BILL ANALYSIS �
AB 1265
Page 1
Date of Hearing: January 14, 2014
ASSEMBLY COMMITTEE ON JUDICIARY
Bob Wieckowski, Chair
AB 1265 (Conway) - As Amended: January 6, 2014
FOR VOTE ONLY
SUBJECT : mental health services: COMPELLED assisted outpatient
treatment
KEY ISSUE : SHOULD THE MAXIMUM TREATMENT PERIOD THAT MAY BE
IMPOSED BY COUNTIES THAT ELECT TO ENACT INVOLUNTARY OUTPATIENT
MENTAL HEALTH TREATMENT PROGRAMS be DOUBLED from six months to
one year, DESPITE LACK OF EMPIRICAL OR SCIENTIFIC EVIDENCE TO
SUPPORT SUCH A CHANGE?
SYNOPSIS
"Laura's Law" is an involuntary mental health treatment program
that was initially adopted in 2001 and reauthorized in 2006 and
again in 2012. The law permits any county that wishes to do so
to provide "assisted outpatient treatment services" (AOT), as
defined. While this program has been authorized for over 10
years, only Nevada County has chosen to fully implement it, and,
according to a 2011 study, only four persons had, as of that
time, been subject to the treatment. Despite this lack of "on
the ground" experience in California, the bill proposes two
changes to the program. First, it doubles, from six months to
one year, the amount of time that a court can initially order an
individual to participate in the program. Second, it permits,
in any county that has elected to implement the program, the
evaluation of a patient about to be released from an
involuntarily inpatient detainment by the professional staff of
the facility to determine if the patient meets the criteria for
assisted outpatient treatment.
While these changes are modeled after changes made in New York a
year ago, the author has not been able to provide any reliable
evidence to support them. In fact, studies provided to the
Committee actually appear to support retaining the program as it
now exists in California. Given the important policy and
ethical principles at issue with respect to involuntary mental
health treatment, it may be more appropriate to wait until there
is persuasive scientific support before making significant
changes to the program.
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This bill was originally heard by the Committee in April, 2013,
but failed on a vote of 3-6. It is now up for reconsideration,
on a vote only basis. The bill is double-referred to the
Assembly Health Committee, and, should it pass this Committee,
will be heard by that Committee.
This bill is supported by the California Mental Health Directors
Association, California Treatment Advocacy Coalition and
California Psychiatric Association, but opposed by Disability
Rights California, California Council of Community Mental Health
Agencies, and Mental Health America of California.
SUMMARY : Increases the maximum period of imposed outpatient
treatment under the Assisted Outpatient Treatment Demonstration
Project from six months to one year. Specifically, this bill :
1)Extends from six to twelve months the time period that a court
may order a person to receive assisted outpatient services,
provided that person meets the criteria for assisted
outpatient treatment and there is no appropriate and feasible
less restrictive alternative.
2)Provides that, in any county that has elected to implement the
Assisted Outpatient Treatment Demonstration Project, when an
individual is released from involuntary treatment, as
provided, the professional staff of the facility that provided
the inpatient treatment may evaluate the individual to
determine if he or she meets the criteria for assisted
outpatient treatment. If the individual meets the criteria,
allows that professional staff to request that the county
mental health director file a petition for assisted outpatient
treatment.
EXISTING LAW :
1)Permits counties to provide assisted outpatient treatment
services for people with serious mental illnesses when a court
determines that a person's recent history of hospitalizations
or violent behavior, and noncompliance with voluntary
treatment, indicates the person is likely to become dangerous
or gravely disabled without the court-ordered outpatient
treatment. (Welfare and Institutions Code Section 5346.
Unless stated otherwise, all further statutory references are
to that code.)
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2)Allows a court, after finding that an individual meets the
criteria for assisted outpatient treatment, and there is no
appropriate and feasible less restrictive alternative, to
order the individual to receive assisted outpatient treatment
for an initial period not to exceed six months. If the
director of the assisted outpatient program determines that
the individual requires further assisted outpatient services,
requires that director, prior to expiration of the time period
of the treatment, to apply to the court for an extension of
the services, not to exceed 180 days. (Section 5346(d), (g).)
3)Sunsets this authorization on January 1, 2017. (Section
5349.5(a).)
4)Grants any person subject to a petition for an order of
assisted outpatient treatment the right to legal counsel at
all steps of the hearing process. (Section 5346(d)(4)(C).)
5)Requires the Department of Health Services to submit a report
and evaluation to the Governor and the Legislature of all
counties implementing an assisted outpatient treatment program
by July 1, 2015. (Section 5349.5(b).)
6)Establishes the Lanterman-Petris Short Act (LPS Act), which
authorizes a person to be involuntarily detained for inpatient
mental health treatment when, as a result of a mental
disorder, the person is a danger to him or herself or to
others, or is "gravely disabled". Defines "gravely disabled"
to mean a condition in which a person, as a result of a mental
disorder, is unable to provide for his or her basic personal
needs for food, clothing or shelter. (Sections 5008 (h)(1)(A)
and 5150.)
7)Allows, under the LPS Act, a person who is gravely disabled to
be involuntarily detained for further inpatient mental health
treatment for an additional 14 days, as provided, which can be
extended for 14 days if the person presents an imminent threat
of taking his or her own life or 30 days if the county has
authorized the program and the person remains gravely
disabled. (Section 5250, 5257, 5260.)
8)Allows, under the LPS Act, a court to order an imminently
dangerous person to be confined for further inpatient
intensive health treatment for an additional 180 days, as
provided. (Section 5300 et seq.)
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FISCAL EFFECT : As currently in print this bill is keyed
non-fiscal.
COMMENTS : The Assisted Outpatient Treatment Demonstration
Project, also known as Laura's Law, allows courts in
participating counties to order a person into an assisted
outpatient treatment program if the court finds that the
individual either meets existing "5150" involuntary commitment
requirements (is gravely disabled or is a danger to self or
others), or the person meets non-5150 criteria including that
the person has refused treatment, their mental health condition
is substantially deteriorating, and assisted outpatient
treatment would be the least restrictive level of care necessary
to ensure the person's recovery and stability in the community.
So far only Nevada County has fully implemented the program and,
as of 2011, only four individuals had participated in the
program.
Despite the lack of experience on the ground in California, the
bill proposes two changes to the program. First, it increases,
from six months to one year, the amount of time that a court can
initially order an individual to participate in the program.
Second, it permits, but does not require, in any county that has
elected to implement the program, when an individual is released
from involuntary detainment under the LPS Act, as provided, the
professional staff of the facility that provided the treatment
may evaluate the individual to determine if he or she meets the
criteria for assisted outpatient treatment. If the individual
meets the criteria, this bill allows the professional staff to
request that the county mental health director file a petition
for assisted outpatient treatment.
In support of the bill the author states:
Current law establishes the Assisted Outpatient Treatment
Demonstration Project Act of 2002, known as "Laura's Law,"
as an important tool empowering family members to initiate
outpatient treatment for severely mentally ill adults who
are incapable of seeking help on their own. Laura's Law
authorizes a court to order a person to obtain assisted
outpatient treatment when specified conditions are met.
Laura's Law provides an opportunity to recognize when a
patient's condition is substantially deteriorating, and to
intervene before the patient becomes gravely disabled and
subject to involuntary civil commitment. Though California
is one of 45 states with an assisted outpatient law,
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Laura's Law is only operative in counties that voluntarily
approve its implementation. To date only Nevada County has
fully implemented Laura's Law. . . . AB 1265 will
implement statutory changes to Laura's Law based on the
experience with similar programs in other states, ensuring
that California patients derive the maximum possible
benefit from assisted outpatient treatment as counties opt
to implement Laura's Law.
California's Laura's Law is based on a New York statute
known as Kendra's Law. The New York Gun Violence
Prevention Law extends the maximum initial period of
court-ordered assisted outpatient treatment from six months
to one year. Reports on the status of assisted outpatient
treatment outcomes in New York for recipients during the
first six months reveal significant improvements in
self-care and community living, social functioning, task
performance, and incidences of harmful behaviors. Average
reductions in difficulties for these categories ranged from
22% to 44%, revealing significant room for improvement.
Because improvement has been demonstrated to be
time-dependent, extending the maximum initial treatment
period to one year should further promote positive
outcomes. . . .
The New York Gun Violence Prevention Law requires that
prior to release of a mental patient, a clinical assessment
must be made to determine whether the inmate qualifies for
assisted outpatient treatment. Applying this same
requirement in California will reduce costs by preventing
recommitment, and protect public safety by preventing
previously dangerous individuals from relapsing.
Statutory History : This act was first adopted in California in
2001, as a pilot program, permitting a special kind of
involuntary commitment designed to get intensive outpatient
treatment to individuals whose mental illness prevents them from
seeking or accepting help. The 2001 bill, AB 1421 by
then-Assemblymember Helen Thomson, authorized, in participating
counties only, a court or hearing officer to order a person into
an assisted outpatient treatment program if the court or hearing
officer finds that the individual either meets existing "5150"
involuntary commitment requirements (is gravely disabled or is a
danger to self or others), or the person meets new non-5150
criteria including that the person has refused treatment, their
mental health condition is substantially deteriorating, and
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assisted outpatient treatment would be the least restrictive
level of care necessary to ensure the person's recovery and
stability in the community. AB 2357 then reauthorized the
provisions of AB 1421 in 2006. As a condition of authorization,
AB 2357 required the Department of Mental Health (DMH) to file a
report on the success of the program in 2011. That report
entitled "Laura's Law Combined Annual Reports and One-Time
Evaluation Required by AB 2357" was filed in July of 2011. Last
year, the act was again extended until January 1, 2017 and the
Department of Health Services was directed to file an updated
report by July 1, 2015. (AB 1569 (Allen), Chap. 441, Stats.
2012.)
Operation of the Program : According to the DMH report, as of
July 2011 only Nevada County has implemented an assisted
outpatient treatment program. Since adopting the program in
2008, Nevada County has committed four patients to involuntary
assisted outpatient programs. Based on information apparently
provided by Nevada County, the DMH reports that Nevada County's
program has been a success because the number of hospitalization
days for program participants in Nevada County has been cut in
half, no patient has encountered problems with law enforcement
since their commitment and all patients in the programs have
seen their medical symptoms improve. Half of the individuals in
the program were stabilized to the point of maintaining their
own home without assistance. The report also states that all of
the family members of the patients reported positive impressions
of the program and reported appreciation for the assistance the
Nevada County treatment program provides to family members of
those in treatment. In addition to the small program operated
in Nevada County, the County of Los Angeles also reports it has
implemented a small pilot program that has been an initial
success. Most recently, Yolo County has elected to operate a
small, pilot program.
Apart from the very small sample size, the DMH report does not
appear to provide information sufficient to determine whether
the AOT approach is scientifically valid because it appears to
omit any control group or other reliable comparators who did not
receive AOT.
Bill Doubles Maximum Treatment Period from Six Months to One
Year, Even Though There Appears to be No Evidence That This
Change is Necessary to Improve Outcomes : The main change this
bill seeks to make to the program is to extend, from six months
to one year, the time period for which an individual can be
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ordered to participate in assisted outpatient treatment. New
York made just such a change a year ago, extending its mandatory
outpatient treatment time from six months to one year in
Kendra's Law, its version of Laura's Law (NY Mental Hygiene
Section 9.60(j)(2)). According to the author, required
outpatient treatment of one year has revealed "significant
improvements in outcomes and care." In addition, the California
Mental Health Directors Association writes that the extension of
treatment from 6 months to 12 months "provides additional local
flexibility to counties that elect to implement" the assisted
outpatient treatment program.
Supporters have provided research papers to support the
extension, all done outside of California. They argue that six
months is the bare minimum time period necessary to achieve
positive outcomes and that those outcomes improve when treatment
times are extended to one year or longer. These studies, they
argue, show that longer treatment periods lead to improved
outcomes, with fewer arrests, fewer hospitalizations and greater
adherence to medication. (See, M. Swartz, et al., Assessing
Outcomes for Consumers in New York's Assisted Outpatient
Treatment Program, 61(10) Psychiatric Services 976 (Oct. 2010);
M. Swartz, et al., A Randomized Controlled Trial of Outpatient
Commitment in North Carolina, 52(3) Psychiatric Services 325
(March 2001).)
However, it is important to note that during the time of the
study in New York, the maximum initial period of imposed
treatment was six months. Patients who received treatment
longer than six months likely received extensions beyond the
initial six-month treatment period. This can be done in
California today, under existing law, which requires the
director of the assisted outpatient program, if he or she
determines that an individual undergoing treatment requires
further assisted outpatient services, to apply to the court,
prior to expiration of the treatment, for an extension of the
services, not to exceed 180 days. In North Carolina, the other
state where the provided studies were done, the maximum initial
time permitted for assisted outpatient treatment is just 90
days. If individuals are receiving treatment for more than six
months, it must be after further court hearing, which can result
in, if the judge so orders, a 180-day extension of the
treatment. ((N.C. Gen. Stats. Sections 122C-271 and 122C-275.)
Again, further treatment can be had in California today, if the
court so orders and our statute already sets out the procedure
for this. Thus, it appears that no change in California law is
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necessary to get the improved outcomes noted in the studies that
supporters tout.
Additionally, opponents, however, argue that Laura's Law in
Nevada County appears to be functioning well and that there is
no need to change it. Writes the California Council of
Community Mental Health Agencies and Mental Health America of
California: "Increasing the time from six months to twelve
months ignores the fact that many people with severe mental
illness can achieve a sufficient recovery in six months to
eliminate the need for longer intensive treatment and it is
difficult to know who they might be upon intake." Opponents
argue that if more treatment time is needed, as discussed above,
the court can be petitioned for further assisted outpatient
treatment.
Given the lack of evidence supporting the need for doubling of
the involuntary treatment period, the lack of participants
to-date in this program, and, most importantly, the options
available, under existing law, to seek more assisted treatment,
this Committee may decide it is more appropriate to delete this
section from the bill.
Bill Also Permits, But Does Not Require, Evaluation For
Application of AOT : As amended, the bill permits, but does not
require, that in counties that have implemented Laura's Law, the
professional staff at an institution that is releasing a patient
from an involuntary treatment program under the LPS Act may
evaluate the patient to see if he or she meets the criteria for
AOT. If the patient meets the criteria, the professional staff
may ask the county mental health director to seek a court order
directing the patient into AOT. As originally drafted, this
bill would have mandated that staff review and evaluate each
patient before release from an involuntary commitment. The
California Mental Health Directors Association appreciates the
local discretion that this now optional assessment gives them.
It is not clear how this provision would work. Would patients
first be evaluated for, and, when appropriate, offered,
voluntary outpatient services? Or would the "professional
staff" simply jump right to the option of involuntary treatment?
Additionally, could this provision create a possible conflict
of interest for the professional staff of an institution
recommending assisted outpatient treatment if they also contract
with the county to provide that treatment? Committee staff was
unable to explore these questions more fully, but they likely
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warrant answers before the program is further expanded.
Opponents argue that they would remove their opposition and
support the bill if it instead focused only on simply evaluating
patients discharged from hospitals to determine what care they
needed and how they might get it:
Too many are rehospitalized due to this lack of follow up
which often leaves people back on the streets without care
and likely to repeat the need for hospitalization.
Accordingly we would support a requirement that people
being discharged be fully evaluated to determine the level
of care needed and to coordinate with county mental health
to ensure that they receive that level of care to the
extent that they have insurance coverage to pay for it or
to the extent there are available resources.
ARGUMENTS IN SUPPORT : In support of the bill, the California
Psychiatric Association writes:
AOT is well studied. Several dozen articles have appeared
in well regarded peer reviewed scientific journals since
1999 demonstrating AOT effectiveness in a number of ways.
Pertinent to AB 1265 is the seminal research conducted at
Duke University in 1998-99 regarding North Carolina's AOT
programs.
The 1999 Duke study found that for a commitment period of
up to six months for individuals with psychotic disorders
control and AOT groups did not differ significantly in
hospital outcomes, i.e., number of hospitalizations and
days of hospitalization were roughly the same up to the 6
month mark. However, individuals undergoing sustained
treatment in AOT beyond the 6 month initial court order had
approximately 57% fewer readmissions and 20 fewer hospital
days when compared to control subjects. Sustained
outpatient commitment was shown to be particularly
effective for individuals with psychotic disorders,
reducing their hospital readmissions approximately 72% and
requiring 28 fewer hospital days when compared to control
subjects.
ARGUMENTS IN OPPOSITION : Disability Rights California writes in
opposition to the bill:
By expanding the length of time people are committed under
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assisted outpatient commitment and routinely evaluating
people released from intensive treatment for an assisted
outpatient commitment, the state will be encouraging the
forced treatment of people who are not currently dangerous
or gravely disabled. Involuntary treatment destroys trust
and pushes people out of the mental health treatment
system. Laura's Law requires that the full array of
services be available on a voluntary basis before
implementing forced treatment. However, counties have not
provided the services on a voluntary basis.
A 2009 study of New York's "Kendra's Law", a comparable law
to California's assisted outpatient commitment law, was
unable to conclude that the court order, as compared to the
underlying services, improved outcomes. . . . A Rand
Corporation 2001 report came to no conclusion about whether
or not assisted outpatient commitment was effective.
Many counties already have in place proven voluntary
treatment programs that have comparable results to Laura's
Law without the expense and coercion of court-ordered
treatment. By comparison, involuntary outpatient treatment
shows forced treatment is often counterproductive -
renewing trauma and steering people away from the mental
health system. (Citations omitted.)
Prior Legislation : AB 1421 (Thomson), Chap. 1017, Stats. 2002,
first enacted Laura's Law and granted counties the authority to
enact pilot programs to determine the effectiveness of
involuntary commitment assisted outpatient programs. AB 2357
(Karnette and Yee), Chap. 774, Stats. 2006, extended the pilot
program established by AB 1421 through January 1, 2013 and
mandated that the Department of Mental Health submit a progress
report to the Governor and Legislature in 2011. AB 1569
(Allen), Chap. 441, Stats. 2012, again extended the pilot
through January 1, 2017 and mandated an additional report on the
program, due July 1, 2015.
Just last year, SB 585 (Steinberg), Chap. 288, Stats. 2013,
clarified that the services under "Laura's Law" may be funded by
the Mental Health Services Act (established by Proposition 63).
REGISTERED SUPPORT / OPPOSITION :
Support
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California Mental Health Directors Association
California Treatment Advocacy Coalition
California Psychiatric Association
Opposition
California Council of Community Mental Health Agencies (unless
amended)
Disability Rights California
Mental Health America of California (unless amended)
Analysis Prepared by : Leora Gershenzon / JUD. / (916) 319-2334