Before Forcing More Mentally Ill People Into Treatment, California Should Try Helping Them First


Californians have had 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 engagement of people living with mental illness in mental hospitals and granted them new rights to refuse treatment.

The law was celebrated as the ‘Magna Carta of the mentally ill’ when it was passed in 1967, but some policymakers now want to relax its rules to force more people who die of drug addiction or mental illness on the streets to follow. a treatment. Civil rights and advocacy groups insist this solution is inhumane and say the answer is more money for volunteer services. But both sides are finally realizing that there is another avenue for reform: to reverse the decades-long abdication of state government responsibility for its most vulnerable citizens.

In recent years, California policymakers have focused on legislation to rewrite the criteria for forced treatment. But in a hearing Wednesday to discuss it, they ended up asking even tougher questions about the state government’s role in implementing existing law. The most telling moment came when Assembly Member Jim Wood D-Turlock asked a Department of Health Services representative if there was anyone in the state government coordinating, strategized and oversaw the implementation of the Lanterman-Petris-Short Act. .

The department did not receive a response.

It was an extraordinary admission, considering that the law is used to force people to undergo treatment at least 120,000 times a year – and thousands more suffer on the streets of California as cities and counties clearly have a hard time taking care of them.

“I beg that there is some person or entity in charge of this,” Wood said in conclusion.

This leadership vacuum did not happen overnight, but was built on a long history of indifference and privatization. When the deed is over, so-Gov. Ronald Reagan used it as a pretext to quickly shut down three quarters of public hospital beds. Patients did not go to community programs – because Reagan quickly withdrew the funding they were promised in law – but rather to private nursing homes and halfway houses, which the state barely has. regulated.

In 1991, California responded to a budget crisis by giving almost all of the responsibility for managing mental health services to counties, without providing dedicated funds for the implementation of Lanterman-Petris-Short. In 2012, the California Department of Mental Health, which had an office to oversee the law, was merged with Health Care Services, which do not have a dedicated law contact.

As a sociologist who has interviewed hundreds of actors in the system, I have seen the dire consequences of abandonment of the state. Most involuntary care takes place in private institutions under contract. The preferences and financial incentives of these providers determine who is served in the public mental health system. Take the case of John Maurer, who languished for weeks in jail despite being retained because no private mental institution would accept someone with a history of relapses, methamphetamine use and arrests.

California clearly needs to revive its dedicated Lanterman-Petris-Short state office. This office could improve California’s appalling data on involuntary treatment (almost half of counties don’t bother to report it, although they have to). It could also set baseline standards, best practices, and benchmarks so providers and families know what their rights and obligations are, whether they’re in San Francisco or Orange County.

A strong state role, however, requires going even further.

Governor Gavin Newsom is investing billions of dollars in increasing the capacity of mental institutions. But that money goes into an irrational and inefficient system where counties compete for scarce beds in private facilities. The state needs to regulate this contracting system to ensure that counties get a fair deal and that customers are served close to home, not where it’s cheapest.

If private entities want public money, we must demand that they act like public services. It means serving those most in need, not just the customers they choose.

Newsom’s budget for 2021 initially proposed to close public hospitals to forcibly hospitalized people, ending its remaining role as a direct provider for patients outside the criminal justice system. But public hospitals must continue to act as a provider of last resort. If they don’t, California will ensure that the only place the hardest-to-treat people can get care for is in jail – and it’s not the kind of treatment they deserve.

The most ambitious reform would do what California is already doing for another group: people with intellectual disabilities. The Lanterman Act of 1977 made an unlimited commitment to meet all the needs of this group, no matter what the cost.

Extending this approach to serious mental illnesses would mean a new market: the state would only impose treatment when a person has been offered and refused a full range of alternatives. Some of these – like early intervention programs for psychosis – are difficult to provide for small counties and rarely paid for by private insurance. They need coordination and state funding.

Defenders are unlikely to disagree on whether more forced treatment is a solution to the crisis on the streets of California. But legislation aimed at ensuring greater state leadership, oversight and accountability could generate less conflict and more change.

Alex V. Barnard is Assistant Professor of Sociology at New York University. He is writing a book on involuntary mental health care in California.


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