This image from: http://www.ekantipur.com/the-kathmandu-post/2011/03/27/oped/all-together-now/219926.html

Introduction

The following statistic’s represent today’s mentally ill in the 45 years since the passage of the Lanterman Petris Short Act, California’s law for responding to crisis and the mentally ill.

“Suicide: 15% of people with untreated or undertreated mental illness kill themselves.

Homeless: 33% of homeless people have an untreated mental illness.

Arrest: 20% of incarcerated inmates in both jails and prisons have a mental illness.

Victimization: People with a mental illness are at least three times as likely to be assaulted or raped compared to the general population.

Violence: 10% of all homicides are committed by individuals with a mental illness.

Death: People with a mental illness die 25 years earlier than the general population.”[1]

This piece seeks to explain the Lanterman Petris Short Act, the current law that must be followed by those responding to crisis and the problems inherent therein. This law sets forth the criteria for involuntary civil commitment of the mentally ill to psychiatric hospitals[2]. One of many problems with this antiquated legislation is its vagueness, as its constructions do not adequately guide those prescribed to initiate involuntary psychiatric commitment. As a result, California is not properly responding to the needs of a very vulnerable and sometimes lethally dangerous population, the severely mentally ill.

Here the illness Schizophrenia will be showcased, as it is one of the most volatile and most difficult disorders to treat, but one that benefits greatly from early and consistent treatment.[3] This treatment is often hampered by the LPS Act as it stands. Involuntary treatment is sometimes necessary considering the features of the severe mental illnesses involved, and though it is not the preferred course of action, it is often the only alternative to  death, crime, and/or the criminal justice system.

To demonstrate how Schizophrenia and the current legislative scheme intertwine, we begin with a story of a California family whose lives have been impacted by Schizophrenia, and the application or lack thereof of the Lanterman Petris Short Act (LPS Act). This is a true story so names have been changed to protect the privacy of these individuals.

Miles’ Story

It was 4-years ago when the Clarks noticed that their youngest member, Miles Clark, began to change. The once vibrant and popular young man was disappearing before his family’s eyes. It wasn’t his body that was deteriorating, however. His kind demeanor, his focus and control, all seemed to be diminishing. He was being replaced it seemed, by something foreign and bizarre.

His mother recalled the thing that startled her most when this change began. She shutters when explaining it, “Miles suddenly had a cold and distant look in his eyes, sometimes frightening and accusatory. It was the gaze of a stranger.”

Miles Clark was sixteen years old when he started exhibiting the prodromal symptoms of Schizophrenia. Prodromal symptoms are often present prior to the active phase of the disease and include mild forms of more severe symptoms that manifest aggressively as the disease progresses.[4] These include positive symptoms such as expressions of unusual beliefs (ideas of reference or magical thinking) and unusual perceptive experiences (sensing presence of an unseen person or force in the absence of formed hallucinations), and also include negative symptoms such as social withdrawal and flat affect (sullenness or lack of emotion).

As the baby of the family, with two older brothers living out on their own, Miles shared a big beautiful house in Northern California with his parents Michael and Dotty Clark.  The Clarks had a tranquil, idyllic life and had seemed immune from the issues that plagued many of their friends and neighbors. There was no divorce, or abuse, or financial problems. “There was no drama at all really,” Dotty Clark recounts. “Until Miles began to isolate socially and emotionally, we felt lucky to have raised three happy and healthy young adults.”

One day, in fall 2008, Miles came home from high school and announced that he was done playing basketball. This was unusual because Miles had loved basketball for as long as anyone could remember. He had started as a freshman on the Varsity team and was already being eyed by scouts from national universities. It was startling to hear him speak so dismissively about a sport he presumably loved. It was the family anecdote that Miles would be a professional basketball player one day. His room was lined with tournament trophies and framed jerseys. His life was basketball.

“We assumed he was just having a bad day,” Mrs. Clark continues sadly. “But unfortunately, he never went back to practice.”

Mrs. Clark remembers this moment as the turning point in her family’s reality. Though she and her husband didn’t want to believe anything was truly wrong with Miles then, she reflects on the behavior and incidents that followed that fall evening in 2008, shaking her head in disgust.

“If only I knew then, what I know now,” she says. “I would’ve recognized that Miles’ sudden lack of interest in everything he’d once loved, along with the increasingly strange rants and sleep patterns, was a bright red light flashing in my face, telling me to stop and recognize that my son might have a serious mental disorder, Schizophrenia.”

According to Schizophrenia.com, “Schizophrenia is a disease that typically begins in early adulthood; between the ages of 15 and 25. Men tend to develop schizophrenia slightly earlier than women; whereas most males become ill between 16 and 25 years old.”[5] Miles age and gender, along with his odd behavior, aligned with those statistics perfectly.

Initially, Schizophrenia was not something that the Clarks had considered as the explanation for their son’s “yearlong bad mood.” Dotty says, “We thought we were just too hard on him by pushing him to be a star athlete while also expecting perfect grades.”

“We assumed he’d grow out of it and would wake up one day, the person he once was: Happy and excited about the future,” Michael Clark remembers wistfully. “The most unsettling part of it all was that Miles seemed to be leaving a shell of himself behind. There was little left of the sweet boy we had raised.”

According to the Diagnostic Manual of Mental Disorders (DSM), it is common for those exhibiting the beginning stages of Schizophrenia to appear to be “gradually slipping away.” Individuals who were once social may become withdrawn, the manual explains. They lose interest in previously pleasurable activities and they may become less talkative and inquisitive.[6] Like Dotty and Michael Clark, family members might find this behavior difficult to interpret and assume that the person is ‘just going through a phase.’

“I wish we would have done something back then,” Mr. Clark says emphatically. “Because things got significantly worse when Miles turned 18.”

Just when Dotty and Michael were beginning to wonder if something really was wrong with their youngest son, he surprised them by telling them that he’d decided to go away to college after all. Though his grades had suffered during his last year of high school, his superior performance early on got him accepted to a big ten school in the Midwest.

“We hoped things would turn around when he got to college. Maybe we were too strict. Maybe he just needed some freedom,” Mr. Clark says.

A few weeks after Miles’ 18^th birthday and just a month into the fall semester, it became clear that their son as they had known him would never be the same again. Disturbingly angry, while also frightened, Miles suddenly insisted on coming home from college. He was convinced his teachers were out to get him, yet could not provide logical examples to substantiate this claim. Despite his very clear unease and increasingly disorganized thought process, Miles didn’t seem to be aware that he had a problem at all. Everyone was against him.

“There is NOTHING wrong with me, Mom,” Miles would say when they first tried to convince him to visit a psychologist, “You’re the one with the problem.”

Mrs. Clark details one particularly difficult period shortly after Miles returned from college, the time she now refers to as his first psychotic episode.  She isn’t sure which was worse, the sullen and withdrawn Miles from the previous year, or this combative and paranoid version.

She says, “He’d accuse us of poisoning his food. He’d pace around the house for hours whistling, staring into space. Then he’d stay up all night digging through boxes in the basement, but yet couldn’t tell us what he was looking for, or why. And when we’d suggest that this behavior wasn’t normal and proceed to beg him to see the counselor we’d found for him, he’d erupt in anger and scare us to death.”

“’It’s you, Mom and Dad’, Miles would shout, ‘YOU are the sick ones,’” Mr. Clark finishes.

The DSM reports that up to 70% of individuals with Schizophrenia “have poor insight regarding the fact that they have a psychotic illness (p. 304).” Evidence suggests that this is a manifestation of the illness itself, rather than a coping strategy, such as denial. This feature has been compared to the lack of awareness often seen in stroke victims, termed anosognosia. Other issues with lack of insight are discussed later in this paper.

Worse still was that now Miles was an adult. Although he was deteriorating more each day, there was nothing his parents could do to assure that he get treatment.

Dotty and Michael Clark proceeded to describe the two years that followed: The unprompted screaming, the violent outbursts (he’d come close to striking them many times), and the sleepless nights. These parents loved their son. But what were they supposed to do? They pleaded with him time and time again to speak to a doctor. And when they’d recount their suffering to friends, people would tell them to “kick him out” or say he was a typical “spoiled rich kid.”

It was becoming clear that there son was very sick. It seemed that beyond convincing him to see a doctor, their only recourse, the result of fear and exhaustion, would be to ask their son to pack his bags and go as friends suggested. But they both agreed that this wasn’t the answer. They could picture their youngest child roaming the streets of Santa Cruz, California, a haven for hippies and homeless people about 30 miles south of their home in Monterrey.  “We knew if we pushed him too far, we might lose him forever,” Mrs. Clark says.

Additionally, they were still reluctant to call the police. After all, this was their ill child, not a criminal! Even when Miles furiously punched a hole through the wall in their living room for no discernible reason they refrained from dialing 9-1-1. The Clarks’ still held on to the waning belief that Miles would grow out of it, or stabilize on his own. The Clarks’ hoped and prayed that they’d get the old Miles back. But Miles wasn’t getting better; in fact he was getting worse. They began to believe that law enforcement and involuntary psychiatric care were their only hope.

When the unsettling behavior escalated to the point that their entire neighborhood block was involved, they decided, frantically, to contact the Monterrey Police Department. Miles had woken up the neighborhood screaming in the middle of their front yard at 4 AM on a cold October morning.

Mr. Clark explains, “There he stood, with his hands cupped around his face, screaming, sobbing in terror, as the neighbors peaked out their windows like he was some kind of circus freak.” It was truly one of the most heartbreaking moments in their lives.

Surely someone could help them.

They were confident that the local emergency room, or the police department, or the psychiatric community would DO something. They couldn’t force Miles to get treatment, but maybe someone could before he hurt himself or someone else.

The Lanterman Petris Short Act

The Los Angeles County Training Guide for application of the LPS Act says that the law, established in 1967, “was hailed across the country as the most progressive and human piece of legislation to date.” Codified in California Welfare and Institutions Code (WIC sections 5000 et. Seq.), the LPS Act “provides specific guidelines for the [involuntary] commitment of mentally disordered individuals, and provides protection for the legal rights of such individuals[7].

The Los Angeles Superior Court proudly displays “The legislative intent of the 1967 Lanterman-Petris-Short Act” on its website, which it lists as the following:

• To end the inappropriate, indefinite, and involuntary commitment of mentally disordered persons, developmentally disabled persons and persons impaired by chronic alcoholism, and to eliminate legal disabilities;

• To provide prompt evaluation and treatment of persons with serious mental disorders or impaired by chronic alcoholism
• To guarantee and protect public safety;
• To safeguard individual rights through judicial review;
• To provide individualized treatment, supervision, and placement services by a conservatorship program for gravely disabled persons;
• To encourage the full use of all existing agencies, professional personnel and public funds to accomplish these objectives and to prevent duplication of services and unnecessary expenditures;
• To protect mentally disordered persons and developmentally disabled persons from criminal acts. [8]

5150 & Involuntary Commitment

Although the LPS Act was intended to end inappropriate, indefinite, and involuntary commitment of the mentally ill, provisions were included therein for the commitment of persons who refuse treatment. Considering that involuntarily committed patients are comprised mostly of those suffering from serious mental disorders like Schizophrenia, where poor insight is a common feature, it is clear that even then, the 1967 act could not ignore the reality that involuntary hospitalization is often the only recourse to stabilize and treat severely psychotic patients.[9]

Sections 5150 through 5157 are the portions of the LPS ACT that attempt to define the characteristics necessary to qualify an individual for involuntary commitment, or more specifically, to retain someone for the purposes of evaluating whether or not they are a danger to themselves or others.  These sections allow a peace officer or other designated person to take an individual into custody for seventy-two hours upon probable cause, that because of a mental disorder, they are gravely disabled and a danger to themselves or others.

Specifically, Welfare and Institutions Code 5150 reads as follows:

“When any person, as a result of mental disorder, is a danger

to others, or to himself or herself, or gravely disabled, a peace

officer, member of the attending staff, as defined by regulation, of

an evaluation facility designated by the county, designated members

of a mobile crisis team provided by Section 5651.7, or other

professional person designated by the county may, upon probable

cause, take, or cause to be taken, the person into custody and place

him or her in a facility designated by the county and approved by the

State Department of Mental Health as a facility for 72-hour

treatment and evaluation.

Such facility shall require an application in writing stating the

circumstances under which the person’s condition was called to the

attention of the officer, member of the attending staff, or

professional person, and stating that the officer, member of the

attending staff, or professional person has probable cause to believe

that the person is, as a result of mental disorder, a danger to

others, or to himself or herself, or gravely disabled. If the

probable cause is based on the statement of a person other than the

officer, member of the attending staff, or professional person, such

person shall be liable in a civil action for intentionally giving a

statement which he or she knows to be false.”

After an evaluation within the 72-hour hold period as prescribed above, the person can be held for an additional period of up to 14-days if the attending psychiatric staff find that doing so is necessary to properly treat the individual.[10]

Depending on one’s experience, or lack thereof, with the severely mentally ill, and the mental health system, the words “for up to 14-days” might conjure disturbing images from “One Flew Over the Cuckoo’s Nest.” This novel depicts the depraved and restrictive institutionalization of the mentally ill. Interestingly, that book was published in 1962, five years before the LPS Act was put in place and seems to personify the abuses and injustices the mentally ill faced in America at that time.   After all, the LA Superior Court assures that “The basis for holding a person in a Designated Psychiatric Treatment Facility is not a medical model. It is a legal model. The law and the Courts have consistently held that personal freedom is the most important right we possess.”[11]

There is much to be considered in reviewing that statement. The Court insists that, “Holding a person in a designated psychiatric facility” is not based on medicine, but on law and the law and values of this country hold that personal freedom and liberty are the most important rights of all.  Unfortunately, however, the law favors those who are able to consciously and knowingly exercise their right to treatment or lack thereof. Often those with severe mental illness are unable to recognize their condition.[12] In its current application, the LPS Act fails to account for the 70% of those with Schizophrenia, who are medically unable to recognize their illness and so would be unable to answer questions logically about their degree of dangerousness to self or others. When one is unaware of the destructive nature of their disease or the presence of a disease at all, how then are they able to appreciate and exercise freedom?

 Overall Vagueness, Ambiguity & Problems with Probable Cause

Some claim that the Act has not gone far enough in assuring that freedom and should be revised to mirror the progressive trends of other jurisdictions, therefore affording greater liberties to those who suffer from mental illness. Over 30 years ago, Meredith Lenell, in arguing for greater legal rights for mentally disordered individuals, wrote for the Golden Gate Law Review, that “the present standards for involuntary commitment in California are vague in that they set no measurable standard for commitment. The vagueness of the terms “mentally disordered,” “gravely disabled” and “dangerous” leads to arbitrary and discriminatory confinement, which strikes most often at nonconformists, the poor, and the aged.”[13]

Today, 34 years after her article, the terms that Lenell mentions continue to be ambiguous. However, it’s difficult to substantiate her claim that they result in discriminatory confinement, as it relies on a Harvard Law Review article also published in 1974.[14]  This statement rests on an analysis of the system back then, ten years after the LPS Act was ratified, and can be contrasted against data from the most recent decade that paints a much different picture.

Though Lenell’s position is different than that of this paper, she touches on an issue that is still relevant. For when it comes to determining who, when, and how the severely mentally ill obtain treatment, there is obvious ambiguity inherent in the LPS Act as it stands. “Due process demands that “a law which serves as a basis for confining individuals must not be vague,” she explains.

Unfortunately, as she points out, “vagueness” is a problem inherent in the LPS Act. In Dr. Douglas Mossman, and Dr. Kathleen Hart’s paper How Bad is Civil Commitment? they quote a 1981 Washington D.C. report on violence and the mentally ill by J. Monahan, “The Tarasof court held that the duty to protect arises when a patient poses “a serious threat of violence” to another individual. While later decisions emphasize that the duty to protect arises “only when a threshold of probability is crossed,…. the terms used to define that threshold has varied, and never has it been specified with any precision.”

The portion of the LPS Act that defines the type of individual that may be held involuntarily might be addressed with the “void for vagueness doctrine.” As Lenell points out, “The void for vagueness doctrine can be divided into two elements, either of which will render a statute invalid.” First, a statute must be sufficiently explicit so as to give fair warning of the conduct that is prohibited by law.[15] Second, a statute is constitutionally vague unless it sets forth a definite enough standard to enable fact finders to apply it uniformly to those being adjudged.[16]

Section 5150 allows for involuntary, short-term civil commitment “When any person, as a result of mental disorder, is a danger to others, or to himself or herself, or gravely disabled.”

The LPS Act does not sufficiently define “Mental disorder.” Rather, the only legal definition could be found in one of the landmark California cases dealing with probable cause and civil commitment. There the court struggled to define “mental disorder” even before the applicable California Administrative Code (now the California Code of Regulations) was repealed. This now defunct statute was the only definitive guidance on how to interpret the term “mental disorder,” as used in the LPS Act. There, [it] [was] defined… “as any of the mental disorders set forth in the Diagnostic and Statistical Manual of Mental Disorders (current edition) of the American Psychiatric Association.”[17]

Additionally, the court in People v. Triplett illuminated further a scenario that might constitute probable cause. [It] held that “[the] defendant’s intoxication and tearful condition coupled with obvious physical signs of a recent suicide attempt constituted probable cause justifying her emergency detention.” There the defendant was displaying plainly obvious signs that her safety might be in imminent danger, but unfortunately not all dangerous individuals can be so easily identified.[18]

The task of defining “probable cause,” a term typically applied to criminal proceedings, remains a challenging one. The People v. Triplett case was distinguished by a 2004 case, Bingham v. Cedars Sinai Health. There a Cedars Sinai Nurse began acting erratically while on the job. Co-workers reported this behavior and asked that she be seen by a Dr. Eklund who concluded that she was having a manic episode, likely brought on by bi-polar disorder. While Eklund had no information about whether or not she was a danger to herself or others, he decided to institute the 5150 hold under the term “grave disability.” His decision was disputed for the following reasons and discussed by P.J. Cooper, of the California Court of Appeals: “He had no reason to believe she slept in public areas or wore filthy or torn clothing. Based on his evaluation of Bingham, Eklund had no opinion on whether Bingham could distinguish between food and nonfood. Bingham was not wearing filthy or grossly torn clothing. Eklund had no reason to believe that she slept on sidewalks, streets, or other public areas. He did not know whether she had a house or an apartment and had no evidence indicating that she did not.”[19]

Cooper’s opinion offers some direction as to what “grave disability” might mean, but serves only to describe the typical homeless person. There is no conclusive scientific authority available that says that all people in need of crisis intervention wear “filthy or grossly torn clothing.”

Additionally, the holding in this case may have had a chilling effect on the involuntary commitment process as it called into question the immunity of those brave enough to institute a 5150 hold. Typically, the individual who authorizes the hold has immunity from liability pursuant to WIC:5278. However, when probable cause is adequately scrutinized, it may be determined that immunity should not be granted.

“Section 5278 was intended to provide immunity for claims based on conduct that is expressly authorized by the LPS Act but would otherwise constitute a civil or criminal wrong…. [A] plaintiff who is properly detained in accordance with the LPS Act may not assert any civil claim based solely on the fact that he was detained, evaluated, or treated without his consent.”[20] However, as we’ll discuss further, the grounds upon which to utilize this authorization are not easily understood.

Furthermore, courts have attempted to explain how a peace officer, one of the parties authorized to hold an individual under the LPS Act, is expected to identify “grave disability” and/or “mental disorder.” In The People v. Triplett the court explains that “A peace officer (or other authorized person), is not required to make a medical diagnosis of mental disorder. It is sufficient if the officer, as a lay person, can articulate behavioral symptoms of mental disorder, either temporary or prolonged. An all-encompassing lay definition of mental disorder is difficult if not impossible to formulate. But, generally, mental disorder might be exhibited if a person’s thought processes, as evidenced by words or actions or emotional affect, are bizarre or inappropriate for the circumstances.”[21] Here, the court offers a definition of “mental disorder” that is broad and ambiguous, and further amplifies the subjective nature of this process.

While some officers do receive training as to identifying mental disorders, along with training on how best to respond to them, that curriculum is not standardized, nor required by the state of California (see section A Tale of Two Cities – LPS Act Training). Therefore, expecting that a subjective decision can be made, without anything for aid beyond the officer’s impression in that moment, puts an alarming, if not unfair burden, on the attending peace officer in circumstances such as that of Miles. This burden, along with the difficulty in determining whether or not his or her perspective qualifies as the requisite probable cause, can perhaps explain why peace officers may be hesitant to act without very obvious (cut wrists) indicators that harm will result if the individual is not committed.

In fact, that was exactly the problem the Clarks’ experienced.

When Mr. and Mrs. Clark called the Monterrey County Sheriff’s department that October early morning, when their son was screaming so loudly that he woke up their neighbors, it was not the family’s first encounter with law enforcement. Miles actually had called them himself almost 6 months earlier.

In June, after days of ranting that he was “bad” and deserved to be in jail, he told authorities to come arrest him. When they arrived he proceeded to confess that he had “raped” a girl while away at college almost a year earlier. Upon hearing this, the responding officers pushed for more information, and Miles finally explained that as an 18 year old he had had sex with a 17 year old. He truly believed that he belonged in jail as a result and found it hard to accept when the officers explained that, because of the closeness in age, this wasn’t a crime. His mother and brothers, who he’d also recounted the story to, had tried to convince him as well, but there was no reasoning with Miles’ nonsensical ranting and obstinate belief that he should be detained immediately for what he perceived as a criminal offense. He aggressively insisted that the officers were “wrong.”

“We asked the police if there was anything they could do. Could they help him? Take him to the hospital? We explained what we’d been going through, the sleepless nights, the pacing, and the increasingly violent and volatile behavior. They could clearly see that Miles was sick, but could only recommend that he see a counselor,” Mr. Clark says.

After all, they explained before driving away that day, Miles had not yet received a diagnosis from a psychiatrist, which the Clarks admitted to the officers when asked. The Clarks tried to make the police see that this was the very issue. Miles refused to get help. Period.

The law plainly states that a person can only be forced into treatment against their will “as a result of mental disorder.” Yet, often it is a police officer who is forced to make that determination as mentioned above. Some case law does exist offering guidance, such as that of People v. Triplett, but the question remains: How are officers to qualify an individual as “mentally ill” with limited, inconsistent, or no training at all? Can they be expected to read and study case law, like the opinion in Triplett for example?

According to a study of the 78,828 police officers in California, it was estimated that between the years 2000 and 2003 that there were 63,064 full time peace officers having direct public contact (field functions) on a daily basis. Of these first responders directly involved in field functions, 1,755 attended special classes on topics related to mental and developmental disabilities during the period July 1, 2000 and July 1, 2001. 9,904 officers attended classes during the period July 1, 2001 and July 1, 2003.[22] That amounts to 2.8% of peace officers in California having received training in the first year, to 15% in the second. Unfortunately, current statistics about police training are not available.

Furthermore, as recently as February 2012, the police in Fullerton, California have been heavily scrutinized for killing a mentally ill homeless man in the course of duty. Interestingly, “Crisis intervention training is free to all Orange County law enforcement officers. But in Southern California, only the Orange County Sheriff and the Irvine Police Department require it.”[23]  With that said, the officers involved in the shooting are being tried for involuntary manslaughter and 2^nd degree murder. It is the Clarks opinion that the men who responded on that early morning in October may not have had the training necessary to help them deal with an increasingly difficult and potentially dangerous situation.

As for the Clarks, officers arrived to the scene about 15 minutes after they called for emergency response. The Clarks detailed the events that had just transpired, as Miles screams quieted to silent sobbing. These concerned and frustrated parents told the officers that Miles refused to go to the hospital voluntarily, despite obvious mental illness and their legitimate belief that he may hurt himself or others, coupled with information provided about the previous emergency call and last year of frightening behavior. Nonetheless, the officers said there was nothing they could do. Despite the facts presented, Miles had no “history” of hospitalization or mental disorder for them to consider and it’s unclear if they would have utilized that information had it been available.

“Mam,” Mrs. Clark remembers the officer’s saying, “He hasn’t formally been diagnosed, so we can’t help you.”

Authorized responders are allowed to “consider available relevant information about the historical course of the person’s mental disorder” if they believe it has a reasonable bearing on the determination as to whether the person is dangerous to themselves or others. [24] Yet, what qualifies as “relevant information about the historical course of the illness?” Could they have considered the information presented by the Clarks? The previous police report about a young man convinced he had raped someone? Should they have been expected to call area hospitals for more information? Would they have even been authorized to obtain that information? What then, if there is no “historical course” because a person has not yet been diagnosed?

When read plainly, section 5150 implies that someone in Miles’ case must have already received a diagnosis of “mental disorder” before a 5150 hold can be applied. However, WIC: 5000.8.2, which defines in more detail “historical course”, is not included in the two training manuals discussed later in this paper. 5000.8.2 states that, “The historical course shall include, but is not limited to, evidence presented by persons who have provided, or are providing, mental health or related support services to the patient, the patient’s medical records as presented to the court, including psychiatric records, or evidence voluntarily presented by family members, the patient, or any other person designated by the patient.”[25] Considering that the definition for “historical course” is missing from the two training manuals used in the largest cities in California, it’s unlikely that the responding officers were aware of their latitude to take into account the information offered by Miles’ parents.

Miles Worsening Condition

The next week was the worst of all. At one point a family friend called the Clarks saying that Miles had arrived at his home asking “where he could buy a gun.” This eccentric and accepting friend said he was frightened by the maniacal look in Miles’ eyes and Miles’ inability to articulate why he wanted the gun in the first place.

After this conversation, the Clarks were even more worried about Miles’ safety, so they did all that they could. They took away his use of their vehicle. Consequently, Miles set out to walk 10-miles into downtown Monterey from their rural neighborhood. Angry and unpredictable, Miles disappeared for the next 24 hours. He wouldn’t answer phones calls and he couldn’t explain where he was going or why he was angry, simply telling his parents that “they better watch out.”

Then, the Clarks and their oldest son Neil called the police a second time. Neil received a text message from Miles that said, “Goodbye.” Around the same time, Mr. Clark arrived home to greet a frantic neighbor who said she’d seen Miles walking down their street brandishing a shovel like a weapon. Later, Miles had locked himself in his room and would not respond to either of his parents.

This time, when the police arrived, Mrs. Clark says, “All they did was ask if Miles was going to hurt himself.”

Because Miles answered with an abrupt “no” to that question, the officers did not, despite Miles’ parent’s insistence, take him to the hospital. They simply asked, a clearly instable young man, who was exhibiting many of the signs of schizophrenia as his parents detailed (delusions, paranoia, sleep disturbances, unprovoked laughter, talking “to himself”, etc., and nonsensical ranting with violent themes), whether or not he planned to hurt himself. Because it appeared that Miles may have been drinking, the officers took him to jail to “sober up” instead of to the hospital for evaluation by a licensed psychiatrist.

As mentioned above those with severe mental illnesses rarely have insight into the fact that they are ill, so asking them if they are “a danger to themselves or others,” is not a question that should expect a reasonable or truthful answer. Severe mental illness includes both bi-polar disorder and Schizophrenia, as in the case study of Miles. “A significant percentage of patients with [these] serious mental illnesses suffer from deficits in insight. Those with impairments in insight are unable to or have difficulty realizing: 1) they are suffering from a serious mental illness; 2) the symptoms they experience, e.g., delusions, hallucinations, mania are part of the mental illness; and, 3) that they would benefit from psychiatric treatment.”[26]

Their ability to make treatment decisions is also impaired, and they are more likely “to receive involuntary rather than voluntary psychiatric treatment; fail to take their prescribed medication in the community and function poorly (Mohamed et al., 2009; Olfson, Marcus, Wilk, & West, 2006; Yen et al., 2005), [and are likely to] experience more hospitalizations, suicidal and violent behavior (Yen, Chen, Yen, & Ko, 2008).”[27] Therefore, questioning a sick person about their ability to care for themselves is quite often a futile exercise. Miles’ situation portrays well the vicious and dangerous cycle that accompanies mental illness. Patients with severe mental illness typically cannot make informed decisions about their own mental health. Yet, without treatment, they cannot improve. According to the DSM, Antipsychotic medications are the most effective treatment for schizophrenia.[28] This is frustrating information for a parent who is trying to get their adult child to accept help.

“After searches on the internet and talking in depth to a psychologist friend a few states away, we learned that our son could get better if we could just get him to take medication,” Mrs. Clark says.

Furthermore, Insight can improve with treatment. If patients with poor insight who initially resist taking medication are ordered to take medication, after a month of treatment, the vast majority of patients (83%) retrospectively agreed with the decision to order medication against their wishes, e.g. they regained insight into the benefits of treatment (Owen et al., 2009).[29]

A Tale of Two Cities – LPS Act Training

Two of the largest cities in California, San Francisco and Los Angeles, make their LPS Act training manuals available online. When comparing them it is apparent that these training resources are not consistent.

In determining whether or not a person is “gravely disabled,” the Community Behavioral Health Services San Francisco Department of Public Health’s (SFDPH) LPS Training Manual quotes the legislative portion that refers to “grave disability” and recommends that the person writing the 5150 include the following: “Signs of malnourishment or dehydration; Inability to articulate a plan for obtaining food; No food available in the house or at hand if not in a house; Irrational beliefs about food that is available (i.e. it’s poisoned, inedible, etc.); Destruction or giving away of clothing to the point where the person cannot clothe themselves; And inability to formulate a reasonable plan to obtain shelter.”

That portion of the SFDPH manual speaks to the person’s condition during that time only, and advises that previous incidents of grave disability should not be considered, which blatantly contradicts the Act’s allowance that “historical course” of the illness can be weighed in determining a person’s current status. Also, this section speaks to the involvement of family and friends explaining that “unless they specifically indicate in writing their willingness and ability to help, family, friends, or others shall not be considered willing or able to provide this help.”

In comparison, the Los Angeles County Training manual also quotes the statute, but does not list out types of documentation to include, nor does it require that any family members’ willingness to help be documented, it simply states that if such person are available and willing to help then “grave disability” is not present.

These are just two examples of how training documents vary. As a result, the state, the public, and the mentally ill would benefit from a more standardized approach.

LPS Act & Law Enforcement

The Clarks live in Carmel, California which sits in Monterey County. In Monterey the police chief was recently honored for “[being] instrumental in bringing the Critical Incident Training Academy to fruition, Bureau Director Wayne Clark said in a statement.” [30]

Some strides have been made it is clear, but that does not mean that a small city like Carmel, a city of about 15,000 people according to Mrs. Clark, requires their police force to receive training.

One officer interviewed for this paper said he thought training of some kind was required, though the handbook applicable to his sector of the force listed it as a “may” and not a “shall.”  Additionally, considering the ambiguities inherent in the LPS Act, it’s not clear that training would directly benefit someone like Miles, who had not yet received a formal diagnosis and so had no documented “historical course” or diagnosed “mental disorder” to consider.

The representative from the Carmel Police Department explained that, “Even if we do take sick individuals to the hospital there’s no guarantee that they will be held for 72-hours.”  He implied that police officers are not the ones who impose the 72-hour hold and said that it was simply “up to” that amount of time. Yet, the law states that a “peace officer” who initiates the hold, “takes the person into custody and places him or her in a facility designated by the county and approved by the State Department of Mental Health as a facility for 72-hour treatment and evaluation.”[31] It was apparent that the officer did not have a good understanding of the law. Instead, he reflected practices that actually contradict it and said that they take ill detainees to the hospital where the decision is made by the hospital staff. What of the time in the car ride there? Has the hold begun at that point? Are they arrested or being held involuntarily? These were questions the officer could not answer.

The problems with application are further described by the LPS Act Reform Report, which explains that, “Holds for involuntary psychiatric treatment vary according to the statute cited. For example, a WIC §5150 hold is generally 72 hours and a WIC §5250 hold adds an additional 14 days. There are other circumstances in which a hold may be extended, such as a when a person is deemed “dangerous” to self or others. Counties in California use different approaches to determine which holds to place and therefore the length of time accumulative holds represent. Some counties use the 30-day LPS hold provision while some do not. Thus, depending on geographical location and varied timelines, individuals throughout California are being given widely divergent access to due process procedures as well as treatment.”[32]

Criminalization of the Mentally Ill

Shortly after its inception, criminalization of the mentally ill was identified as a resulting problem of the LPS Act. Just five years after ratification, Marc Abramson, a psychiatrist in San Mateo County, published data showing that the number of mentally ill persons entering the criminal justice system doubled in the first year after [it] went into effect. Abramson said, “As a result of LPS, mentally disordered persons are being increasingly subjected to arrest and criminal prosecution.”[33]

Recent statistics regarding criminalization of the mentally ill are startling. “About 40 percent of people with serious mental illness will be arrested at least once.”[34]

Additionally, “The average percentage of emergency calls that were mental health crises were reported as four percent,” but [upon further analysis] actuality equated to 29 percent of field personnel responses.[35] This data was obtained from 1995 an analysis of a study of over 400 police departments and 250 Sheriff’s offices, across multiple counties in California.

Whether police officers are ill equipped to handle interactions with the mentally ill or simply reluctant to, is complicated by the diminishing facilities available should they wish to institute the 5150 hold.  According to California Hospital Association’s June 2012 report, “As of 2010 data, California has lost almost 30% of the beds it had [to accommodate acute psychiatric crisis] in 1995, a drop of nearly 3000 beds.”[36] Additionally, they report that we fare far worse than 49 other states in the nation where there is one bed for every 4,798 people. In California, a state with a population of approximately 36 million people, we have one bed for every 5,651 people[37]. Most startling of all, however is that 25 counties have no inpatient services at all.[38]

Though criminalization is certainly not the answer, Mossman and Hart argue that “the low base rate of violent behavior, and the relative costs of false positive predictions of violence (deprivation of a few days’ liberty) and false negative predictions (physical injury or death), suggest [that] it is best to over predict violence. Commitment policy should favor false positive prediction errors because, “it may be better than ten ‘false positives’ suffer commitment for three days than that one ‘false negative” go free to kill someone in that period.[39] One might conclude, however, that arrest or criminalization, as an alternative to involuntary commitment, is the less of the evils when danger looms and resources are limited. Yet in those instances, due process problems remain.

Lots and Lots of Poorly Allocated Money

In California, approximately eighty-four percent of all persons in state hospitals are under involuntary commitment.[40] As ofMay 2007, California Health and Human Services Agency, Department of Mental Health released the FY 2004-2005 involuntary detention statistics.  737 adults who were placed on a 72-hour involuntary hold (W.I.C. 5150) in California psychiatric hospitals. Los Angeles County had 48, 473 adults [under hospitalization] and this accounted for 34% of the California detention total.[41] These numbers provide some idea as to the number of individuals who are detained against their will each year.

Yet these figures may be misleading, because as recent as August 2011, mental health professionals contend that “California’s mental health system has stopped treating people with the most severe mental illnesses.”[42] DJ Jaffe, executive director of Mental Illness Policy. Org and author of the article California Eliminating Mental Illness Treatment, explains that instead of using the funds allocated by Proposition 63 which generated $7 billion in funding for the Mental Health Services Act (MHSA) and specifically earmarked it to fund services for “severe” mental illness, counties have used the money for other things that they think will help “prevent” such illnesses, despite the fact that there is no known way to prevent severe diseases like Schizophrenia.[43]

He lists several examples of how these funds are being used in ways that do not serve the population that needs them most: “San Francisco County is spending money earmarked for prevention of “severe mental illness” for yoga, line dancing and drumming. King County spends MHSA funds meant for people with “severe mental illness” on youth reading below grade level. Butte County is using funds meant for “severe mental illness” to fund a “Therapeutic Wilderness Experience“. [Finally], Contra Costa County is using MHSA funding meant for “severe’ mental illness” for a hip-hop carwash, family activity nights and a homework club.”[44] His research about MHSA funds spending might explain the dramatic decline in beds in acute psychiatric care facilities.[45]

Jaffe and his colleagues are angered by this. The money allocated for the MHSA was meant to “fund services for “severe” mental illness so the “severely ill” wouldn’t be turned over to police.” While the community at large may benefit from the programs cited above, the minority, those with severe mental illness, sit in jail cells or roam the streets, waiting for much needed mental health services.

However, some progress has been made. Carla Jacobs, a member of the LPS Act Reform Task Force and a member of the California Advocacy Coalition talks about Laura’s Law, one program that does what voters wanted Prop 63 to do: help the really needy get really better.

“Only two counties have adopted Laura’s Law, which allows courts, after extensive due process, to order a small subset of people with “severe” mental illness (those likely to become violent without a court order) to accept treatment as a condition for living in the community,” Jacobs explains.

According to Jacobs, “research in New York State shows [that this similar] program reduces danger to self, [by] 55 percent; danger to others, [by] 47 percent; and arrest, [by] 8 percent; incarceration, [by] 87 percent; number of hospitalizations, [by] 77 percent; length of hospitalizations, [by] 56 percent; and improves almost every barometer of wellness.”[46]

The solution, the article argues, is to encourage, if not require, more counties to adopt Laura’s law before other deadly crimes are committed.

Miles Today

Fortunately, Miles, an 18 year old young man temporarily lost to mental illness, finally received a diagnosis of disorganized Schizophrenia, along with a requirement to take medication. It seems an odd thing to be thankful for, but to Miles and his family it meant a return to the light.

This return began with an incident that occurred a few weeks after he was released from jail for the first time, where he was sent to sober up. Unfortunately, however, his diagnosis was not obtained voluntarily nor was it result of involuntary commitment to a designated mental health facility.

Just 24-hours after his release from jail, Miles ignored his parents’ pleas to stay home. He set out on foot, for the second time that week, to journey through the 17-mile Drive National Forest. He walked toward downtown Monterey, those same 10 miles he’d walked just days before, but this time in the cold northern California rain. He finally arrived around 1 AM at a small bar and grill next to a hotel where he had worked in better times. There, he ordered a beer, looked at the only other patron in the bar quizzically, and pulled a brick from underneath his coat. He stood up and threw the brick out the window which lead out to the street, glass shattering onto the sidewalk. He didn’t run. Instead, he sat there and waited for the police to arrive, deeply unsettling the lone female bartender and shocked bar customer that hid in the kitchen.

That night Miles was booked for property damage and released the next morning. While waiting for his preliminary hearing he assaulted his father, Mr. Clark, because Miles was paranoid that Mr. Clark was scheming with Miles’ publicly appointed attorney to “harm him.” This time, Miles was not released immediately. The Clarks’ wrote letters to the District Attorney begging them to assure that their son receive a court appointed evaluation as to his competency to stand trial.

The county held Miles for 4-days where a jail mental health professional made a preliminary diagnosis of Schizoaffective disorder (the precursor to schizophrenia[47]) and recommended that Miles remain under the care of a psychiatrist and begin medical treatment immediately. After receiving the formal diagnosis of Disorganized Schizophrenia a few weeks later by a court appointed psychiatrist, Miles was stabilized on an anti-psychotic medication. He was then able to stand trial 6 months after committing the two crimes that occurred during acute psychosis.

Though Mr. and Mrs. Clark are thrilled “to have their son back” who is now preparing to begin school again at the local community college, they’re angry that the system didn’t respond sooner and that their son now has a criminal record. After all, the local police department had knowledge of three separate incidents, two within a week’s time that spoke to their son’s mental instability and violent proclivities. Now, at 18 years old Miles will be on probation for the next three years and will be forced to indicate that he was convicted of a crime on job applications.

While the Clarks are glad that medication adherence is a condition of Miles’ probation, they are still appalled that their happy ending was achieved in this way. They try to think positive about how things will be when Miles is no longer required to take his anti-psychotic medication. Though it’s impossible to say that the situation might be different if Miles had been forced to undergo the 72-hour hold, the Clarks now know one thing for sure: The system, as it stands, is flawed.

California and Laura’s Law & Other Jurisdictions

The ratification of Laura’s Law,[48] demonstrates that some progress for treatment advocacy, is being made. With this law, those who have already been diagnosed and have a long history of severe mental illness, can be required to comply with medication adherence. It “allows courts–after extensive due process, to order a small subset of people with serious mental illness who meet very narrowly defined criteria to accept treatment as a condition of living in the community….Counties have the option to implement Laura’s Law, [but] most have not.”[49]

Perhaps, as more is learned about the success of the pilot programs and attention is drawn to the misuse of the MHSA’s funding, this will change and resources will be re-allocated. According to Wikipedia, “as of 2010, Nevada County has fully implemented the law and Los Angeles County has a pilot project. In 2010 the California State Association of Counties chose Nevada County to receive its Challenge Award for implementing Laura’s Law. Subsequently in 2011, a National Association of Counties Achievement Award in Health was awarded to Nevada County for the Assisted Outpatient Treatment Program.”[50] These awards indicate that mentally ill individual’s quality of life is improving as the result of programs that resulted for the Laura’s Law legislation.

The problem for families like the Clarks, however, remains. Though strides have been made for the long-time mentally ill, what can be done when the early stages of severe mental illness are recognized, but a loved one still refuses to accept treatment?

States other than California provide some guidance for how the 5150 hold process, and the requirement for an involuntary evaluation, might be revisited. The statutes listed below, from South Carolina, South Dakota, and Delaware make it possible for anyone, who has reason to believe a person is dangerous to themselves or others, to file an affidavit with the court so that their position can be heard and the individual can be assessed without law enforcement involvement. This would allow parents, who know their child best, to make a case for psychiatric evaluation and/or an involuntary hold where necessary. This would also put the decision in the hands of the court where a neutral party could weigh the points presented, rather than asking police to make a subjective, liability prone, judgment call. That’s not to say that police response would be eliminated, or that training would not still be required, but perhaps it could help to ease the burden on law enforcement agencies.

 The Treatment Advocacy Center provides a state by state table detailing the involuntary commitment procedures in every jurisdiction. The law of the three model states is summarized below:

In South Carolina, “A person may be admitted to a public or private hospital, mental health clinic, or mental health facility for emergency admission upon: (1) written affidavit under oath by a person stating: (a) a belief that the person is mentally ill and because of this condition is likely to cause serious harm to himself or others if not immediately hospitalized; (b) the specific type of serious harm thought probable if the person is not immediately hospitalized and the factual basis for this belief; (2) a certification in triplicate by at least one licensed physician stating that the physician has examined the person and is of the opinion that the person is mentally ill and because of this condition is likely to cause harm to himself through neglect, inability to care for himself, or personal injury, or otherwise, or to others if not immediately hospitalized. The certification must contain the grounds for the opinion…[51]

In South Dakota, “If any person is alleged to be severely mentally ill and in such condition that immediate intervention is necessary for the protection from physical harm to self or others, any person, eighteen years of age or older, may complete a petition stating the factual basis for concluding that such person is severely mentally ill and in immediate need of intervention.[52]

Finally, in Delaware, “Upon the signed complaint of any person stating the person has knowledge that a designated person appears to be so mentally ill as to be likely to cause injury to oneself or others and to require immediate care, treatment or restraint, setting forth a description of the behavior and symptoms which led the person to the person’s conclusion, such alleged mentally ill person shall be promptly taken into custody by any peace officer of the State to whom the complaint is delivered without the necessity of a warrant.[53]

Here, these three states, allow “any person” to file a signed affidavit, petition, or complaint with the court setting forth evidence that an individual is in critical need of mental health services. These statutes allow families, like the Clark’s, to circumvent the criminal justice system and certify in civil court, under oath, why they believe their loved one is a danger to himself or others.

Conclusion

As it is written, the LPS Act is vague and may be subject to the “void for vagueness doctrine.” Furthermore, the Act is implemented in a system that does not require standardized training of the people to whom it gives the most power. The Act should be revised to include an easier process for admitting and treating mentally ill individuals involuntarily, but this does not suggest that probable cause and due process should be ignored. On the contrary, reform calls for clarified legislation and a comprehensive system founded on judicially certified evidence and testimony so as to prevent criminalization of the mentally ill.

Related posts:

Part 1 – Broken Part 2 – A Million Little Marbles Just Bouncing Around Updates The act of being “Unprivate” Part 3 – Wiles of the Nile