San Francisco Courts Will Order Mentally Ill Into Treatment

On Christmas Eve in 2012, 62-year-old William Spengler set a house on fire in Webster, New York. When firefighters arrived on the scene he started shooting with an assault rifle, killing two and wounding two others in the process.

Spengler was already a convicted murderer. In 1981, he was sent to prison for 18 years for killing his 92-year-old grandmother by beating her with a hammer. Parole records indicate he spent the early part of his sentence in a corrections facility for those with mental health issues and he received treatment for anger and violence.

Politicians, mental health officials, and activists alike argue the Christmas Eve shooting could have been prevented through court-ordered, mandated outpatient treatment for individuals who have previously been arrested or admitted to a hospital with a mental illness, but do not seek medical care.

On Tuesday, San Francisco’s Board of Supervisors took a step towards this kind of outpatient commitment program after voting to enact Laura’s Law — state legislation that took effect in California in 2003. A final vote will take place on July 15. The law established an assisted outpatient treatment (AOT) program that allows a judge to issue an order requiring a patient who meets certain criteria to seek care.

According to the bill, a person must suffer from a mental illness, while not able to “survive safely in the community without supervision.” There must also be a history of not complying with mental health treatment. An individual must also have a history of hospitalization related to their illness within the last three years and violence within the last four.

Jamie Mondics, the communications director at the Treatment Advocacy Center in Washington DC, told VICE News that San Francisco’s vote to implement Laura’s Law, gives the city a “critical lifeline for patients who refuse treatment and end up on the streets, are a risk to themselves or others, in jail or worse.”

“The implementation of Laura’s Law is one step closer to ensuring that people with severe mental illness in California have access to treatment before a tragedy occurs,” she said.

But while many are in favor of the law, there is a vocal constituency firmly against assisted outpatient treatment, both in San Francisco and the rest of the country. According to the Los Angeles Times, at the hearing on Tuesday, representatives with the Mental Health Association of San Francisco wore t-shirts that said: “Force is the Opposite of Treatment. Demand Dignity Now.”

Eduardo Vega, executive director of the Mental Health Association, told VICE News that while his organization agrees with the enhanced services that come along with Laura’s Law, it does not agree with the aspect that “compels people to seek them.”

Citing concerns for civil rights, Vega said that these type of policies “can lend themselves to abuse.” He added that in many of the violence and murder cases cited by politicians and advocates in favor of the policy, the patient wouldn't have actually met the criteria.

"In general, outpatient commitment is not a useful strategy to pursue," Jennifer Mathis, the deputy legal director at Bazelon Center for Mental Health Law, told VICE News. "There's no evidence that it's a court order that makes a difference, it seems to be the services they are getting that are otherwise unavailable."

This debate is not exclusive to San Francisco. In fact, it has been going on throughout the US between various actors in the mental health community for decades. There are currently 45 states in the country that have passed some form of outpatient commitment legislation.

But the extent to which these laws have been implemented varies wildly. In California, only three counties — not including San Francisco — have put Laura's Law into effect. Mondics says 12 states rarely use court-ordered outpatient commitment treatment, including eight with specific AOT statutes. The cost of implementation has been one barrier.

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In other issues, Dr. Tom Burns, social psychiatry chair at the University of Oxford and an early advocate of the practice, told VICE News that when the idea first came up in the 1980s initial rejections revolved around civil rights violations.

According to Vega, these policies further drive the oppression of a minority group already facing stigmatization. “Seeing this measure pass in San Francisco, a haven for progressive thought, individual liberty, and compassion, is especially disturbing,” he said.

Dr. Paul Appelbaum, the director of law, ethics, and psychiatry at Columbia University’s psychiatry department, told VICE News he understands the sensitivity of the idea that these laws will diminish someone’s civil liberties.

“But that’s just not what these laws are about,” he said. “The opposition is misdirected towards an imagined scenario that, in fact, is not possible under any of these existing outpatient statutes.”

According to Dr. Appelbaum, these policies are far from coercive and do not give the courts a mechanism for forcing care or medication on a patient. If a patient does not show up to treatment, someone can be sent to escort them there, yet little legal action can be taken.

But Dr. Burns, who has begun rethinking outpatient commitment after a study he conducted found the practice ineffective, said you are still taking someone’s personal choice away and so must decide whether the outcome is worth it.

“If you’re going to expose someone to some sort of restriction, the benefit to the patient should be at least comparable to what you’re taking away from them,” he said.

There are three main studies on AOT. One dissected North Carolina’s AOT program and another looked at the system in New York, both conducted by Dr. Marvin Swartz at Duke University. The third is by Dr. Burns, which was an analysis of the UK program that he helped pass.

According to Dr. Burns, his 2013 study “found zilch, not a single bit of difference.” He said it was embarrassing to disprove his own life’s work, but his research found mandated outpatient therapy did not make any difference to hospital re-admittance rates, nor to the duration of stay or the severity of symptoms.

“The bulk of evidence is saying mandated outpatient treatment doesn’t work in its primary aim of keeping patients well,” he said.

Dr. Swartz, however, told VICE News that his 1999 North Carolina study found a patient under court ordered AOT for more than six months was less likely to be re-hospitalized or arrested.

His 2009 paper on New York state also found people under court order were less likely to be hospitalized. The program is utilized there more than any other state, with 2,500 total patients in the system in 2013.

Dr. Swartz said the court order definitely added an ingredient to these results. But the success of New York’s program could speak to the all-around better services it offers.

The state of New York allocates $32 million annually to its AOT program, with an additional $125 million for statewide expansions — including both AOT and non-AOT services.

While we still don’t know exactly why they work, Dr. Appelbaum said the prioritization of access to services for these AOT patients is a key factor. He explained that this forces the health system to commit to the patient, making it less likely for individuals to fall through the cracks.

“There have been a number of states who have passed outpatient commitment programs and never funded them,” he warned though. “Unless funding is enabled to deliver the impact, just passing a statute isn’t going to do anything.”

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Follow Kayla Ruble on Twitter: @RubleKB

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