BILL ANALYSIS �
AB 2266
Page 1
Date of Hearing: April 22, 2014
ASSEMBLY COMMITTEE ON JUDICIARY
Bob Wieckowski, Chair
AB 2266 (Waldron) - As Introduced: February 21, 2014
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 in 2012, 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.
This bill is a nearly identical reintroduction of AB 1265
(Conway) from last year. That bill failed in this Committee in
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April 2013. In January 2014, the Committee was asked to
reconsider AB 1265, without any substantive amendments, and
again the bill failed to pass. Should the bill be approved by
this Committee, it will then be referred to the Assembly Health
Committee.
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.)
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
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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.)
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
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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:
"Laura's Law" provides family members with important
tools for initiating outpatient treatment for severely
mentally ill adults who are incapable of seeking help on
their own. It helps to identify when a patient's
condition is significantly worsening and to intervene
before the patient becomes too ill and is subject to
involuntary civil confinement.
Based on previous evidence, the first six months in the
program demonstrate significant improvements in
self-care and community living, social functioning, task
performance, and incidents of harmful behaviors in
patients. Studies also show that improvement takes time
therefore, to insure full stability of patients once the
initial period is complete, AB 2266 will extend it from
six months to one year.
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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
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
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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.
This bill doubles the 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 ordered to participate in assisted outpatient treatment. New
York made just such a change in 2012, 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
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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
necessary to get the improved outcomes noted in the studies that
supporters tout.
Additionally, opponents 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.
This bill also permits, but does not require, evaluation for
application of AOT : 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
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may ask the county mental health director to seek a court order
directing the patient into AOT. It is not clear, however, 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 warrant answers
before the program is further expanded.
Opponents, including the California Council of Community Mental
Health Agencies (CCCMHA) and Mental Health America of California
(MHAC), state 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
Medical Association (CMA) states that it believes this bill "is
an important step in the statewide implementation of AB 1421
(Laura's Law) that provides assisted outpatient treatment
programs for the mentally ill with Proposition 63 mental health
funds."
ARGUMENTS IN OPPOSITION : Disability Rights California writes in
opposition to the bill:
By expanding the length of time people are committed
under assisted outpatient commitment and routinely
evaluating people released from intensive treatment
for an assisted outpatient commitment, the state will
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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 Related 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.
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).
This bill is a reintroduction of the last amended version of AB
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1265 (Conway) from 2013. That bill failed passage in this
Committee in April 2013. In January 2014, the Committee was
asked to reconsider AB 1265, without any substantive amendments,
and again AB 1265 failed to pass.
REGISTERED SUPPORT / OPPOSITION :
Support
California Medical Association
Opposition
California Psychological Association
California Council of Community Mental Health Agencies (unless
amended)
Disability Rights California
Mental Health America of California (unless amended)
Analysis Prepared by : Anthony Lew / JUD. / (916) 319-2334