A bill facing the California legislature aims to strengthen involuntary commitment laws and establish "community-assisted outpatient treatment," or outpatient commitment. Such a law is hoped to reduce homelessness and the incarceration of people with mental illness in prisons instead of hospitals. The fate of the bill is uncertain.

California Assemblywoman Helen Thomson (D-Davis) introduced AB 1800 in January. The bill would allow persons with severe and persistent mental illness to receive treatment in community-assisted outpatient treatment programs, allowing for early intervention at a stage when treatment could have a stabilizing effect on severely ill people who might otherwise refuse treatment.

Current law "allows the symptoms of untreated schizophrenia, bipolar disorder, major depression, and other severe mental illnesses to become increasingly worse," Thompson emphasized in a speech to the California Assembly, "while the afflicted person becomes more and more resistant to treatment, and the options for effective treatment diminish."

Current commitment laws in California can keep someone in inpatient treatment for up to 180 days, and Thomson’s proposed legislation would increase that period to up to a year. However, patients who are judged to be stable enough and are agreeable to the idea would receive their medications and therapy in an outpatient setting instead of a locked ward. A team of mental health professionals led by a psychiatrist would supervise the outpatients, and an "outpatient care expediter" would coordinate all services provided to the patient. The outpatient treatment would provide immediate crisis response around the clock as well as support in coping with life’s daily demands, such as obtaining insurance coverage, housing, and financial entitlements.

Under the proposed legislation, if the patient is noncompliant with the terms of the outpatient treatment program as determined by the psychiatrist and treatment team, or if his or her mental or physical health deteriorates, the court may order that the patient be returned to inpatient treatment for the remainder of the commitment period.

The bill would reform the 30-year-old Lanterman-Petris-Short (LPS) Act, which led to the discharge of most of the nearly 30,000 patients housed in state psychiatric hospitals in California after its passage. Unfortunately, many of these patients ended up in jail or on the streets.

The problem with the LPS law, said Thomson, is that it provides for involuntary commitment and treatment of those with severe mental illness, but only after they have lost the ability to provide for their own food, clothing, or shelter or are about to hurt themselves or someone else seriously.

"The effectiveness of mental health treatment depends on timely, early intervention. Unfortunately, those suffering from an untreated severe mental illness and in most need of intervention are the least likely to seek treatment because they often lack the insight to think rationally," Thomson emphasized.

AB 1800 would also reform the hearing process, specifying that a patient’s psychiatric history be presented during the commitment hearing and recommending the consolidation of hearings. The consolidation of hearings refers to the hearing officer finding whether there is probable cause that the person should be involuntarily detained at the same time that he or she decides whether the person has the capacity to make an informed refusal of treatment. Under the current LPS law, the capacity determination for each individual is made separately from the determination of probable cause for involuntary commitment.

In addition, AB 1800 adds to the definition of "gravely disabled," the standard by which mental illness is measured under the LPS law. The LPS law defines a person as gravely disabled if he or she is unable to provide food, clothing, or shelter for himself or herself. Under these circumstances, a person could be committed involuntarily. Thomson’s bill adds to the commitment criteria having a mental disorder that causes symptoms to escalate during the 30 days prior to commitment. This condition would cause the person to be unable to provide for basic needs or become more dangerous to himself or herself or others in the absence of treatment.

Elizabeth Galton, M.D., who was elected president of the Southern California Psychiatric Society in 1994, chaired the LPS reform task force steering committee with Carla Jacobs, an advocate for people with mental illness and board member of the National Alliance on Mental Illness (NAMI). Together with a multidisciplinary group that included attorneys, patients, and experts in psychiatry, the two women laid the groundwork for Assembly bill 1800.

Galton told Psychiatric News, "Since the passage of the LPS Act, there have been great medical advances in the understanding and treatment of mental disorders, and this bill reflects those changes," she

Conni Barker, lobbyist for the California Psychiatric Association, remarked that the Association strongly supports the bill, and believed the most crucial aspects of the bill for psychiatrists were that the presentation of medical history during the patient hearing, the consolidation of patient hearings, and the creation of outpatient commitment programs.

This bill faces significant opposition from various groups. Vocal psychologists have wanted to turn it into a scope-of-practice bill permitting prescribing privileges. Other adversaries have included current and former patients who believe that new and improved involuntary commitment laws are a threat to their civil liberties. However, Senator John Burton (D- San Francisco), the Senate’s president pro-tem and majority leader, has proved to be the bill’s most formidable opponent.

Although the bill emerged from the California Assembly victorious with a 53 to 16 vote and has the support of major government officials, newspapers, and advocacy groups locally and nationally, Burton wielded his power as president to stall the bill in the Senate. Burton, a known civil libertarian, is concerned about the rights of people with mental illness and suggested that much of the evidence given by supporters of AB 1800 regarding problems with the LPS law is anecdotal. Bypassing the usual democratic process, he referred the bill to a research committee in mid-June and commissioned an $87,000 study of involuntary treatment programs to be conducted by the RAND Institute for Civil Justice. He has also stated that legislation on the bill will halt until the study is completed.

In the meantime, Thomson’s office reports that she is vowing to do everything she can do to get the bill into a policy hearing within the California Senate, where it will be subject to a fair rule. n