Monday our chances of getting funding got an important boost. The Assembly Budget Committee decided to include $ 35 million in its counterproposal to the Governor's budget. The "key players" in the Assembly typically make decisions concerning the budget -- so this support is a promising omen.

But this does not mean we can let up on Appropriations. The budget will be used by the leaders of the Assembly to negotiate funding levels with the leaders of the Senate and Governor Davis. Even if funds for our bill are in the resulting compromise budget, no money will be available for assisted outpatient treatment unless a specific appropriation is attached to AB 1421 and the bill is then approved by a general vote of the Assembly.

And the only place to get an appropriation is in the Appropriations Committee. Truthfully, after the inclusion of funding for AB 1421 in the budget, we expect to get some level of appropriation. But we are fearful that it will be less than the $35 million in the budget. And don't forget that while this budget allocation was a victory, it is still $15 million less than what Assemblywoman Thomson asked for.

You might want to tell those on Appropriations where money allocated to AB 1421 will go. The legal reforms incorporated into the programs will cost little money. The vast bulk of what we seek will fund assertive community treatment teams ("ACT" or in NAMI parlance "PACT"). These are teams of various types of mental health professionals offering intensive and personalized services, including vocational and consumer education, social and psychological counseling, housing, and medication. The members of an ACT offer support all day and every day throughout the year.

For those most in need of help, ACT has been proven to be the most effective service model available.

And now that we have a commitment from the Budget Committee for new ACT programs, we have a new advantage. The overriding plea of mental health advocates generally is "more funding for services." AB 1421 now offers an avenue to obtain service funding -- and in a year when other programs are being slashed to make up for the energy drain on the State's funds. Those who may before have been ambivalent about LPS reform should now be behind our bill for the services it can provide. Be sure to remind them of that.

While we don't wish to distract you from your efforts with the Appropriations Committee, a floor vote on AB 1421 must be held by June 8. For the general vote, we ask each of you to reach out to your Assemblymember. You will have by far the greatest impact by visiting the local district office and meeting with your Assemblyperson (they tend to be in on Fridays) or staff. You can obtain the identity of and contact information for your Assemblymember from a link at the end of the Appropriations list.

For the floor vote we will need to dig for every vote. Because--with luck--there will be an appropriation attached to AB 1421, we will need a two-thirds majority to move out of the Assembly and on to the Senate. That means we must educate at least 54 of the Assembly's 80 members. Last year with AB 1800, we got 53. And that was without the financial implications of an attached appropriation.

Below is an LA TIMES op-ed by Professor Jeffrey Swanson. He was one of the researchers behind the Duke Outpatient Commitment Study, which is recognized (including by the RAND study) as the best academic examination to date of programs like the one AB 1421 would create. Especially interesting is Prof. Swanson's comments concerning RAND's misstatement of key findings of the Duke Study.

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Los Angeles Times
May 4, 2001 Friday
Op Ed Desk

Commentary; Whose Mind Is It Anyway?

By: JEFF SWANSON, Jeffrey Swanson is a sociologist and associate professor of, psychiatry and behavioral sciences at Duke University Medical Center

Next week brings new debate in the California state Legislature over how to solve an old problem: What to do about adult members of our communities who suffer from debilitating psychiatric illnesses such as schizophrenia but who refuse to accept treatment until they deteriorate to the point of requiring involuntary hospitalization or commit a crime and get arrested.

To some degree, every state has faced this dilemma in the decades after deinstitutionalization, when laws were strengthened to protect the right to refuse psychiatric treatment.

Assemblywoman Helen Thomson (D-Davis) is sponsoring legislation, AB 1421, that would authorize court-mandated treatment in the community, a legal policy adopted in most other states. The law would establish a program called Assisted Outpatient Treatment (also known as involuntary outpatient commitment).

At the heart of a national debate over outpatient commitment lies a legal-ethical tension between respect for individuals' rights to make their own decisions about medical treatment and the social responsibility to care for people with severe mental disorders--people who, at times, may fail to recognize the gravity of their conditions.

Opposing arguments are heard from two extremes. On one side are civil libertarian legal advocates and representatives for mental health consumer groups who see outpatient commitment as an infringement on constitutionally protected personal freedom. At the other extreme, advocates for outpatient commitment point to rare acts of violence committed by people with untreated psychoses and insist that such people should be forced to "stay on their medications."

There is ample room for consensus in the middle ground, where the real issue is not whether one favors or opposes any use of legal coercion in community mental health treatment, but for which subgroups it may be beneficial and appropriate, and how should it be applied. Thomson's bill goes a long way toward addressing these matters while safeguarding citizens' civil rights.

Whatever one thinks of outpatient commitment as a public policy, it is unfair to reject mandated treatment without considering the larger context of the real limits of a debilitating condition such as schizophrenia--the impoverishment of life's choices, the loss of chances and constrained self-determination. Coercion compared to what? Autonomy in what sense?

Outpatient commitment offers a less-restrictive alternative to hospitalization. The goal is to ensure that beneficial treatment and case management are maintained consistently, rather than delaying intervention until rehospitalization is required.

Does outpatient commitment work? Our recent study in North Carolina addressed this question with a one-year experiment among 331 people with severe mental illness. Outpatient commitment works in North Carolina assuming two conditions: The court order is extended for a reasonable period of time (six months or more) and regular follow-up is provided with a case manager or therapist. Under these conditions, outpatient commitment is credited with reducing repeat hospitalizations by 57% and reducing violent behavior by about half.

A Rand report has interpreted our results to mean that if a court order and intensive treatment work together, it is difficult to tell if there is any net benefit to outpatient commitment per se. In fact, our study tested the net effect of outpatient commitment as well as the complementary role of intensive services delivery. We found that subjects who were high-intensity service users without outpatient commitment had no better outcomes than their counterparts who received infrequent services or no services at all. Clearly, the court order added something.

We concluded that outpatient commitment can help an individual adhere to a beneficial regimen of psychiatric treatment, and may also influence the mental health service system by getting case managers more invested in outreach, in mobilizing resources and in leveraging more services on behalf of a patient.

Admittedly, outpatient commitment presents thorny dilemmas. Policy decisions about benefits and quality of life involve subjective evaluation. Which is worse: a year under court-ordered treatment or a week in the hospital or three days in jail for vagrancy? Worse for whom? And with whose money? Answering these questions for a whole state is a difficult task but one worth pursuing.

AB 1421 does not represent a panacea, the end of violence or the end of civil rights in California. It wouldn't affect the majority of people with some form of psychiatric illness. It wouldn't fix a fiscal crisis that threatens to further shrink resources for mental health services. But the proposed law does offer a reasonable and measured policy that could make effective treatment much more consistently available to many people.

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