Laura’s Law: Innovative compromise proposed around assisted outpatient treatment

July 17, 2014

An important read from our colleagues at No Health without Mental Health. As the debate about assisted outpatient treatment continues, San Francisco is exploring some innovative approaches to making it work in a way that addresses need, is respectful of individual choice and includes family involvement.

On July 8, 2014 the 11 member San Francisco Board of Supervisors (city council) voted 9-2 to implement a 2002 California state law, called Laura’s Law, which can compel certain individuals suffering from serious mental illness to undergo, under strict safeguards, outpatient treatment. The ordinance now goes to the Mayor Ed Lee who supports it. Los Angeles County is considering a similar ordinance next week.

In so doing, San Francisco reached a potentially historic compromise in the battle between treatment for serious mental illness versus patients right to decide their care. It may set an example for the rest of the country.

The setting for this landmark compromise is dramatic and telling. As the widely acknowledged most beautiful city in America, with its iconic Golden Gate Bridge and long history of incoming migrants, San Francisco has long been a magnet for people with mental illness, creating a large population of those with psychiatric disorders. The “City” (as locals call it) has also been dubbed “the most liberal city in America” going back to the UC Berkeley free speech movement of the 1960s. For years the issue of whether to implement Laura’s Law, which focuses strictly on persons with severe mental illness who due to the illness cannot ask for help themselves, has been a political hot potato. Families, mental health providers and law enforcement have pleaded for ways to be able to treat these individuals. Conversely, many patient advocates have strenuously argued that the individual’s right to determine their own care, should be paramount.

Laura’s Law is named for Laura Wilcox, a 19 year old college sophomore shot and killed, while working as a temporary receptionist in a government office, by a psychiatric patient with untreated mental illness. Laura’s parents had for years fought to create an option of seeking court-ordered mandatory treatment for patients unable to seek help themselves. In 2002 the State Legislature enacted Laura’s Law but requires each county in the State to opt-in before it is effective. Many in the patients’ rights field and some behavioral health advocates fought its implementation, believing that individuals should never be coerced to accept care.

With last week’s historic vote, San Francisco may be setting an example for Washington, D.C. in how to reach across aisles and find new solutions to complex health care policy debates.

The Compromise:

  • The law does not mean the mentally ill will be forced into locked psychiatric wards, rather the involuntary care prescribed may take place while living in their homes;
  • A court order compelling treatment will apply to a tiny fraction of the population, the county health department estimates 100 out of SF’s total population of 800,000: specifically, those hospitalized, with a history of unsuccessful psychiatric treatment, or jailed twice in the prior three years due to mental illness, who have been violent to themselves or others, or threatened violence in the past four years;
  • Family, mental health providers, probation officers, police and others can request that authorities evaluate individuals for inclusion in the program; the order for treatment can be obtained only for those who have refused voluntary treatment and have a “substantially deteriorating” condition; the requestors must obtain the agreement of the county mental health director who then petitions the court for involuntary treatment; the civil court order is implemented by the country department of public health;
  • A “care team” must be established that includes another person with a mental illness, a forensic psychiatrist, and a person who has a family member suffer from mental illness; this care team will engage with the patient prior to court-ordered treatment with the aim of steering people towards voluntary treatment; voluntary treatment with the same level of outpatient services must be offered throughout the process;
  • Law enforcement will be summoned to take someone to a hospital only if person a danger to him/herself or others;
  • An independent outside group will conduct an assessment of Laura’s Law after three years;

Another California county, Nevada County, where Laura Wilcox lived and died, has a record of Laura’s Law implementation with documented positive results: with just 41 cases in 10 years in that county, data show a decrease in patients’ rates of hospitalizations and incarcerations, and sufficient stabilization of formerly homeless people to secure housing. San Francisco County went even further in creating an innovative list of new ground rules for how Laura’s Law is implemented.

Washington pay attention! This is how compromise gets done when there is a will to find a way to help vulnerable citizens, while at the same time listening to all points of view. Out in the States, in municipalities across this country, leaders and activated citizens are finding creative negotiated solutions to balancing both the need for mental health treatment access, along with respect for patient rights and dignity and civil liberties. It’s time Washington’s elected representatives take note of what the States and cities can teach them In the art of compromise.

Florence C. Fee, J.D., M.A. 
Executive Director, No Health without Mental Health

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