others.

Ms. Wright is known as “the General” for her work in coordinating the campaign to enact the ADA. She is widely considered the main force behind the campaign lobbying for the ADA.

Support and Opposition

Support

About the importance of making employment opportunities inclusive, Shirley Davis, director of global diversity and inclusion at the Society for Human Resource Management, said: “People with disabilities represent a critical talent pool that is underserved and underutilized”.

Opposition from Religious Groups

The debate over the ADA led some religious groups to take opposite positions. The Association of Christian Schools International opposed the ADA in its original form, primarily because the ADA labelled religious institutions “public accommodations” and thus would have required churches to make costly structural changes to ensure access for all. The cost argument advanced by ACSI and others prevailed in keeping religious institutions from being labelled as “public accommodations”.

Church groups such as the National Association of Evangelicals testified against the ADA’s Title I employment provisions on grounds of religious liberty. The NAE believed the regulation of the internal employment of churches was “… an improper intrusion [of] the federal government.”

Opposition from Business Interests

Many members of the business community opposed the Americans with Disabilities Act. Testifying before Congress, Greyhound Bus Lines stated that the act had the potential to “deprive millions of people of affordable intercity public transportation and thousands of rural communities of their only link to the outside world.” The US Chamber of Commerce argued that the costs of the ADA would be “enormous” and have “a disastrous impact on many small businesses struggling to survive.” The National Federation of Independent Businesses, an organization that lobbies for small businesses, called the ADA “a disaster for small business.” Pro-business conservative commentators joined in opposition, writing that the Americans with Disabilities Act was “an expensive headache to millions” that would not necessarily improve the lives of people with disabilities.

“Capitol Crawl”

Shortly before the act was passed, disability rights activists with physical disabilities coalesced in front of the Capitol Building, shed their crutches, wheelchairs, powerchairs and other assistive devices, and immediately proceeded to crawl and pull their bodies up all 100 of the Capitol’s front steps, without warning. As the activists did so, many of them chanted “ADA now”, and “Vote, Now”. Some activists who remained at the bottom of the steps held signs and yelled words of encouragement at the “Capitol Crawlers”. Jennifer Keelan, a second grader with cerebral palsy, was videotaped as she pulled herself up the steps, using mostly her hands and arms, saying “I’ll take all night if I have to.” This direct action is reported to have “inconvenienced” several senators and to have pushed them to approve the act. While there are those who do not attribute much overall importance to this action, the “Capitol Crawl” of 1990 is seen by some present-day disability activists in the United States as a central act for encouraging the ADA into law.

Final Passage

Senator Tom Harkin (D-IA) authored what became the final bill and was its chief sponsor in the Senate. Harkin delivered part of his introduction speech in sign language, saying it was so his deaf brother could understand.

George H. W. Bush, on signing the measure on 26 July 1990, said:

I know there may have been concerns that the ADA may be too vague or too costly, or may lead endlessly to litigation. But I want to reassure you right now that my administration and the United States Congress have carefully crafted this Act. We’ve all been determined to ensure that it gives flexibility, particularly in terms of the timetable of implementation; and we’ve been committed to containing the costs that may be incurred…. Let the shameful wall of exclusion finally come tumbling down.

ADA Amendments Act (2008)

The ADA defines a covered disability as a physical or mental impairment that substantially limits one or more major life activities, a history of having such an impairment, or being regarded as having such an impairment. The Equal Employment Opportunity Commission (EEOC) was charged with interpreting the 1990 law with regard to discrimination in employment. The EEOC developed regulations limiting an individual’s impairment to one that “severely or significantly restricts” a major life activity. The ADAAA directed the EEOC to amend its regulations and replace “severely or significantly” with “substantially limits”, a more lenient standard.

On 25 September 2008, President George W. Bush signed the ADA Amendments Act of 2008 (ADAAA) into law. The amendment broadened the definition of “disability”, thereby extending the ADA’s protections to a greater number of people. The ADAAA also added to the ADA examples of “major life activities” including, but not limited to, “caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working” as well as the operation of several specified major bodily functions. The act overturned a 1999 US Supreme Court case that held that an employee was not disabled if the impairment could be corrected by mitigating measures; it specifically provides that such impairment must be determined without considering such ameliorative measures. It also overturned the court restriction that an impairment that substantially limits one major life activity must also limit others to be considered a disability. In 2008, the United States House Committee on Education and Labour stated that the amendment “makes it absolutely clear that the ADA is intended to provide broad coverage to protect anyone who faces discrimination on the basis of disability.” Thus the ADAAA led to broader coverage of impaired employees.

25th Anniversary (2015)

As of 2015 the ADA had improved access to public services, the built environment (e.g. crosswalks with curb cuts and accessible pedestrian signals), understanding of the abilities of people with disabilities, established a right to equal access to public services and has demonstrated the contributions which people with disabilities can make to the economy. Disparities have remained in employment, earned income, Internet access, transportation, housing, and educational attainment and the disabled remain at a disadvantage with respect to health and health care.

On 20 July 2015, the White House held a reception to celebrate the 25th anniversary of the ADA. The introductory remarks were given by Haben Girma, a deafblind disability rights lawyer and advocate. Among the guests was Alice Wong, a disability rights activist who came via telepresence robot.

Web Content Accessibility Guidelines (2019)

In October 2019, the Supreme Court declined to resolve a circuit split as to whether websites are covered by the ADA. The Court turned down an appeal from Domino’s Pizza and let stand a US 9th Circuit Court of Appeals ruling which held that the Americans With Disabilities Act protects access not just to brick-and-mortar public accommodations, but also to the websites and apps of those businesses.

Disabilities Included

ADA disabilities include both mental and physical medical conditions. A condition does not need to be severe or permanent to be a disability.

Equal Employment Opportunity Commission regulations provide a list of conditions that should easily be concluded to be disabilities: deafness, blindness, an intellectual disability (formerly termed mental retardation), partially or completely missing limbs or mobility impairments requiring the use of a wheelchair, autism, cancer, cerebral palsy, diabetes, epilepsy, attention deficit hyperactivity disorder, Human Immunodeficiency Virus (HIV) infection, multiple sclerosis, muscular dystrophy, major depressive disorder, bipolar disorder, post-traumatic stress disorder, obsessive compulsive disorder, and schizophrenia. Other mental or physical health conditions also may be disabilities, depending on what the individual’s symptoms would be in the absence of “mitigating measures” (medication, therapy, assistive devices, or other means of restoring function), during an “active episode” of the condition (if the condition is episodic).

Certain specific conditions that are widely considered anti-social, or tend to result in illegal activity, such as kleptomania, paedophilia, exhibitionism, voyeurism, etc. are excluded under the definition of “disability” in order to prevent abuse of the statute’s purpose. Additionally, gender identity or orientation is no longer considered a disorder and is also excluded under the definition of “disability”.

Titles

Title I – Employment

The ADA states that a “covered entity” shall not discriminate against “a qualified individual with a disability”. This applies to job application procedures, hiring, advancement and discharge of employees, job training, and other terms, conditions, and privileges of employment. “Covered entities” include employers with 15 or more employees, as well as employment agencies, labour organisations, and joint labour-management committees. There are strict limitations on when a covered entity can ask job applicants or employees disability-related questions or require them to undergo medical examination, and all medical information must be kept confidential.

Prohibited discrimination may include, among other things, firing or refusing to hire someone based on a real or perceived disability, segregation, and harassment based on a disability. Covered entities are also required to provide reasonable accommodations to job applicants and employees with disabilities. A reasonable accommodation is a change in the way things are typically done that the person needs because of a disability, and can include, among other things, special equipment that allows the person to perform the job, scheduling changes, and changes to the way work assignments are chosen or communicated. An employer is not required to provide an accommodation that would involve undue hardship (significant difficulty or expense), and the individual who receives the accommodation must still perform the essential functions of the job and meet the normal performance requirements. An employee or applicant who currently engages in the illegal use of drugs is not considered qualified when a covered entity takes adverse action based on such use.

There are many ways to discriminate against people based on disabilities, including psychological ones. Anyone known to have a history of mental disorders can be considered disabled. Employers with more than 15 employees must take care to treat all employees fairly and with any accommodations needed. Even when an employee is doing a job exceptionally well, she or he is not necessarily no longer disabled; employers must continue to follow all policies for the disabled.

Part of Title I was found unconstitutional by the United States Supreme Court as it pertains to states in the case of Board of Trustees of the University of Alabama v. Garrett as violating the sovereign immunity rights of the several states as specified by the Eleventh Amendment to the United States Constitution. The Court determined that state employees cannot sue their employer for violating ADA rules. State employees can, however, file complaints at the Department of Justice or the Equal Employment Opportunity Commission, who can sue on their behalf.

Title II – Public Entities (and Public Transportation)

Title II prohibits disability discrimination by all public entities at the local level, e.g., school district, municipal, city, or county, and at state level. Public entities must comply with Title II regulations by the US Department of Justice. These regulations cover access to all programmes and services offered by the entity. Access includes physical access described in the ADA Standards for Accessible Design and programmatic access that might be obstructed by discriminatory policies or procedures of the entity.

Title II applies to public transportation provided by public entities through regulations by the US Department of Transportation. It includes the National Railroad Passenger Corporation (Amtrak), along with all other commuter authorities. This section requires the provision of paratransit services by public entities that provide fixed-route services. ADA also sets minimum requirements for space layout in order to facilitate wheelchair securement on public transport.

Title II also applies to all state and local public housing, housing assistance, and housing referrals. The Office of Fair Housing and Equal Opportunity is charged with enforcing this provision.

Title III – Public Accommodations (and Commercial Facilities)

Under Title III, no individual may be discriminated against on the basis of disability with regards to the full and equal enjoyment of the goods, services, facilities, or accommodations of any place of public accommodation by any person who owns, leases, or operates a place of public accommodation. Public accommodations include most places of lodging (such as inns and hotels), recreation, transportation, education, and dining, along with stores, care providers, and places of public displays.

Under Title III of the ADA, all new construction (construction, modification or alterations) after the effective date of the ADA (approximately July 1992) must be fully compliant with the Americans With Disabilities Act Accessibility Guidelines (ADAAG) found in the Code of Federal Regulations at 28 C.F.R., Part 36, Appendix A.

Title III also has applications to existing facilities. One of the definitions of “discrimination” under Title III of the ADA is a “failure to remove” architectural barriers in existing facilities. See 42 U.S.C. § 12182(b)(2)(A)(iv). This means that even facilities that have not been modified or altered in any way after the ADA was passed still have obligations. The standard is whether “removing barriers” (typically defined as bringing a condition into compliance with the ADAAG) is “readily achievable”, defined as “…easily accomplished without much difficulty or expense”.

The statutory definition of “readily achievable” calls for a balancing test between the cost of the proposed “fix” and the wherewithal of the business and/or owners of the business. Thus, what might be “readily achievable” for a sophisticated and financially capable corporation might not be readily achievable for a small or local business.

There are exceptions to this title; many private clubs and religious organizations may not be bound by Title III. With regard to historic properties (those properties that are listed or that are eligible for listing in the National Register of Historic Places, or properties designated as historic under state or local law), those facilities must still comply with the provisions of Title III of the ADA to the “maximum extent feasible” but if following the usual standards would “threaten to destroy the historic significance of a feature of the building” then alternative standards may be used.

Under 2010 revisions of Department of Justice regulations, newly constructed or altered swimming pools, wading pools, and spas must have an accessible means of entrance and exit to pools for disabled people. However, the requirement is conditioned on whether providing access through a fixed lift is “readily achievable”. Other requirements exist, based on pool size, include providing a certain number of accessible means of entry and exit, which are outlined in Section 242 of the standards. However, businesses are free to consider the differences in the application of the rules depending on whether the pool is new or altered, or whether the swimming pool was in existence before the effective date of the new rule. Full compliance may not be required for existing facilities; Section 242 and 1009 of the 2010 Standards outline such exceptions.

Service Animals

The ADA provides explicit coverage for service animals. Guidelines have been developed not only to protect persons with disabilities but also to indemnify businesses from damages related to granting access to service animals on their premises. Businesses are allowed to ask if the animal is a service animal and ask what tasks it is trained to perform, but they are not allowed to ask the service animal to perform the task nor ask for a special ID of the animal. They cannot ask what the person’s disabilities are. A person with a disability cannot be removed from the premises unless either of two things happen: the animal is out of control and its owner cannot get it under control (e.g. a dog barking uncontrollably in a restaurant), or the animal is a direct threat to people’s health and safety. Allergies and fear of animals would not be considered a threat to people’s health and safety, so it would not be a valid reason to deny access to people with service animals. Businesses that prepare or serve food must allow service animals and their owners on the premises even if state or local health laws otherwise prohibit animals on the premises. In this case, businesses that prepare or serve food are not required to provide care or food for service animals, nor do they have to provide a designated area for the service animal to relieve itself. Lastly, people that require service dogs cannot be charged an extra fee for their service dog or be treated unfairly, for example, being isolated from people at a restaurant. People with disabilities cannot be treated as “less than” other customers. However, if a business normally charges for damages caused by the person to property, the customer with a disability will be charged for his/her service animal’s damages to the property.

Auxiliary Aids

The ADA provides explicit coverage for auxiliary aids.

Auxiliary aids and services are items, equipment or services that assist in effective communication between a person who has a hearing, vision or speech disability and a person who does not.

ADA says that a public accommodation shall take those steps that may be necessary to ensure that no individual with a disability is excluded, denied services, segregated or otherwise treated differently than other individuals because of the absence of auxiliary aids and services, unless the public accommodation can demonstrate that taking those steps would fundamentally alter the nature of the goods, services, facilities, privileges, advantages, or accommodations being offered or would result in an undue burden, i.e. significant difficulty or expense. The term “auxiliary aids and services” includes:

  • Qualified interpreters on-site or through video remote interpreting (VRI) services; notetakers; real-time computer-aided transcription services; written materials; exchange of written notes; telephone handset amplifiers; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning, including real-time captioning; voice, text, and video-based telecommunications products and systems, including text telephones (TTYs), videophones, and captioned telephones, or equally effective telecommunications devices; videotext displays; accessible electronic and information technology; or other effective methods of making aurally delivered information available to individuals who are deaf or hard of hearing;
  • Qualified readers; taped texts; audio recordings; Brailled materials and displays; screen reader software; magnification software; optical readers; secondary auditory programmes (SAP); large print materials; accessible electronic and information technology; or other effective methods of making visually delivered materials available to individuals who are blind or have low vision;
  • Acquisition or modification of equipment or devices; and
  • Other similar services and actions.

Captions are considered one type of auxiliary aid. Since the passage of the ADA, the use of captioning has expanded. Entertainment, educational, informational, and training materials are captioned for deaf and hard-of-hearing audiences at the time they are produced and distributed. The Television Decoder Circuitry Act of 1990 requires that all televisions larger than 13 inches sold in the United States after July 1993 have a special built-in decoder that enables viewers to watch closed-captioned programming. The Telecommunications Act of 1996 directs the Federal Communications Commission (FCC) to adopt rules requiring closed captioning of most television programming. The FCC’s rules on closed captioning became effective 01 January 1998.

Title IV – Telecommunications

Title IV of the ADA amended the landmark Communications Act of 1934 primarily by adding section 47 U.S.C. § 225. This section requires that all telecommunications companies in the U.S. take steps to ensure functionally equivalent services for consumers with disabilities, notably those who are deaf or hard of hearing and those with speech impairments. When Title IV took effect in the early 1990s, it led to the installation of public teletypewriter (TTY) machines and other TDD (telecommunications devices for the deaf). Title IV also led to the creation, in all 50 states and the District of Columbia, of what was then called dual-party relay services and now are known as Telecommunications Relay Services (TRS), such as STS relay. Today, many TRS-mediated calls are made over the Internet by consumers who use broadband connections. Some are Video Relay Service (VRS) calls, while others are text calls. In either variation, communication assistants translate between the signed or typed words of a consumer and the spoken words of others. In 2006, according to the Federal Communications Commission (FCC), VRS calls averaged two million minutes a month.

Title V – Miscellaneous Provisions

Title V includes technical provisions. It discusses, for example, the fact that nothing in the ADA amends, overrides or cancels anything in Section 504. Additionally, Title V includes an anti-retaliation or coercion provision. The Technical Assistance Manual for the ADA explains this provision:

III-3.6000 Retaliation or coercion. Individuals who exercise their rights under the ADA, or assist others in exercising their rights, are protected from retaliation. The prohibition against retaliation or coercion applies broadly to any individual or entity that seeks to prevent an individual from exercising his or her rights or to retaliate against him or her for having exercised those rights … Any form of retaliation or coercion, including threats, intimidation, or interference, is prohibited if it is intended to interfere.

Reaction

Criticism

Employment

The ADA has been criticised on the grounds that it decreases the employment rate for people with disabilities and raises the cost of doing business for employers, in large part due to the additional legal risks, which employers avoid by quietly avoiding hiring people with disabilities. Some researchers believe that the law has been ineffectual. Between 1991 (after the enactment of the ADA) and 1995, the employment rate of men with disabilities dropped by 7.8% regardless of age, educational level, or type of disability, with the most affected being young, less-educated and mentally disabled men. Despite the many criticisms, a causal link between the ADA and declining disabled employment over much of the 1990s has not been definitively identified.

In 2001, for men of all working ages and women under 40, Current Population Survey data showed a sharp drop in the employment of disabled workers, leading at least two economists to attribute the cause to the Act. By contrast, a study in 2003 found that while the Act may have led to short term reactions by employers, in the long term, there were either positive or neutral consequences for wages and employment. In 2005 the rate of employment among disabled people increased to 45% of the population of disabled people.

“Professional Plaintiffs”

Since enforcement of the act began in July 1992, it has quickly become a major component of employment law. The ADA allows private plaintiffs to receive only injunctive relief (a court order requiring the public accommodation to remedy violations of the accessibility regulations) and attorneys’ fees, and does not provide monetary rewards to private plaintiffs who sue non-compliant businesses. Unless a state law, such as the California Unruh Civil Rights Act, provides for monetary damages to private plaintiffs, persons with disabilities do not obtain direct financial benefits from suing businesses that violate the ADA.

The attorneys’ fees provision of Title III does provide incentive for lawyers to specialise and engage in serial ADA litigation, but a disabled plaintiff does not obtain a financial reward from attorneys’ fees unless they act as their own attorney, or as mentioned above, a disabled plaintiff resides in a state that provides for minimum compensation and court fees in lawsuits. Moreover, there may be a benefit to these “private attorneys general” who identify and compel the correction of illegal conditions: they may increase the number of public accommodations accessible to persons with disabilities. “Civil rights law depends heavily on private enforcement. Moreover, the inclusion of penalties and damages is the driving force that facilitates voluntary compliance with the ADA.” Courts have noted:

As a result, most ADA suits are brought by a small number of private plaintiffs who view themselves as champions of the disabled. For the ADA to yield its promise of equal access for the disabled, it may indeed be necessary and desirable for committed individuals to bring serial litigation advancing the time when public accommodations will be compliant with the ADA.

However, in states that have enacted laws that allow private individuals to win monetary awards from non-compliant businesses (as of 2008, these include California, Florida, Hawaii, and Illinois), “professional plaintiffs” are typically found. At least one of these plaintiffs in California has been barred by courts from filing lawsuits unless he receives prior court permission. Through the end of fiscal year 1998, 86% of the 106,988 ADA charges filed with and resolved by the Equal Employment Opportunity Commission, were either dropped or investigated and dismissed by EEOC but not without imposing opportunity costs and legal fees on employers.

Case Law

There have been some notable cases regarding the ADA. For example, two major hotel room marketers (Expedia.com and Hotels.com) with their business presence on the Internet were sued because its customers with disabilities could not reserve hotel rooms through their websites without substantial extra efforts that persons without disabilities were not required to perform. These represent a major potential expansion of the ADA in that this, and other similar suits (known as “bricks vs. clicks”), seeks to expand the ADA’s authority to cyberspace, where entities may not have actual physical facilities that are required to comply.

Green v. State of California

Green v. State of California, No. S137770 (Cal. Aug. 23, 2007) was a case in which the majority of the Supreme Court in California was faced with deciding whether the employee suing the state is required to prove he is able to perform “essential” job duties, regardless of whether or not there was “reasonable accommodation,” or if the employer must prove the victim was unable to do so. The court ruled the burden was on the employee, not the employer, and reversed a disputed decision by the courts. Plaintiff attorney David Greenberg brought forth considerations of the concept that, even in the state of California, employers do not have to employ a worker who is unable to perform “essential job functions” with “reasonable accommodation.” Forcing employers to do so “would defy logic and establish a poor public policy in employment matters.”

National Federation of the Blind v. Target Corporation

National Federation of the Blind v. Target Corporation was a case where a major retailer, Target Corp., was sued because their web designers failed to design its website to enable persons with low or no vision to use it.

Board of Trustees of the University of Alabama v. Garrett

Board of Trustees of the University of Alabama v. Garrett was a United States Supreme Court case about Congress’s enforcement powers under the Fourteenth Amendment to the Constitution. It decided that Title I of the Americans with Disabilities Act was unconstitutional insofar as it allowed private citizens to sue states for money damages.

Barden v. The City of Sacramento

Barden v. The City of Sacramento, filed in March 1999, claimed that the City of Sacramento failed to comply with the ADA when, while making public street improvements, it did not bring its sidewalks into compliance with the ADA. Certain issues were resolved in Federal Court. One issue, whether sidewalks were covered by the ADA, was appealed to the 9th Circuit Court of Appeals, which ruled that sidewalks were a “program” under ADA and must be made accessible to persons with disabilities. The ruling was later appealed to the US Supreme Court, which refused to hear the case, letting stand the ruling of the 9th Circuit Court.

Bates v. UPS

Bates v. UPS (begun in 1999) was the first equal opportunity employment class action brought on behalf of Deaf and Hard of Hearing (d/Deaf/HoH) workers throughout the country concerning workplace discrimination. It established legal precedence for d/Deaf/HoH Employees and Customers to be fully covered under the ADA. Key findings included:

  • UPS failed to address communication barriers and to ensure equal conditions and opportunities for deaf employees;
  • Deaf employees were routinely excluded from workplace information, denied opportunities for promotion, and exposed to unsafe conditions due to lack of accommodations by UPS;
  • UPS also lacked a system to alert these employees as to emergencies, such as fires or chemical spills, to ensure that they would safely evacuate their facility; and
  • UPS had no policy to ensure that deaf applicants and employees actually received effective communication in the workplace.

The outcome was that UPS agreed to pay a $5.8 million award and agreed to a comprehensive accommodations programme that was implemented in their facilities throughout the country.

Spector v. Norwegian Cruise Line Ltd

Spector v. Norwegian Cruise Line Ltd was a case that was decided by the United States Supreme Court in 2005. The defendant argued that as a vessel flying the flag of a foreign nation it was exempt from the requirements of the ADA. This argument was accepted by a federal court in Florida and, subsequently, the Fifth Circuit Court of Appeals. However, the US Supreme Court reversed the ruling of the lower courts on the basis that Norwegian Cruise Lines was a business headquartered in the United States whose clients were predominantly Americans and, more importantly, operated out of port facilities throughout the United States.

Olmstead v. L.C.

Not to be confused with Olmstead v. United States, 277 U.S. 438 (1928), a case regarding wiretapping.

Olmstead v. L.C. was a case before the United States Supreme Court in 1999. The two plaintiffs, L.C. and E.W., were institutionalised in Georgia for diagnosed mental retardation and schizophrenia. Clinical assessments by the state determined that the plaintiffs could be appropriately treated in a community setting rather than the state institution. The plaintiffs sued the state of Georgia and the institution for being inappropriately treated and housed in the institutional setting rather than being treated in one of the state’s community-based treatment facilities.

The Supreme Court decided under Title II of the ADA that mental illness is a form of disability and therefore covered under the ADA, and that unjustified institutional isolation of a person with a disability is a form of discrimination because it “…perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life.” The court added, “Confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.”

Therefore, under Title II no person with a disability can be unjustly excluded from participation in or be denied the benefits of services, programmes or activities of any public entity.

Michigan Paralysed Veterans of America v. The University of Michigan

This was a case filed before The United States District Court for the Eastern District of Michigan Southern Division on behalf of the Michigan Paralysed Veterans of America against University of Michigan – Michigan Stadium claiming that Michigan Stadium violated the Americans with Disabilities Act in its $226-million renovation by failing to add enough seats for disabled fans or accommodate the needs for disabled restrooms, concessions and parking. Additionally, the distribution of the accessible seating was at issue, with nearly all the seats being provided in the end-zone areas. The US Department of Justice assisted in the suit filed by attorney Richard Bernstein of The Law Offices of Sam Bernstein in Farmington Hills, Michigan, which was settled in March 2008. The settlement required the stadium to add 329 wheelchair seats throughout the stadium by 2010, and an additional 135 accessible seats in clubhouses to go along with the existing 88 wheelchair seats. This case was significant because it set a precedent for the uniform distribution of accessible seating and gave the DOJ the opportunity to clarify previously unclear rules. The agreement now is a blueprint for all stadiums and other public facilities regarding accessibility.

Paralysed Veterans of America v. Ellerbe Becket Architects and Engineers

One of the first major ADA lawsuits, Paralysed Veterans of America v. Ellerbe Becket Architects and Engineers (PVA 1996) was focused on the wheelchair accessibility of a stadium project that was still in the design phase, MCI Centre (now known as Capital One Arena) in Washington, D.C. Previous to this case, which was filed only five years after the ADA was passed, the DOJ was unable or unwilling to provide clarification on the distribution requirements for accessible wheelchair locations in large assembly spaces. While Section 4.33.3 of ADAAG makes reference to lines of sight, no specific reference is made to seeing over standing patrons. The MCI Centre, designed by Ellerbe Becket Architects & Engineers, was designed with too few wheelchair and companion seats, and the ones that were included did not provide sight lines that would enable the wheelchair user to view the playing area while the spectators in front of them were standing. This case and another related case established precedent on seat distribution and sight lines issues for ADA enforcement that continues to present day.

Toyota Motor Manufacturing, Kentucky, Inc. v. Williams

Toyota Motor Manufacturing, Kentucky, Inc. v. Williams, was a case in which the Supreme Court interpreted the meaning of the phrase “substantially impairs” as used in the Americans with Disabilities Act. It reversed a Sixth Court of Appeals decision to grant a partial summary judgement in favour of the respondent, Ella Williams, that qualified her inability to perform manual job-related tasks as a disability. The Court held that the “major life activity” definition in evaluating the performance of manual tasks focuses the inquiry on whether Williams was unable to perform a range of tasks central to most people in carrying out the activities of daily living. The issue is not whether Williams was unable to perform her specific job tasks. Therefore, the determination of whether an impairment rises to the level of a disability is not limited to activities in the workplace solely, but rather to manual tasks in life in general. When the Supreme Court applied this standard, it found that the Court of Appeals had incorrectly determined the presence of a disability because it relied solely on her inability to perform specific manual work tasks, which was insufficient in proving the presence of a disability. The Court of Appeals should have taken into account the evidence presented that Williams retained the ability to do personal tasks and household chores, such activities being the nature of tasks most people do in their daily lives, and placed too much emphasis on her job disability. Since the evidence showed that Williams was performing normal daily tasks, it ruled that the Court of Appeals erred when it found that Williams was disabled. This ruling is now, however, no longer good law – it was invalidated by the ADAAA. In fact, Congress explicitly cited Toyota v. Williams in the text of the ADAAA itself as one of its driving influences for passing the ADAAA.

US Airways, Inc. v. Barnett

Decided by the US Supreme Court in 2002, this case held that even requests for accommodation that might seem reasonable on their face, e.g. a transfer to a different position, can be rendered unreasonable because it would require a violation of the company’s seniority system. While the court held that, in general, a violation of a seniority system renders an otherwise reasonable accommodation unreasonable, a plaintiff can present evidence that, despite the seniority system, the accommodation is reasonable in the specific case at hand, e.g. the plaintiff could offer evidence that the seniority system is so often disregarded that another exception would not make a difference.

Importantly, the court held that the defendant need not provide proof that this particular application of the seniority system should prevail, and that, once the defendant showed that the accommodation violated the seniority system, it fell to Barnett to show it was nevertheless reasonable.

In this case, Barnett was a US Airways employee who injured his back, rendering him physically unable to perform his cargo-handling job. Invoking seniority, he transferred to a less-demanding mailroom job, but this position later became open to seniority-based bidding and was bid on by more senior employees. Barnett requested the accommodation of being allowed to stay on in the less-demanding mailroom job. US Airways denied his request, and he lost his job.

The Supreme Court decision invalidated both the approach of the district court, which found that the mere presence and importance of the seniority system was enough to warrant a summary judgment in favour of US Airways, as well as the circuit court’s approach that interpreted ‘reasonable accommodation’ as ‘effective accommodation.’

Access Now v. Southwest Airlines

Access Now v. Southwest Airlines was a case where the District Court decided that the website of Southwest Airlines was not in violation of the Americans with Disabilities Act, because the ADA is concerned with things with a physical existence and thus cannot be applied to cyberspace. Judge Patricia A. Seitz found that the “virtual ticket counter” of the website was a virtual construct, and hence not a “public place of accommodation.” As such, “To expand the ADA to cover ‘virtual’ spaces would be to create new rights without well-defined standards.

Ouellette v. Viacom International Inc.

Ouellette v. Viacom International Inc. followed in Access Now’s footsteps by holding that a mere online presence does not subject a website to the ADA guidelines. Thus Myspace and YouTube were not liable for a dyslexic man’s inability to navigate the site regardless of how impressive the “online theatre” is.

Authors Guild v. HathiTrust

Authors Guild v. HathiTrust was a case in which the District Court decided that the HathiTrust digital library was a transformative, fair use of copyrighted works, making a large number of written text available to those with print disability.

Zamora-Quezada v. HealthTexas Medical Group

Zamora-Quezada v. HealthTexas Medical Group (begun in 1998) was the first time this act was used against HMOs when a novel lawsuit was filed by Texas attorney Robert Provan against five HMOs for their practice of revoking the contracts of doctors treating disabled patients.

Campbell v. General Dynamics Government Systems Corp.

Campbell v. General Dynamics Government Systems Corp. (2005) concerned the enforceability of a mandatory arbitration agreement, contained in a dispute resolution policy linked to an e-mailed company-wide announcement, insofar as it applies to employment discrimination claims brought under the Americans with Disabilities Act.

Tennessee v. Lane

Tennessee v. Lane,[89] 541 U.S. 509 (2004), was a case in the Supreme Court of the United States involving Congress’s enforcement powers under section 5 of the Fourteenth Amendment. George Lane was unable to walk after a 1997 car accident in which he was accused of driving on the wrong side of the road. A woman was killed in the crash, and Lane faced misdemeanour charges of reckless driving. The suit was brought about because he was denied access to appear in criminal court because the courthouse had no elevator, even though the court was willing to carry him up the stairs and then willing to move the hearing to the first floor. He refused, citing he wanted to be treated as any other citizen, and was subsequently charged with failure to appear, after appearing at a previous hearing where he dragged himself up the stairs. The court ruled that Congress did have enough evidence that the disabled were being denied those fundamental rights that are protected by the Due Process clause of the Fourteenth Amendment and had the enforcement powers under section 5 of the Fourteenth Amendment. It further ruled that “reasonable accommodations” mandated by the ADA were not unduly burdensome and disproportionate to the harm.

What is the Bazelon Centre for Mental Health Law?

Introduction

The Bazelon Centre for Mental Health Law is a national legal-advocacy organisation representing people with mental disabilities in the US (Washington, D.C.).

Originally known as The Mental Health Law Project, the Centre was founded as a national public-interest organization in 1972 by a group of specialised attorneys and mental disability professionals who were working to help the court define a constitutional right to treatment in terms of specific standards for services and protections.

In 1993, the organisation changed its name to the Judge David L. Bazelon Centre for Mental Health Law to honour the legacy of Judge David L. Bazelon, whose decisions as Chief Judge of the United States Court of Appeals for the District of Columbia Circuit had pioneered the field of mental health law.

Refer to the Treatment Advocacy Centre.

Litigation

The Centre’s precedent-setting litigation has established important civil rights for people with mental illnesses or developmental disabilities. These include the right to treatment in Wyatt v. Stickney (decided in 1971 and successfully concluded in 1999), and the Supreme Court’s 1999 Olmstead v. L.C. ex rel. Zimring decision affirming the right of people with disabilities to receive public services in the most integrated setting consistent with their needs.

Federal Policy

The Centre also engages in federal policy advocacy, working with Congress and the administrative agencies to ensure, for example, that people with mental disabilities are included under the protections of the Americans with Disabilities Act and amendments to the federal Fair Housing Act, and to generate resources such as Supplemental Security Income and Medicaid that can enable them to live and thrive in the community. In 2009, a major thrust was the integration of mental health in healthcare reform.

Publications

The Bazelon Centre’s publications include reports; issue papers; law, regulation, and policy analyses; advocacy manuals; and consumer-friendly guides to legal rights. These are available for free download from the centre’s website, or print copies may be ordered by postal mail, telephone, or email.

Funding

During the 2015 fiscal year, most of the Bazelon Centre’s revenue came from contributions, gifts, and grants. Notable organisations providing grant support to the Bazelon Centre include the Open Society Foundations and the MacArthur Foundation. Beginning in 1978, the MacArthur Foundation has awarded multiple grants to the Bazelon Centre, totalling $14,035,000 as of 2016.