SAN FRANCISCO — In a city with a $2.7 billion social safety net, the largest in the country, people with severe mental health issues are still falling through the cracks, posing a potential risk to themselves and others. But attempts to combat the problem by imposing a law that could compel individuals to enter outpatient psychiatric treatment are provoking debate and opposition.
San Francisco city supervisors are contemplating putting “Laura’s Law” to voters in the city’s general election this November. If approved, it would mandate what's known as assisted outpatient treatment — involuntary psychiatric treatment on an outpatient basis — for residents who have thus far refused the county's help.
But in a city known for its commitment to civil liberties, some mental health advocates say Laura’s Law is a violation of patient rights.
“What they do is set up a legal system for forcing people, or compelling people, into things that didn’t necessarily work for them before,” Eduardo Vega, executive director of San Francisco Mental Health Association, said.
The law was passed by the California state legislature back in 2002, but in order to authorize it locally, a county’s board of supervisors has to pass a resolution. While some 44 U.S. states have passed similar laws that haven't drawn much controversy, in California only two counties have fully authorized Laura’s Law.
The first was Nevada County. It was there in 2001 that Laura Wilcox, a 19-year-old college student for whom the law is named, was shot dead while working at a behavioral health clinic. The shooter, Scott Thorpe, had been diagnosed with paranoid schizophrenia, but he refused to take his medication, and his family hadn’t been able to get him committed to treatment despite his disturbing behavior. While the shooting sparked the state push to put Laura’s Law on the books a year later, Nevada County did not authorize Laura’s Law until seven years after the shooting.
Since then, county officials estimates that Laura’s Law — which uses funds already earmarked from the state’s Mental Health Services Act — has saved at least $1.81 for every $1 invested (PDF) in the program due to reduced jail and hospitalization costs.
On May 13, Orange County became the first large California county to fully implement the law, spurred by the death of a homeless schizophrenic man following a violent confrontation with police.
The slow progress of Laura’s Law in California is in part due to the state's historic emphasis on civil liberties. But it's also due to arguments that, while the program does create a structured treatment network that's an alternative to forced institutionalization, Laura's Law does not necessarily allow for medication (PDF).
San Francisco’s city supervisors shot down a previous bid to authorize Laura's Law in 2010 after the city's then-public health director Dr. Mitch Katz insisted that compelled medication was necessary for the law to be effective.
"Psychosis requires medication and Laura's Law does not increase our ability to require medication," Katz told supervisors. "Ethical principle is not infringing on someone's rights unless you have an efficacious treatment. And because Laura's Law doesn't allow for medication, I do not believe it fulfills that ethical principle."
But proponents say that court-ordered outpatient treatment like Laura's Law often motivates patients to take their meds in what's known as the "black robe" effect, from judges’ attire — so forced medication isn't imperative.
San Francisco's public health department did launch a Community Independence Placement Project (CIPP) in 2011, a pilot program that Mayor Ed Lee has called "our version of Laura’s Law." But unlike Laura's Law, participants must agree to be part of the pilot program, essentially volunteering for temporary conservatorship. As a result, CIPP does compel patients to take medication.
Some 20 people from the psychiatric ward of San Francisco General Hospital were referred, and received housing and inpatient treatment for mental health or substance abuse problems.
Advocates of both the pilot program and Laura's Law say they fill an important gap between the extremes of permanent conservatorship, which involves lengthy court battles, and the 72-hour or 14-day involuntary psychiatric holds California law authorizes for people who prove to be “gravely disabled,” and as such are unable to meet their own basic needs for food, shelter or clothing.
To qualify, patients must be at serious risk of harming themselves or others, have been hospitalized or jailed at least twice during a three-year period or have committed at least one violent act within the last four years, and have resisted previous attempts at treatment.
“They have to be really impaired,” said Jo Robinson, behavioral health director at the San Francisco Department of Public Health, who oversees CIPP. “You’re heading in the direction of a locked facility, which really doesn’t help you get better in your community. Our goal is to help people be resilient and to be able to live in San Francisco as a resident of San Francisco, not someone that’s locked away in a hospital.”
She said most people who are referred to CIPP end up voluntarily deciding to sign on, and many have gone on to “graduate” and lead independent lives.
Laura’s Law, CIPP and similar programs are aimed at solving the “revolving door” problem. Ever since the U.S. began closing down state-run mental institutions in the mid-20th century to curb rampant abuse and reinstate decision-making rights for patients, deinstitutionalization has meant that people with severe mental health issues or substance abuse problems often cycle from the streets to a jail cell or the hospital and back again.
Mayor Lee in his January 2014 state of the city address lamented the fact that city jails had diagnosed nearly 800 inmates with a psychotic, bipolar or major depressive disorder within the last year alone — people he said could have possibly been helped through mental health services.
On May 16, Lee announced the city would expand CIPP, creating a new psychiatric center at San Francisco General Hospital that would provide 24-hour crisis counseling and admit a few dozen more people to the current program.
Still, Vega said there’s a reason so few counties have implemented Laura’s Law in the last 12 years, pointing to the RAND Corporation’s 2001 review for the California Senate of the available studies on the efficacy of assisted outpatient treatment (PDF), which concluded that it couldn’t definitively say whether or not treatment works. “The involuntary outpatient commitment process has not shown better results than the actual services that people get without a commitment process,” he said.
Some have said Laura’s Law could have prevented tragedies like the killing of Laura Wilcox, and perhaps even curtail the spate of mass shootings that have befallen schools across the country. But Julian Plumadore, a community health advocate for the San Francisco Mental Health Association, says a distinction must be made between actual criminal behavior and the involuntary aspects of Laura’s Law that he called “a euphemism, basically, for types of incarceration without commission of a crime.” He said people suffering from mental health problems should be able to have a say in their own treatment. “It’s morally wrong to compel people to be treated against their will,” he said.
But for Patricia, a mother living in in Berkeley, having her son committed to such a program seems to be the only answer. She said her son was diagnosed with bipolar disorder 10 years ago at the age of 19, but still doesn’t accept his mental illness.
Patricia, who did not want to reveal her full name in order to protect her son’s privacy, said he went from a healthy, happy child to an anxious and distracted teenager, although he still scored a perfect score on the SAT and had over a 4.0 GPA.
But manic episodes took over his life. Today, at 29, he is homeless. He refuses to see doctors and still doesn’t believe he has a problem, due to anosognosia, a lack of awareness of his own illness, a common symptom in those with schizophrenia, and sometimes among those with bipolar disorder.
Patricia said the criteria for conservatorship is so high that, even though her son has been involuntarily hospitalized seven times in the last year, the hospital releases him once he has begun to improve after being given antipsychotic drugs. After that, he stops taking his medication to the point of deteriorating all over again.
She explained how therapists and social workers told her there was nothing they could do. “You have to wait until he hits bottom,’” she says they told her. “I said, ‘Well isn’t this bottom? This feels pretty bad.’”