Aug. 7 2013 10:02 AM

San Diego County inches forward in getting resistant mentally ill people into treatment


It's a question that's divided the behavioral-health community in San Diego: What's the best way to care for someone who's severely mentally ill and refuses treatment?

Near the center of the split is Laura's Law, legislation named for 19-year-old Laura Wilcox, who was gunned down in Northern California on Jan. 10, 2001, by a mentally ill man. Laura's Law says a person who meets certain criteria—refusing treatment, showing signs of being a threat to himself or others, a history of hospitalizations and/or incarcerations— can be court-ordered to follow a treatment plan. Advocates have dubbed the law "5149 1/2," a reference to 5150, the state code for the process under which a person can be involuntarily confined to a psychiatric facility. Laura's Law, advocates say, is supposed to catch someone before the point of forced hospitalization, incarceration or worse. They say the law succeeds via what they call "the black-robe effect"—the authority of a judge seems to compel people into treatment.

But because the law allows counties to decide whether or not to enact it, only tiny Nevada County (population 97,000), where Wilcox lived, has done so. Late last month, supervisors in Yolo County agreed to a one-year pilot.

San Diego County's position on Laura's Law depends on whom you talk to. Supporters of the law left a July 30 Board of Supervisors meeting "discouraged," says Theresa Bish, who in 2011 was chair of the county's Mental Health Board—which advises the supervisors on policy matters—when it voted in favor of implementing Laura's Law. County staff, however, called the law "flawed" and shelved further discussion until earlier this year, when Supervisor Dave Roberts, the first Democrat to be elected to the board in more than 20 years, made the issue a priority. 

"There was momentum," Bish says.

In March, Roberts and Supervisor Dianne Jacob asked county staff to take a close look at how Laura's Law compares with existing county programs—particularly an outreach program, still in the pilot stage, targeted at treatment-resistant individuals—and recommend next steps. Those next steps, approved by supervisors at the July 30 meeting, included expanding the In Home Outreach Team (IHOT) from a regional to countywide program and to hold off on Laura's Law pending state legislation aimed at clearing up questions about how the law's services are funded.

But Bish said advocates hoped to see a clear directive from Roberts and Jacob to have county mental-health staff actively work toward crafting a plan for a Laura's Law pilot program.

"Laura's Law saves taxpayer money and assists the severely mentally ill, and IHOT doesn't do either," Bish says. "It is derelict to wait further when lives are at stake."

Indeed, a 2012 Nevada County Grand Jury report showed that for every $1 the county invested in Laura's Law, it realized nearly $2 in savings from reduced hospital and jail stays by participants.

But Roberts sees last week's vote as progress rather than delay. Expanding mental-health services, he says, was a huge step for a board that's been criticized in the past for not doing enough for people in need.

"To me, the vote last Tuesday—a unanimous vote—was probably the biggest success in my first seven months on the Board of Supervisors," he says. "What we specifically did was begin to change the dialog and really focus on why mental-health services are so important.

"You have to remember, not all of my colleagues are going to support Laura's Law," Roberts adds, "so you have to take incremental steps in order to get to where you want to go from a policy perspective, and you have to make sure that you're covering all the needed ground."

While there's been ongoing debate over the effectiveness of forcing someone into treatment, the key issue hanging over Laura's Law is how to pay for it. Nevada County used state money earmarked for mental-health services after getting the OK from the California Department of Mental Health. But in Orange County—where supervisors considered enacting Laura's Law after Fullerton police beat to death Kelly Thomas, a schizophrenic homeless man, in 2011—county lawyers said state funds could be spent only on voluntary treatment programs; Laura's Law's court-ordered treatment makes it an involuntary program, they said. Earlier this year, state Senate President Pro- Tem Darrell Steinberg introduced SB 585, legislation that would allow state mental-health dollars to be spent on Laura's Law.

"We're hoping [SB 585] will pass and will legally clarify this, because any time a large county gets involved in this, you know we'll immediately be the subject of a lawsuit, so we have to be very, very careful," Roberts says.

Alfredo Aguirre, the county's director of behavioral health services, believes the county's got a good thing in IHOT. It's voluntary and it reaches Laura's Law-eligible folks, in addition to people who haven't deteriorated to the point of meeting Laura's Law criteria.

"We have a pretty good idea that the majority of people we outreach do engage. It takes time sometimes," he says.

In an October 2011 interview, Aguirre told CityBeat that IHOT, which cost $1.1 million in its first year, was expected to help between 300 and 360 people. But, according to a county study, of 402 people referred to IHOT in 2012, 173 were deemed eligible (referrals might not have lived in the pilot area). Of those, 73 entered the "engaged" phase, meaning the individual or family members were receptive to being connected to services. Out of the 73, only 14 were successfully linked up to services.

Bish calls it "a very expensive referral program" that fails to reach enough people.

"The numbers who are treated are so miniscule compared to the need," she says.

But Aguirre urges patience. 

"Most of these people we're still doing outreach to and still engaging with," he says. "These are people who have traditionally turned down the services we have. It takes time."

Bish doesn't understand why Laura's Law can't be seen as one more tool to get people into treatment. Nevada County might be too small to compare to San Diego, but Bish is ready with an analogy:

"It's like saying to a drug company that's gone through a clinical trial, ‘We're totally going to ignore that.' Nevada County is that clinical trial."

Email or follow her on Twitter at @citybeatkelly.


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