[Noozhawk’s note: Noozhawk is following the ordeal of Rich Detty, a Santa Maria man whose son, Cliff, died while under restraints at a Santa Barbara County psychiatric health facility in April. Click here for the first story in the series.]
Noozhawk reporter Lara Cooper’s heartbreaking series on the life and death of Cliff Detty highlights much that is wrong with mental health care in California (and most other states):
» A severe hospital bed shortage that impels the system to turn away people in need of inpatient care
» Poor training of police officers on the nature of mental illness and the legal standards for involuntary detention
» A warped conception of “confidentiality” that slams doors on the very loved ones whose inclusion is essential to recovery
» In some cases, the questionable and unsupervised use of restraints in hospitals
But each of these failures represents a breakdown in the mental health system’s response to crisis. Equally sad is that Detty’s mental health crisis on that fateful April day might have been avoided altogether if Santa Barbara County had implemented Laura’s Law, California’s law for court-ordered “assisted outpatient treatment.”
Laura’s Law was signed by Gov. Gray Davis in 2002 and named in honor of Laura Wilcox, an idealistic young Californian shot and killed on her job at a public mental health clinic in Nevada City by an actively psychotic, untreated mentally ill man. The law is designed to squarely address the problem that causes some people with severe mental illness to reject prescribed treatment, dooming themselves to terrifying hallucinations and delusions, homelessness, repeated hospitalizations, jail and violence.
The clinical term for the problem is “anosognosia,” or lack of insight. For many people with schizophrenia or bipolar disorder, a corollary of their disease is an inability to recognize that anything is wrong with them.
As may have occurred in Detty’s case, this is often mistaken for “denial.” But anosognosia is critically different. Denial is a coping mechanism in which the person really knows the truth, deep down. With the aid of a good friend or therapist, he will hopefully come to admit it to himself. By contrast, anosognosia is a physical disorder of the brain in which the person does not know that he or she suffers an illness, on any level. And unfortunately, the medication that stabilizes the person and keeps the demons at bay doesn’t always restore insight. When such an individual is stabilized, released from a hospital and left to his own devices, he soon abandons treatment and falls back into the cycle of deterioration.
The solution under Laura’s Law is to substitute the reasoned judgment of an impartial court for the impaired judgment of the patient. The process begins with a request to the mental health department, usually by a family member, treatment provider or law enforcement officer, to investigate the person’s qualification for the services. This request by itself can put the system on “high alert” that the individual needs intervention. If the mental health director finds the criteria within the law to be met, she can then petition to the court, for an order directing the person to comply with a specific community-based treatment plan. In granting the order, the court also directs county mental health authorities to ensure that the individual’s needed services are provided, including intensive case management.
The assisted outpatient treatment order does not use punishment or involuntary administration of drugs to a person who fails to comply. Instead, it works to keep the person from straying off the path of treatment, in three basic ways:
» Through the symbolic power of the court — sometimes called “the black robe effect” — it impresses upon the patient the need to commit himself to treatment, even if he doesn’t see it himself
» It makes treatment providers accountable to the court and ensures consistent, coordinated services
» It provides for careful monitoring so that noncompliance may be detected early, and appropriate steps may be taken to get the person back on course before tragedy strikes
Anyone wondering whether this works should examine the results of two recent studies of New York’s Kendra’s Law, upon which Laura’s Law was modeled.
One study, led by Duke University researchers, documented steep declines in rates of homelessness, incarceration and hospitalization. (Fiscal hawks take note: These represent enormous categories of avoided costs to local government, far exceeding the costs of providing decent outpatient care.)
The second study, from Columbia University, examined Kendra’s Law’s impact on public safety in New York City and found that after assisted outpatient treatment, patients were four times less likely than members of a control group to perpetrate serious violence.
There is, however, one major difference between Kendra’s Law and Laura’s Law. In New York, all counties were mandated to create assisted outpatient treatment programs immediately. In California, lobbyists managed to insert a “poison pill” into Laura’s Law, restricting it to counties whose boards of supervisors affirmatively vote to implement it. By all accounts, the counties whose supervisors found the political will to pass that resolution are thrilled with the results. Counties that have used lame excuses not to follow their lead continue to waste money and lives.
Citizens shouldn’t let them get away with it. If I lived in Santa Barbara County, I’d bring the sorrowful story of Cliff Detty’s trashed life to the next Board of Supervisors meeting, and I’d demand to know: When will you implement Laura’s Law?
— Brian Stettin is policy director of the Treatment Advocacy Center, a national nonprofit organization based in Arlington, Va., that works to remove legal barriers to treatment for people with severe mental illness. As a New York assistant attorney general in 1999, Stettin helped to draft the New York law upon which Laura’s Law was modeled. From 2005 to 2006, Stettin served on the New York Office of Mental Health’s Assisted Outpatient Treatment Quality Improvement Panel.
Related Stories
» Click here for the first story in Noozhawk’s series on the Cliff Detty case: While Son Struggled with Mental Illness, Father Fought His Own Battle
» Click here for the second story in Noozhawk’s series: Seclusion, Restraints and Screams Marked Man’s Final Hours at Psychiatric Unit
» Click here for the third story in Noozhawk’s series: Seclusion and Restraint Practice Poses Risks, Prompts Questions
» Click here for a Noozhawk slide show.
» Click here for mental health care resources that are available 24 hours a day.