An alternative to forced treatment
Californians have been having the same argument about involuntary psychiatric treatment for over 50 years. At the heart of the debate is California’s Lanterman-Petris-Short Act, which ended the indefinite commitment of people living with mental illnesses to psychiatric hospitals and granted them new rights to refuse treatment.
The law was celebrated as the “Magna Carta of the mentally ill” when it passed in 1967, but some policymakers now want to loosen its rules to force more people dying of drug abuse or mental illness on the streets into treatment. Civil rights and advocacy groups insist this solution is inhumane, and counter that the answer is more money for voluntary services. But both sides are finally realizing there’s another avenue for reform: reversing the state government’s decades-long abdication of responsibility for its most vulnerable citizens.
In recent years, California policymakers have been fixated on legislation to rewrite the criteria for forced treatment. But at a hearing Wednesday to discuss them, they ended up asking even tougher questions about state government’s role in putting existing law into practice. The most telling moment came when Assembly Member Jim Wood, D-Turlock, asked a representative from the Department of Health Care Services if there was someone in state government who was coordinating, strategizing, and monitoring how the Lanterman-PetrisShort Act is implemented.
The department had no answer.
It was an extraordinary admission, given that the law is used to force people into treatment at least 120,000 times per year — and that thousands more are suffering on California’s streets while cities and counties are clearly struggling with how to care for them.
“I’m begging for there to be some person or entity in charge of this,” Wood said in closing.
This leadership void didn’t happen overnight, but was built on a long history of indifference and privatization. When the act passed, then-Gov. Ronald Reagan used it as a pretext to rapidly close three-quarters of state hospital beds. Patients did not go into community programs — because Reagan quickly yanked the funding promised to them in the act — but instead to private nursing homes and halfway houses, which the state barely regulated.
In 1991, California responded to a budget crisis by turning nearly all responsibility for running mental health services over to counties, without providing any dedicated funds for implementing Lanterman-Petris-Short. In 2012, California’s Department of Mental Health, which had an office monitoring the act, was merged into Health Care Services, which has no dedicated pointperson for the law.
As a sociologist who has interviewed hundreds of system stakeholders, I’ve seen the dire consequences of state abandonment. Most involuntary care happens in private, contracted facilities. These providers’ preferences and financial incentives drive who gets served in the public mental health system. Consider the case of John Maurer, who languished for weeks in jail, despite being conserved, because no private psychiatric facility would take someone with his history of relapses, meth use and arrests.
California clearly needs to revive its dedicated state office for the Lanterman-Petris-Short. This office could improve California’s abysmal data on involuntary treatment (nearly half of counties don’t bother reporting it, despite being required to). It could also set basic standards, best practices and evaluation criteria so that providers and families know what their rights and obligations are, whether they’re in San Francisco or Orange County.
A robust state role, however, demands going even further.
Gov. Gavin Newsom is making a multibillion-dollar investment in increasing capacity in psychiatric facilities. But that money is going into an irrational and inefficient system where counties bid against each other for scarce beds in private facilities. The state needs to regulate this contracting system to make sure counties are getting a fair deal and clients are served close to home, not wherever is cheapest.
If private entities want public money, we should demand they act like public services. That means serving the neediest individuals, not just clients of their choosing.
Newsom’s budget for 2021 initially proposed closing off state hospitals to people forcibly hospitalized, ending its remaining role as a direct provider to patients outside the criminal justice system. But state hospitals need to continue to act as the provider of last resort. If they don’t, California will all but ensure that the only place the hardest-to-treat individuals will get any care is in jail — and that is not the kind of treatment they deserve.
The most ambitious reform would do what California is already doing for another group: people with developmental disabilities. The 1977 Lanterman Act made an open-ended commitment to meeting this group’s full needs, whatever the cost.
Extending this approach to severe mental illness would mean a new bargain: The state would force treatment only when a person has been offered and turned down a full suite of alternatives. Some of those — like early intervention programs for psychosis — are difficult for small counties to provide and rarely paid for by private insurance. They need state coordination and funding.
Advocates are unlikely to budge on their disagreements over whether more forced treatment is a solution to the crisis on California’s streets. But legislation to ensure greater state leadership, oversight and accountability could generate less conflict and more change.