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IGS Public Affairs Reports

Institute of Governmental Studies
University of California, Berkeley

California law now imposes a criminal standard as a condition for supervised medicine for the mentally ill. AB 1800, a reform bill that passed the state Assembly 53-16, would remove that stigma. But this effort to open the door to more enlightened and effective treatment of the mentally ill through legislative reform has run headlong into a so-far insurmountable obstacle in the state Senate.

Authored by Assembly Woman Helen Thomson, a psychiatric nurse, AB 1800 would reform the 1967 Lanterman-Petris-Short (LPS) Act. This law was passed well before medical research had identified the physical causes of mental illness and developed medicines to treat them.

When AB1800 was introduced, Senator President Pro Tem John Burton declared there would be "no forced medicine" in California. Burton held the Assembly-passed bill in the Senate Rules Committee. Although he initiated an unusual hearing on the "subject matter" in a research committee that cannot hear bills, he never moved the bill to a policy committee where it could be voted on. AB 1800 remains stuck in the Senate Rules Committee.

LPS now provides that only certain individuals, chiefly law enforcement officials, can place a person into involuntary hospitalization to initiate a 72-hour evaluation period, and it specifically excludes family or friends. It provides two requirements for involuntary hospitalization: first, that the individual has a mental disorder and, second, as a result of that disorder the individual is a danger to self or gravely disabled. Gravely disabled is defined as an inability to take care of one’s basic needs, such as food, clothing or shelter.

The law does not define mental disorder nor does it define what constitutes danger. The patient -- psychotic or not -- goes before a judge or court-appointed hearing officer, who rules within the narrow confines of the law and who most often releases the individual, even over the objection of medical advice and family or friends.

The process -- which seldom considers the medical history and often disregards the medical diagnosis -- prematurely discharges the mentally ill. This is a major reason some 40 per cent of the homeless in California and 10 per cent of the prison inmates suffer from mentally illness.

Many others are secluded in a room or apartment and depend on family members to provide necessities of life or end up with arrest records, face bankruptcy and find their lives in turmoil. Many more are victims of assault and rape when let go.

"Under the present law people can’t be treated involuntarily unless they are acutely dangerous, immediately suicidal, or so mentally disabled that they can’t eat out of garbage cans," testified Dr. Edward Titus at a 1998 LPS hearing. "It’s paradoxical that this situation has come to pass at a time when really excellent treatments are available, but legal restraints make it impossible to give them the treatment that could really help them."

There is provision in the LPS Act for two consecutive 14-day holds, but after that, even if the person is suicidal, they must be released. Rarely is an 180-day hold invoked because of procedures and costs involved. The state’s burden of proof equates to that of a criminal conviction: beyond a reasonable doubt.

According to an LPS Reform Task Force report edited by Carla Jacobs, Dr. Elizabeth Galton, and Beth Howard: "Mental illnesses, such as schizophrenia, bipolar disorder, obsessive compulsive disorder, and clinical depression, are neurobiological diseases of the brain." They can be likened to Parkinson’s and Alzheimer’s disease in that respect.

Reform of California’s system for treating the mentally ill began in 1957 with the passage of the Short-Doyle Act, which aimed to move the mentally ill from incarceration in state mental health hospitals to community mental health programs. LPS sought to move the mentally ill out of state hospitals but failed to realize the structure and support that would be needed in the communities. It paralleled cuts by the administration of then-Governor Ronald Reagan in state hospital staffing. Funding for county mental health programs suffered a major blow when California voters passed Proposition 13.

"One of the difficulties in providing continuous treatment in the community," argued the reform task force report, "is that since these illnesses are brain disorders that affect the ill person’s reasoning, some individuals do not recognize that they are ill or that the symptoms of their condition will respond to medicine."

The Coalition Advocating for Rights Empowerment and Services, organized to "fight expansion of forced treatment," opposes reform. It includes the federally funded Protection & Advocacy, Inc., the California Network of Mental Health Clients and the California Association of Mental Health Patients Rights Advocates. Civil rights lawyers and the defense bar that supply the bulk of hearing officers under the LPS Act generally also oppose reform.

This coalition has a six-point position:

• Current criteria are adequate and expanding involuntary treatment will not provide a "quick fix."
• Although most people with mental disabilities "are competent to make decisions, the myth that they are incompetent drives the...agenda to expand forced treatment."
• Research does not support the public stereotype of people with mental disabilities as violent.
• "Expanding forced treatment is not a solution to treatment noncompliance...."
• Mental health clients need community-based choices, "not coercion."
• "Expanding forced mental health treatment violates basic constitutional rights guaranteed to all Americans."

While coalition members would argue that the "broken-brain" theory does not agree with conventional wisdom and that most mentally disabled can make their own decisions, those mentally ill who come to the attention of authorities get there through their antisocial behavior. In most cases, the trigger is unlawful behavior.

As an Associated Press reporter just back from Korea, I was among press corps members when the Short-Doyle Act was passed in 1957 and heard the arguments that getting patients out of the hospitals and into their communities would enhance their recovery. At the Oregon State capitol in Salem during the early ‘60s, I was invited by Dean Brooks, Superintendent of the state hospital, and Dr. Maxwell Jones, who initiated the therapeutic community, to observe and to write about these efforts among patients, staff, and doctors at a time when it was believed the mentally ill could be stabilized through therapy alone. It did not work.

What the LPS Reform Task Force and the expert witnesses before the Joint Committee on Mental Health Reform clearly demonstrated was the need to medicate the psychotic patients to bring them to a point where therapy can and will benefit the patient.

Burton recently explained his opposition to AB1800 by saying the mental health system and the judicial system are too fragmented to provide any more treatment to people with mental illness. Yet, when it came to his own bill to provide DNA testing to all convicts, Burton said: "Bureaucratic excuses for keeping innocent people in jail don’t do it for me."

Carla Jacobs of the California Treatment Advocacy Coalition responded: "Senate procedural blocks do not do it for us when it comes to saving people from going to jail and salvaging the lives of the mentally ill."

"This is inequity plain and simple," Jacobs explained. "The state never would leave a person unconscious because of stroke or heart attack without treatment. To claim that giving life saving medicines to a psychotic individual is ‘forced medicine,’ then by the same standard giving aid to a delirious fever victim is forced medicine."

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