BILL ANALYSIS �
SENATE JUDICIARY COMMITTEE
Senator Noreen Evans, Chair
2011-2012 Regular Session
AB 1569 (Allen)
As Amended April 16, 2012
Hearing Date: June 26, 2012
Fiscal: Yes
Urgency: No
TW
SUBJECT
Community Mental Health Services: Assisted Outpatient Treatment
DESCRIPTION
Existing law, until January 1, 2013, the Assisted Outpatient
Treatment Demonstration Project Act of 2002, otherwise known as
Laura's Law, permits counties to provide court-ordered
outpatient treatment services for people with serious mental
illnesses when a court finds that a person's recent history of
hospitalizations or violent behavior, coupled with noncompliance
with voluntary treatment, indicate the person is likely to
become dangerous or gravely disabled without the court-ordered
outpatient treatment. This bill would extend the sunset of
Laura's Law to January 1, 2017, and require a report to be
submitted by July 1, 2015, as specified.
(This analysis reflects author's amendments to be offered in
committee.)
BACKGROUND
In 2002, the Assisted Outpatient Treatment Demonstration Project
Act of 2002 (AB 1421, Thomson, Ch. 1017, Stats. 2002; see Welf.
& Inst. Code Sec. 5345 et seq.) (Act) was established to
supplement the Lanterman-Petris-Short Act (LPS), which provides
for the involuntary treatment of people with mental health
disorders who are a danger to themselves or others. The Act was
also named "Laura's Law" in memory of Laura Wilcox, a 19-year
old college student who was gunned down by a man suffering from
serious delusional paranoia. Laura's Law permits local counties
to provide court-ordered outpatient mental health services to
(more)
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individuals with serious mental illnesses. Laura's Law
initially contained a sunset of January 1, 2008 and was
subsequently amended to extend the sunset date to January 1,
2013. (AB 2357 (Karnette, Ch. 774, Stats. 2006).)
This bill, sponsored by the California Psychiatric Association,
would extend the sunset of Laura's Law from January 1, 2013 to
January 1, 2017, and require the �Department of Health Care
Services] to submit a report and evaluation, as specified, to
the Governor and Legislature by July 1, 2015.
This bill was heard by the Senate Health Committee on June 12,
2012, and passed out on a vote of 7-0.
CHANGES TO EXISTING LAW
Existing law , under Laura's Law, authorizes, in participating
counties, a court to order a person age 18 or older into
assisted outpatient treatment (AOT) if the court finds by clear
and convincing evidence that all of the following criteria are
met:
(1) The person is suffering from a serious mental illness, as
defined in existing law, and is unlikely to survive safely in
the community without supervision, based on a clinical
determination;
(2) The person has a history of lack of compliance with
treatment for mental illness that has:
(a) At least twice within the last 36 months been a
substantial factor in necessitating hospitalization,
treatment in a mental health unit of a correctional
facility, or incarceration (not including any
hospitalization or incarceration immediately preceding the
filing of the petition); or
(b) Resulted in one or more acts, attempts, or threats of
serious violent behavior toward self or others, within the
last 48 months (not including any hospitalization or
incarceration immediately preceding the filing of the
petition);
(3) The county mental health director or designee has offered
the person an opportunity to participate in a treatment plan,
the person continues to fail to engage in treatment, and the
person's condition is substantially deteriorating;
(4) In view of the person's treatment history and current
behavior, the person is in need of AOT in order to prevent a
relapse or deterioration which would be likely to result in
grave disability or serious harm to the person or others; and
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(5) AOT would be the least restrictive placement necessary to
ensure the person's recovery and stability, and the person is
likely to benefit from the treatment. (Welf. & Inst. Code
Sec. 5346(a).)
Existing law authorizes a request for the filing of a petition
for an AOT order to be made to the county mental health
department by: (1) an adult living with the person who is the
subject of the petition; (2) the parent, spouse, sibling, or
adult child of that person; or (3) specified mental health and
law enforcement personnel. (Welf. & Inst. Code Sec.
5346(b)(1)-(2).)
Existing law requires the county mental health director or
designee to investigate the request, including conducting an
examination of the person who is the subject of the petition,
and to file the petition only upon a determination that there is
a reasonable likelihood that all the necessary elements to
sustain the petition can be proved by clear and convincing
evidence. (Welf. & Inst. Code Sec. 5346(b)(3).)
Existing law requires the petition to state why the subject of
the petition meets the criteria for AOT services, and to include
an affidavit by the licensed mental health provider who was
directed to examine the person by the mental health director,
stating that the provider either (1) after personally examining
the person, recommends AOT, and is willing to testify at the
hearing, or (b) attempted but failed to persuade the person to
submit to an examination, but has "reason to believe" that the
person meets the criteria for AOT. (Welf. & Inst. Code Sec.
5346(b)(4)-(5).)
Existing law provides that the person who is the subject of the
petition shall have the right to be represented by counsel at
all stages of an AOT proceeding, and if requested by the person,
the court shall immediately appoint a public defender or other
attorney to assist the person in all stages of the proceedings.
The person shall pay the cost of the legal services if he or she
is able. (Welf. & Inst. Code Sec. 5346(c).)
Existing law requires the court to hold a hearing within five
court days of receipt of the petition (conducted in accordance
with the rules of evidence), and would permit the court to
conduct the hearing in the person's absence, as specified, if
the person fails to appear after appropriate notice. (Welf. &
Inst. Code Sec. 5346(d)(1)-(2).)
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Existing law provides that, if the person refused to be examined
during the petition examination, the court may request that the
person consent to such an examination, and if the person still
refuses and the court believes an examination is warranted, the
court may order the person to be taken into custody for up to 72
hours for examination by a licensed mental health provider.
(Welf. & Inst. Code Sec. 5346(d)(3).)
Existing law provides that the person who is the subject of an
AOT petition has the rights to: (1) adequate notice of the
hearing; (2) a copy of the court ordered evaluation; (3) legal
representation at all stages of the proceedings (by the public
defender, if the person has not retained counsel); and (4) at
the hearing, to be present, to call or cross-examine witnesses,
and to appeal decisions. (Welf. & Inst. Code Sec. 5346(d)(4).)
Existing law requires the court to dismiss the petition if the
court finds that the person who is the subject of the petition
does not meet the criteria for AOT. (Welf. & Inst. Code Sec.
5346(d)(5)(A).)
Existing law authorizes the court, if it finds that the person
meets the AOT criteria, and there is no less restrictive
alternative, to order the person to receive AOT services, set
forth in a written treatment plan as specified, for an initial
period not to exceed six months. (Welf. & Inst. Code Sec.
5346(d)(5)(B).)
Existing law provides that AOT services shall not be ordered
unless the court finds, in consultation with the mental health
director or designee, that the specified services are available
in the county. (Welf. & Inst. Code Sec. 5346(e).)
Existing law provides that, if in the clinical judgment of a
licensed mental health provider, a person ordered into an AOT
program has failed or refused to comply with the order, efforts
were made to solicit compliance, and the person may be in need
of involuntary admission to a hospital, the provider may request
that person be detained up to 72 hours for evaluation by a
licensed mental health provider to determine if the person is in
need of involuntary treatment. (Welf. & Inst. Code Sec.
5346(f).)
Existing law requires that, if at any time during the 72-hour
hold the person is determined not to meet the criteria for a
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72-hour hold, and does not agree to stay in the hospital as a
voluntary patient, the person shall be released, as specified.
Failure to comply with an AOT order alone shall not be grounds
for involuntary civil commitment or a finding of contempt of
court. (Welf. & Inst. Code Sec. 5346(f).)
Existing law provides that, at 60-day intervals during an AOT
program, the director of the program shall file a declaration
with the court confirming that the person continues to meet the
AOT criteria; the person shall have a right to dispute the
declaration at a hearing, with the burden of proof on the
director; and during each 60-day period, the person may file a
petition for a writ of habeas corpus requiring the director to
prove the person continues to meet the AOT criteria. (Welf. &
Inst. Code Sec. 5346(h)-(i).)
Existing law provides that after a petition is filed, but before
the conclusion of the hearing, a person who is the subject of
the petition may enter into a settlement agreement approved by
the court that shall have the same effect as an order for AOT
services. (Welf. & Inst. Code Sec. 5347.)
Existing law requires counties implementing the AOT procedure to
provide specified services, which also would be available on a
voluntary basis, and would require persons subject to AOT orders
to be provided services by trained mobile mental health teams
with no more than 10 clients per team member. (Welf. & Inst.
Code Sec. 5348.)
Existing law only authorizes Laura's Law in any county where the
board of supervisors has authorized its application, and has
made a finding that any additional costs incurred by the AOT
program will not result in reductions in the county's current
voluntary mental health programs. (Welf. & Inst. Code Sec.
5349.)
Existing law requires implementing counties to work with other
interested parties to develop a training and education program
to improve delivery of services to mentally ill individuals
affected by this bill, which shall include education as to the
legal requirements for commitment, and methods to ensure
effective treatment and to encourage individuals' informed
consent to assistance. (Welf. & Inst. Code Sec. 5349.1.)
Existing law sunsets Laura's Law on January 1, 2013. (Welf. &
Inst. Code Sec. 5349.5.)
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Existing law required the State Department of Mental Health to
submit a report and evaluation of all counties implementing
Laura's Law to the Governor and to the Legislature by July 31,
2011. (Welf. & Inst. Code Sec. 5349.5.)
This bill would extend the sunset on Laura's Law to January 1,
2017.
This bill would require the �Department of Health Care Services]
to submit a report and evaluation, including data as specified,
of all counties implementing any component of Laura's Law to the
Governor and to the Legislature by July 1, 2015.
COMMENT
1. Stated need for the bill
The author writes:
AB 1569 would extend the sunset date of Laura's Law which
authorizes counties to implement assisted outpatient treatment
services to severely mentally disabled individuals who have
chronically refused mental health treatment.
Scientific research demonstrates that sustained assisted
outpatient treatment services can be highly successful for
individuals with the most severe and persistent mental
illnesses. In fact, numerous studies of New York's assisted
outpatient treatment law, also known as Kendra's Law, have
demonstrated reduced violence and danger, jail time,
hospitalizations, and homelessness. For example, the New York
State Office of Mental Health released a status report on
Kendra's Law in 2005 that detailed the outcomes for the first
five years of the program. The report found that 3,908
individuals received treatment orders, engagement in services
increased from 41 �percent] to 62 �percent], adherence to
prescribed medications increased from 34 �percent] to 68
�percent], hospitalizations decreased from 97 �percent] to 22
�percent], homelessness decreased from 19 �percent] to 5
�percent], arrests decreased from 30 �percent] to 5 �percent],
and incarcerations decreased from 23 �percent] to 3 �percent].
In California, the Nevada County Assisted Outpatient Treatment
Program demonstrated that 50 �percent] of those in the program
recovered, were stable, and were receiving voluntary intensive
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mental health treatment. The county also documented that in
2008, the program cost the county $482,443 but provided
$986,064 in savings for a net savings of $503,621. The totals
provided by Nevada County were based on decreased
hospitalizations and reduced incarcerations in the local
county jail. Furthermore, in December, 2011, the Department
of Mental Health also released a report on the effectiveness
of Laura's Law as required by AB 2357 (Statutes of 2002). The
report found that hospitalization days decreased, no
individual had contact with law enforcement, most individuals
were able to live independently, and all individuals were
fully engaged with the program.
Laura's Law is simply another tool for treating the severely
mentally ill who chronically refuse voluntary treatment and
are a danger to themselves or others but are not so gravely
disabled that they qualify for conservatorship. A model
program for treatment, Laura's Law provides the legal and
clinical treatment structure necessary to give certain
severely mentally disabled people the support they need to
achieve stability and meaningful recovery.
2. Positive Effects of Laura's Law
This bill would extend the sunset of Laura's Law from January 1,
2013 to January 1, 2017. Established by AB 1421 (Thomson, Ch.
1017, Stats. 2002), Laura's Law received strong support from
mental health organizations, law enforcement, and families of
mentally ill individuals frustrated by the inadequacies of the
mental health system. Supporters of AB 1421 argued that
assisted outpatient treatment (AOT) orders would reduce repeated
hospitalizations and incarcerations, and halt the downward
spiral of seriously ill people who otherwise fall through the
cracks of the Lanterman-Petris-Short Act (LPS)
Enacted in 1967, the Lanterman-Petris-Short (LPS) Act (Welf &
Inst. Code Sec. 5000 et seq.) provides for the involuntary civil
commitment of an individual to a mental health institution and
set the precedent for modern mental health commitment procedures
in the United States. Laura's Law follows the involuntary
commitment procedures established by LPS, but Laura's Law is
aimed at providing outpatient treatment through community
services.
Pursuant to the reporting requirements enacted by AB 1421 and AB
2357 (Karnette, Ch. 774, Stats. 2006), which extended the
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initial sunset, the Department of Mental Health evaluated
counties that had implemented Laura's Law and submitted its
report as required. (See Cliff Allenby, Acting Director,
Laura's Law Report - Combined annual reports for 2009-2011 and
One Time Evaluation required by AB 2357, Department of Mental
Health (July 2011) (Report). The Report disclosed that only
Nevada County, through the Turning Point Providence Center
(TPPC), operates an AOT program, which served a total of four
individuals between 2008 and 2010. (Id. at p. v.) The Report
further provided as follows:
During the first year (FY �Fiscal Year] 2008-2009 that the
Laura's Law program was implemented in Nevada County, two
individuals were referred to the program by the court and
participated in services. The most dramatic outcome noted in
the date was the reduction in number of hospitalization days
for both individuals. One individual had 135 days of
inpatient psychiatric hospitalization in the 12 months prior
to the Laura's Law program, but had only 50 days of
hospitalization during the year in the Laura's Law program.
The other individual had 59 days of inpatient psychiatric
hospitalization in the 12 months prior to Laura's law services
and 21 days of hospitalization during the time the individual
participated in the Laura's Law program. Neither client had
contact with local law enforcement, participated in employment
services, or was victimized.
In FY 2009-2010, two additional individuals were ordered by
the Court to participate in the Laura's Law services. One
individual had 45 days of inpatient psychiatric
hospitalization in the 12 months prior to Laura's Law services
and 26 days while being served. The other was hospitalized
for most of the term of Laura's Law services but is reported
to have attained stability after many years of frequent and
severe mental health relapses. The individual is now in
contact with family again after being estranged due to
behavior associated with severe symptoms. TPPC reports
continuing contact with this individual, under their regular
AACT �Adult Assertive Community Team] services, because the
psychiatric hospitalization was under �LPS] laws. The other
individual was able to maintain engagement in services and was
able to live independently when not hospitalized. (Id. at p.
4.)
Additional support for the Laura's Law program comes from the
Presiding Judge of the Nevada County Superior Court. In a
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letter to the Orange County Board of Supervisors, Hon. Thomas M.
Anderson wrote:
I am writing to encourage the implementation of Laura's Law in
Orange County, California.
Laura's Law has provided life-saving services to individuals
suffering from mental illness and kept many from the trauma
and brain damage associated with involuntary commitments to
mental health facilities . . . and the jail commits and
tragedies associated with untreated mental health crisis.
Most notable, is that the process of initiating a Laura's Law
Petition, by itself, most often results in negating the need
for Court action. In over 75 �percent] of our cases, the
intervention of the designated mental health professional by
their personal outreach to the individual in crisis resulted
in that person accepting some level of treatment. Thus,
avoiding continued decompensation that could potentially
result in injury to themselves or others. This outreach
provided that person with the stability to allow them to
remain free of forced commitment (hospital and/or jail) and
provided relief to their families and security to our
community. This process has reduced the need for action by
law enforcement, medical emergency personnel, and the Courts,
and lessens the trauma and anguish of family and friends.
Money: Laura's Law saves a lot of money! During our
experiences with Laura's Law, it has provided a return of
$1.80 for every $1.00 spent. In this era of ongoing budget
cuts and close scrutiny of all public spending, having a
program that is successful, efficient, lifesaving and cost
effective is priceless.
Laura's Law is not a panacea for all that is needed for proper
mental health care. However, it is a much needed safety net
that works. It saves lives and money. Most importantly, the
assisted outpatient treatment that is provided through Laura's
Law is the "best practice model" for those who qualify. It
is, simply stated, the right thing to do. (Hon. Thomas M.
Anderson, Presiding Judge, Nevada County Superior Court,
Letter to Bill Campbell, Chairman, Orange County Board of
Supervisors (Sept. 28, 2011).)
As the Report and Hon. Anderson's personal experience with the
Laura's Law program suggests, the Laura's Law program in Nevada
County appears to have had a positive outcome for the
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individuals involved.
3. Opposition concerns
Many mental health patient advocacy groups and civil rights
organizations oppose the concept of "assisted outpatient
treatment" for several reasons: (1) they object to any
involuntary treatment of mental health patients as a violation
of due process rights; (2) they assert that lesser standards for
outpatient care are unwarranted, as conservatorships are
available under existing law; (3) they dispute the author's
contention that a core group of mentally ill are too resistant
to accept voluntary treatment, arguing that the real problem is
lack of sufficient voluntary outpatient services; (4) they are
concerned that counties wishing to implement AOT programs may
take funds from existing voluntary outpatient programs for that
purpose; and (5) they argue that only voluntary treatment is
effective.
In response, the author argues that voluntary treatment is not
100 percent effective. Further, "�e]ven with the best voluntary
mental health treatment services, some people are too mentally
ill to recognize that they have an illness but not so gravely
ill that they meet the criteria for conservatorship. Simply
put, this bill is needed to provide tools to address this
population that falls in the middle �of] voluntary treatment and
gravely disabled."
Additionally, the author argues that no study has been presented
that demonstrates that court-ordered outpatient treatment is
unsuccessful. "The New York law, which is mandated in all
counties as opposed to California's law which is county
permissive, has been monitored and studied for over 10 years.
Every study has shown positive results." Proponents of this
bill agree that voluntary treatment should be the first priority
for mentally ill individuals. However, some individuals are
chronically ill, have continually refused voluntary treatment,
and there are studies that show that individuals who are at
first compelled to seek treatment ultimately continue treatment
on a voluntary basis.
The Urban Counties Caucus, in support if the bill is amended,
expresses concern that "�w]hile �Laura's Law] can save funding
in other areas of county provided services, there is no limit as
to how many individuals could apply or be ordered into the
program. For more counties to utilize this important law, urban
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counties would like to have a cap placed in the bill so that
costs would be limited and to provide a funding source for the
program."
4. Reporting requirement
This bill contains a reporting requirement that specified data
be provided to the Governor and the Legislature by July 1, 2015.
Given the continued concerns regarding the effectiveness in
treating mentally ill individuals and the difficulty of
implementing Laura's Law, this reporting requirement will
provide important information as to whether the sunset should be
further extended.
This bill, as currently in print, would require the Department
of Mental Health to fulfill the reporting requirement in this
bill. To reflect recent changes to the Department of Mental
Health pursuant to the Governor's revised 2012-2013 Budget, the
author proposes to amend this bill in Committee to instead
require the Department of Health Care Services to evaluate and
report to the Governor and Legislature.
Author's amendment
On page 2, in line 7, delete "State Department of Mental
Health" and insert "Department of Health Care Services"
Support : American Federation of State, County and Municipal
Employees, AFL-CIO; California Association of Marriage and
Family Therapists; California Association of Psychiatric
Technicians; California Hospital Association; California Medical
Association; California Probation, Parole and Correctional
Association; California Psychiatric Association; California
State Sheriffs' Association; California Treatment Advocacy
Coalition; Friends Committee on Legislation in California; Los
Angeles County Board of Supervisors; Mental Illness Policy Org.;
National Alliance on Mental Illness California; National
Alliance on Mental Illness, Mendocino County - Coast; National
Alliance on Mental Illness, Orange County National Alliance on
Mental Illness, Westside-Los Angeles; Nevada County Suicide
Prevention Taskforce; Treatment Advocacy Center; Urban Counties
Caucus (support if amended); 35 individuals
Opposition : American Civil Liberties Union of California;
Bazelon Center for Mental Health Law; California Association of
Mental Health Patients' Rights Advocates; California Association
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of Mental Health Peer Run Organizations; California Association
of Social Rehabilitation Agencies; California Client Action
Workgroup; California Council of Community Mental Health
Agencies; California Mental Health Planning Council; California
Network of Mental Health Clients; California Right to Life
Committee, Inc.; Disability Rights California; Mental Health
America of California; Mental Health Association of San
Francisco; MindFreedom International; National Association for
Rights Protection and Advocacy; United States Psychiatric
Rehabilitation Association; Voices of the Heart, Inc.,
Queensbury, NY; eight individuals
HISTORY
Source : California Psychiatric Association
Related Pending Legislation : None Known
Prior Legislation :
AB 2357 (Karnette, Ch. 774, Stats. 2006) See Background and
Comment 2.
AB 1421 (Thomson, Ch. 1017, Stats. 2002) See Background and
Comment 2.
Prior Vote :
Senate Committee on Health (Ayes 7, Noes 0)
Assembly Floor (Ayes 68, Noes 4)
Assembly Committee on Appropriations (Ayes 16, Noes 0)
Assembly Committee on Judiciary (Ayes 10, Noes 0)
Assembly Committee on Health (Ayes 15, Noes 3)
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