On February 1, Contra Costa became the eighth of California’s 58 counties to begin implementation of AB 1421, also known as Laura’s Law, which allows for court-ordered assisted outpatient treatment of the mentally ill.
The law is nicknamed after Laura Wilcox, a woman who was one of three killed by an untreated mentally ill person in Nevada County on January 10, 2001. Its supporters believe that while treatment should first be offered as a choice, mentally ill people who pose a threat to society and resist medical help should be ordered into treatment by a court.
Assisted outpatient treatment was adopted by the state legislature in 2002 with the goal of getting treatment to seriously mentally ill people who had previously refused it. Under the plan adopted by Contra Costa Health Services, people are eligible if they are unlikely to survive in the community without supervision, have a history of lack of compliance with treatment, have been hospitalized or incarcerated due to mental illness in the past three years or have committed a serious act of violence to himself or others in the last four years.
“The hope is that it will get people to be stabilized and just to have a better life,” said Karen Cohen, a volunteer at Contra Costa’s National Alliance on Mental Illness (NAMI). As the parent of a daughter who has suffered from mental illness, Cohen said it is difficult for families to support their adult children. “It’s a huge emotional burden,” Cohen said. “Here’s your beautiful child who you have hopes and dreams for, and then you worry about them every day.”
People who oppose the law, however, believe it is a step backwards. Haydée Cuza is the executive director of Peers Envisioning and Engaged in Recovery Services (PEERS), a group whose goal is to reduce stigma and discrimination toward the mentally ill. The group offers peer-support programs for people who have experienced psychosis. Assisted outpatient treatment “is taking more of a punitive and compliance approach to mental health, as opposed to treating it like a mental health issue or focusing on recovery or wellness,” said Cuza.
If somebody doesn’t take the medication that’s prescribed to them, Cuza said—even if it’s the wrong medication—under the law they could be found incompliant and put into a locked facility. “It’s a quick fix,” Cuza said. She said that her organization’s support group, called Special Messages, is grounded on the belief that long-term personal care, peer-to-peer attention, community building and people having choices about treatment is a more effective way to heal people than court-ordered therapy.
Under Laura’s Law, a county-funded health services program provides the assisted outpatient treatment. The goal is to get the person to enter treatment voluntarily, but if they refuse or their health deteriorates after they have complied, a person can also be ordered into treatment by a judge.
“Healthy decisions are what we’re trying to achieve,” said David Seidner, program manager at Contra Costa Health Services. During the program’s first week in the county. five or six people were accepted into treatment, he said. Seidner was pleased by this success. “It was good turnout and we expect more and more people to enter the program,” he said.
The process begins with a family member, a clinician, or any figure who knows the mentally ill person well, who recommends them for treatment to county health services. Next, a care team of county mental health clinicians evaluates the person to see if they meet the law’s requirements: A client must be a county resident with a serious deteriorating mental disorder, who is believed unlikely to survive safely in the community, and who has refused or failed to respond to a prior opportunity to participate in treatment.
If the person meets these criteria, the care team recommends them for outpatient treatment. A family partner works with the person’s household, helping family members develop coping skills and providing them information about support resources. A peer specialist makes direct contact with the person and works to form trust so the patient can make an informed decision about entering a treatment program. “We want to get into a ‘yes situation’ by making contact and offering information,” said Seidner.
If a person accepts the treatment but his or her mental health deteriorates, or the person disappears or begins to refuse the treatment plan and services, including medication, health services staffers can now legally require the person to appear in court for a judge to order them to finish their treatment. Thereafter, the person in treatment has to report to the judge every 60 days. Treatment lasts for a total of 360 days.
After state legislators approved Laura’s Law in 2002, it was left up to the board of supervisors of each county to implement the law. Counties that have implemented the law include Los Angeles, Orange, San Francisco, Nevada and, as of last year, Yolo, who implemented a small five-person pilot program. Some counties’ reasons for waiting include insufficient funding and opposition from groups like PEERS. On a state survey taken last year by 46 counties, 26 said they do not intend to implement Laura’s Law.
For counties that did implement the law much of their funding came from the statewide Mental Health Services Act in 2004, which allotted funds for the purpose of providing better mental health care,
Untreated mental illness can be expensive, both for families and for local governments. Ill people often have “numerous hospitalizations or arrests or are homeless,” Cohen said. Part of her hope for Laura’s Law, she said, is to achieve employment for the ill in order to alleviate the financial burden on families, and to reduce the cost of hospitalizations.
It was this cost that convinced Douglass Dunn, vice president of NAMI, of the necessity of Laura’s Law. Dunn investigated how much the county spent on hospitalizations for untreated mentally ill people. “I started with a two-page financial summary to show the cost and it turned out to be a 70-page proposal discussing pros of why Contra Costa needed a full Laura’s Law program, not just a pilot program,” he said. This full program includes staffing a four-person care team for every one person in treatment, and a treatment duration of 360 instead of 180 days.
By evaluating county Emergency Medical Services, transportation costs, law enforcement costs and costs of paying for stays at four county mental health and detention facilities and one state-funded hospital, Dunn concluded that in budgeting for Laura’s Law staffing and services, the county would save $2 for every dollar it was spending to help untreated mentally ill people.
He went on to calculate that between the years 2012 and 2013, 181 distinct hospitalizations cost it 63 percent of its psychiatric budget. “That’s two-thirds. That should stick out like a sore thumb,” Dunn said.
Currently, the county has budgeted $2.25 million for Laura’s Law treatments.
Dunn also cited a study called Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) published yearly between 2005 and 2008 by the National Institute of Health (NIH). The study evaluated 1,445 patients over a six-year period and showed the substantial risk that not treating the mentally ill can pose to society. Harmful psychotic breaks that posed a danger to the person or others were three times more likely to occur when a patient was untreated.
“Can we lower these risks if they’re caught in time? We believe [Laura’s law] can,” said Dunn.
Cuza believes, though, that assisted outpatient treatment reinforces the stigma attached to those who are mentally ill. “Anytime a judge is involved, it feels criminal,” she said.
Of people referring to the untreated mentally ill as a danger to society, Cuza said, “That’s an unfortunate prejudice. And it actually limits the amount of services you’re going to come by.” She said that if people—family members, health providers, community members—paid attention early on when a person began to feel distant from society, and could provide preventative attention before the person has a harmful psychotic break, there would be less bias against the mentally ill.
Dunn believes two related state senate bills will help create greater compassion and treatment for mental health issues. Senate Bill 11, which passed the legislature last October, will be binding on October 1, requires police officer training to include an additional 15 hours of crisis intervention training regarding recognizing the mental illness and substance abuse. Senate Bill 29, also passed last October, will apply to police officers already in the force.
Cohen says Laura’s Law is reassuring for the families of mentally ill, “Even if you don’t have the more extreme worries, like arrest for example, you know that life is so difficult due to depression; paranoia; vulnerability to be victim of crime.” If a relative gets into a Laura’s Law program, Cohen said, “Where they’re going to get help and get better, it’s emotionally better for the family. That’s why we have pushed so hard to get a program in Contra Costa County.”