Health Care

California Takes a Real Step Toward Helping the Mentally Ill

(kieferpix/Getty Images)
New York and other states should take note.

Individuals with serious mental illness and their families lost their most prominent advocate a week ago when DJ Jaffe, the executive director of Mental Illness Policy Org., died after battling leukemia. But Jaffe would be elated to see the fight for those he championed take a major step forward in California last Thursday when the state senate voted to make Laura’s Law permanent.

Laura’s Law was enacted in 2002 when 19-year-old Laura Wilcox was shot and killed by a man with untreated serious mental illness. It was inspired by the success of a similar law in New York that Jaffe was instrumental in establishing, named for Kendra Webdale, who was pushed to her death in front of a subway car by a man with untreated schizophrenia. Other states have since followed suit, having learned what works to keep patients and the public safe.

In more specific terms, Laura’s Law and Kendra’s Law both created programs for assisted outpatient treatment (AOT) in their respective states. AOT allows judges to mandate community-based treatment for a small, highly specific population of adults with serious mental illnesses, such as schizophrenia or bipolar depression, who have a history of noncompliance with treatment that has led to multiple hospitalizations, violence, or arrests. While in the program, individuals are able to continue living in their communities and receive monitored treatment—and, importantly, the mental-health system is held accountable for providing it.

AOT is massively successful. Multiple studies have shown it to improve outcomes for those with serious mental illness by meaningful metrics such as reduced homelessness, arrests, incarceration, and needless hospitalization, each down by around 70 percent. And these outcomes allow for the positive side effect of reduced taxpayer costs to the tune of around 50 percent. While opponents claim that AOT violates civil liberties by requiring treatment, in reality it enables avoiding more restrictive measures such as involuntary commitment or incarceration. In fact, participants have reported that it helped them gain control over their lives, get well, and stay well. It is important to note that these remarkable results are true for those with the most severe illnesses, as the program serves that specific group.

Sadly, AOT has been an underutilized tool as, broadly, mental-health funds have shifted away from programs that serve those with debilitating brain disorders to the “worried well.” Not exclusive to California, the mental-health industry often has disincentives to move the most seriously ill — with the greatest need for treatment and care — to the front of the line. For one thing, this group can be difficult to serve. About 40 percent of those with serious mental illness experience a symptom called anosognosia, which prevents insight into an individual’s illness — meaning they are so ill that they do not know they are ill. For this reason, they may not voluntarily seek treatment, or they may be inclined to refuse treatment.

Also, an outdated, discriminatory Medicaid provision, the Institutions for Mental Disease (IMD) exclusion, prevents federal Medicaid dollars from funding care for the mentally ill in psychiatric hospitals with more than 16 beds. This has led states to continue shuttering psychiatric beds in favor of community mental-health centers to save money. Community mental-health centers have historically not served those leaving long-term psychiatric-care facilities and cannot provide the level of adequate medical care that some may need.

From insufficient bed capacity and inconsistently sought voluntary care, a cycle of homelessness, repeated hospitalizations and then releases, and arrests tends to follow for those most ill — a grim example of which can be found in Rashid Brimmage. Brimmage, a homeless New Yorker with serious mental illness, shoved a 92-year-old woman to the ground in June. He had been arrested 102 times over the past 15 years. It’s possible that Brimmage would have been a candidate for AOT. If unable to live successfully in the community under supervised treatment, he would have needed a level of care that could be provided only in a hospital.

Rather than using government funds to keep patients and the public safe, money can too easily be obtained to instead create pop-psychy services such as mental-health first aid and “[insert your choice of animal/art/surfing/yoga] therapy” for the general population. These programs get attention because improving “mental wellness” is politically popular. Things such as poverty, poor academic performance, and divorce are declared mental illness and then mental-health funding is diverted to them. More and more taxpayer money is spent, and yet problems become worse.

The impact of this mental-health mission creep is clear. An aptly named state audit report from July revealed “California Has Not Ensured That Individuals With Serious Mental Illnesses Receive Adequate Ongoing Care.” The report found that a paltry 9 percent of those who were subjected to five or more instances of involuntary treatment were then being connected to continuous care. Despite billions of dollars spent in the state each year, the most severely mentally ill are still  provided “limited treatment options,” with many waiting an average of one year to receive specialized care in state hospitals. As a society, our normal mental-health response should be concern that the most vulnerable are being left behind.

Laura’s Law is an effective policy solution that could help correct this misallocation of resources. The legislation being sent to Governor Newsom aims to do so by both making Laura’s Law permanent and requiring all counties in California to adopt AOT programs, as currently only 19 have done.

“For many of the most seriously ill it is the last off-ramp before jail,” DJ Jaffe said. “AOT is the best tool we have.” Signing the bill is a no-brainer. Governor Newsom should lead the way in demonstrating to other states, including New York, that further utilizing AOT is the sane thing to do.

Carolyn D. Gorman is the vice chair of the board of Mental Illness Policy Org., a non-profit founded by DJ Jaffe that advocates for those with serious mental illness.

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