Helping mentally ill people: The debate over ‘involuntary treatment’

Lee Davis says flatly that without involuntary treatment for her raging psychosis, she would be dead. “It saved my life.”

A mental health activist, she chairs the Alameda County Mental Health Advisory Board, which advises the board of supervisors and county officials on mental health policy. Davis acknowledges hers is not a popular view among disability rights advocates, who largely oppose any kind of “forced” treatment for mental illness.

Involuntary treatment is at the core of the intense debate over Gov. Gavin Newsom’s proposed California CARE Court plan to help the mentally ill.

“I fundamentally disagree with the notion that everybody is in a position to make a decision voluntarily.” — Lee Davis

“While I was ill, I was a danger to myself,” Davis told a virtual forum sponsored by Disability Rights-California, which strongly opposes involuntary treatment and organized the March 10 “town hall” to air opposition to a far-reaching Newsom administration plan for court-ordered treatment. “I thought I could fly. I almost jumped off a building.”

“I fundamentally disagree with the notion that everybody is in a position to make a decision voluntarily,” Davis added, a distinct outlier in the town hall testimony. “I was absolutely in a different state of consciousness and needed help. I’m so glad I was involuntarily committed and stabilized, and now I’m in a position to speak for people who have had that experience.”

She likens the altered consciousness and delusions that characterize serious mental illness to dementia, and says people in the throes of psychosis deserve the same medical interventions as those with so-called “physical” illnesses – a concept rapidly gaining ground in mental health policy and law.

“You wouldn’t leave an elderly person in a state of mental confusion to just fend for themselves,” she said.

In one of several recent interviews with Capitol Weekly, she said she sometimes feels “like a lone ranger” among disability rights activists, “but I still have to speak to the issue based on my own experiences.”

Davis, 47, is bipolar, and has survived two major psychotic breaks that ultimately landed her in jail, where increasing numbers of mentally ill people are detained, at huge public and human cost.

In 2009, while actively psychotic and refusing treatment, Davis was taken to the notorious Santa Rita Jail in Alameda County following an argument with a friend.

Unlike many others, she lived to tell the tale, and credits the involuntary treatment she received with setting her on a path to long-term recovery. With degrees in anthropology (UC-Santa Barbara) and civil engineering (California State University, Sacramento), she works fulltime as an electrician and has become a prominent activist on mental health issues, openly challenging the prevailing view among civil rights groups that mental health treatment must be entirely voluntary.

She is also a writer and illustrator, and her articles  about her own struggles with bipolar disorder have been widely published.

In 2009, while actively psychotic and refusing treatment, Davis was taken to the notorious Santa Rita Jail in Alameda County following an argument with a friend who was trying to get her into treatment.

“I was belligerent, as is common for people in psychiatric distress,” she wrote in a March 23 letter to the state Health and Human Services Agency, which sought public comment on Newsom’s sweeping CARE Court proposal to overhaul California’s mental health system, requiring court-ordered treatment in all 58 counties.

“I was denied medication, and then was released in the middle of the night, floridly psychotic, with only a bus ticket. It is a miracle I found my way home safely.” Soon after, she was involuntarily detained on a mental health hold, and taken to a psychiatric facility rather than jail.

“I have had the opportunity to recover,” she wrote in a 2019 article, “Being Bipolar” published on Medium, in which she acknowledged the strong support from family, friends and “a deeply compassionate and gifted personal therapist.” And she has long been, “by choice, medication-compliant and, equally important, as a matter of luck, consistently responsive to medication.”

“It was like watching your child slow-walk off a cliff, and not being able to reach them.” — Cheryl Davis

Calling her recovery “more anomaly than standard,” she said too many individuals with serious mood disorders “cycle in and out of hospitals and jail, disproportionately experiencing homelessness and early death. Our systems fail.”

In video testimony for a recent Washington, D.C., conference of the National Alliance on Mental Illness (NAMI), an influential national organization representing families, Davis said opposition to all forms of involuntary treatment is “irresponsible” and ignores the reality of resistance to treatment while deeply psychotic. “I received treatment when I did not want treatment, and it saved my life.”

Her mother, Cheryl Davis, spoke in the video of trying to get her adult daughter into treatment, and instead learning that she had been jailed.

“It was like watching your child slow-walk off a cliff, and not being able to reach them,” she said, her voice breaking. Unlike many others with fewer resources, who end up in jail as a result of their mental illness — often for months or even years without trial, while awaiting sanity evaluations in badly backlogged state mental hospitals — Davis was not charged.

Persistent debate over the legal limits of mental-health treatment is at the heart of Newsom’s Community Assistance, Recovery and Empowerment (CARE) Court  plan, which would create an entirely new system of civil court oversight, combined with intensive treatment, housing and support systems.

Newsom estimates 7,000-12,000 people would be helped annually by a CARE Court system.

Unlike other court-involved mental health programs – Laura’s Law or Assisted Outpatient Treatment (AOT) in civil court, and Mental Health diversion programs in the criminal courts – CARE Court would be mandatory in all 58 counties, with potential court sanctions against counties that fail to provide required care and supervision.

Currently the subject of heated debate in the state Legislature, the plan is designed to help thousands of seriously mentally ill people who are clearly unable to care for themselves, yet refuse help, wandering the streets – and often dying there — or cycling through hospital ER’s and stuck in overcrowded, dangerous county jails ill-equipped to help them.

Newsom estimates 7,000-12,000 people would be helped annually by a CARE Court system, which does not replace existing programs such as Laura’s Law, the 2002 law that gives family members one of the few legal tools to get mentally ill relatives into treatment.

Critics say counties have been slow to adopt effective AOT programs, despite compelling evidence that such programs help stabilize participants, keep them out of hospital ER’s and jails, and save public funds.

Nor does the Newsom plan propose significant change to the 1967 Lanterman-Petris-Short (LPS) law that has dictated mental health policy in California for more than half a century. It was passed in response to abuse and forced treatment of mentally ill and developmentally disabled people in state mental hospitals, which were largely closed in the 1960s and ‘70s. The law has since been widely criticized  – including by its three bipartisan authors — as outdated, overly restrictive, and leading to the current mental health and homelessness crisis in cities throughout California.

“One of the important and early strategic policy decisions the governor made was not to attempt a significant reform of LPS or Laura’s Law.” — Jason Elliott

Several major bills to improve a fractured community mental health care system and reform LPS are currently before the Legislature – including an eight-bill package by Sen. Susan Eggman, D-Stockton, a former social worker and social work professor who has long been at the forefront of mental health policy in California and is also co-author of an administration-backed CARE Court bill currently before the state Senate.

The governor decided early-on not to propose major changes in LPS, historically regarded as the untouchable “third rail” of mental health policy in the Legislature, which has repeatedly failed to enact substantive LPS reform.

“One of the important and early strategic policy decisions the governor made was not to attempt a significant reform of LPS or Laura’s Law,” said Newsom’s senior counselor, Jason Elliott, who has advised the governor on homelessness and mental health issues for many years, starting in 2009 as policy director and later chief of staff to Newsom when he was mayor of San Francisco.

Noting that LPS reform has long generated contentious policy debates over individual rights, Elliott told Capitol Weekly in a May 5 interview, the result has been “many decades of battle scars, hurt feelings and entrenched opinions.”

“Sometimes to make a real policy breakthrough,” he added, “you need to cut a new path.”

The administration-backed CARE Court bill, SB 1338, by Eggman and Sen. Tom Umberg, D-Santa Ana, has overwhelmingly cleared two major committee hurdles.

Confronting a tight timeline for a massive proposal first unveiled in early March, the administration is pursuing the CARE Court plan through intense policy and budgetary debates in the Legislature, aiming for full adoption by the start of the new fiscal year July 1. Statutory adoption of the state budget is required by June 15.

“You take it one step at a time, one committee at a time, and convince as many members as you can that you’ve got a good idea,” Elliott said of the legislative process. “We’ve been through two committees, 19 ayes, zero nays. There has been a lot of ink spilled on the so-called hurdles, and certainly we’re not expecting an easy glide path to the governor’s signature. But I want to push back on this notion that we have this steep, double-black diamond ahead of us.

“No committee in the Legislature is an easy committee. These are people who take their work and their responsibility very seriously. . . .We’re putting all of our efforts into every committee and vote as it comes before us. Step by step, we will get this done.”

The administration-backed CARE Court bill, SB 1338, by Eggman and Sen. Tom Umberg, D-Santa Ana, has overwhelmingly cleared two major committee hurdles — the Senate Judiciary and Health committees —  in the Senate, where it is expected to pass.

But the measure faces an unknown future in the state Assembly, where mental-health reforms have often met with stiff opposition and multiple amendments in the Assembly Judiciary and Health Committees.

Although CARE Court was originally unveiled as part of the governor’s annual budget proposals, Elliott said Assembly Speaker Anthony Rendon called for a “full policy process” in the Legislature, “not just the budget process.”

A companion Assembly bill to the Eggman-Umberg CARE Court bill, by Assemblyman Richard Bloom, D-Santa Monica, was abruptly tabled in Assembly Judiciary last month after the governor’s office and key legislators reportedly rejected extensive proposed amendments. That leaves the Senate bill, which Bloom supports, as the sole policy measure to move through a series of lengthy and often heated committee sessions.  The measure could still be adopted through the budget process alone.

Funding for behavioral health programs is notoriously complex, coming from multiple state, federal and local sources

Regardless of the legislative hurdles, and citing broad support for the proposal from local officials and mental-health advocacy groups, the administration is moving forward with significant funding in the state budget to establish CARE Court in all of California’s 58 counties beginning July 1.

Following release of the governor’s May budget revision on Friday, which included $65 million  in additional funding to create CARE Courts in the counties, even supporters of the plan said it remains short on key details.

Funding for behavioral health programs is notoriously complex, coming from multiple state, federal and local sources. Twelve billion dollars in multi-year state funding was approved last year for homelessness and mental health programs, and $4 billion for improved children’s mental health, with another $2 billion this year in the 2022-23 proposed state budget.

Additional funding is provided by the Mental Health Services Act, the 2004 ballot measure to tax the wealthiest Californians, which has provided billions for mental health care and is expected to add another $3.8 billion this year.

County officials, including judges and public defenders, remain concerned that significantly more funding – and staff — will be necessary to create and maintain the CARE Courts and related support services, particularly for the severely mentally ill people targeted by the proposal.  The governor’s office says it will continue working with state and local officials to implement and fund the program.

In order to achieve even “baseline stability,” some will need “a lot of inpatient time to get better, and medications throughout the process.” — Randall Hagar

Randall Hagar, a veteran mental health policy expert who is legislative advocate for the Psychiatric Physicians Alliance of California, said psychiatrists support the proposal but “are a little skeptical without more details.”

“Some of the people who meet the criteria for CARE Court have been on the streets for so long, it’s hard to imagine them needing less than the complex treatment that is only available in inpatient facilities — and then, once they are discharged, supportive housing. Both are in short supply.”

In order to achieve even “baseline stability,” Hagar added, some will need “a lot of inpatient time to get better, and medications throughout the process.”

He also shares concerns among CARE Court supporters that the proposal does not address deep, systemic failures in existing law, primarily Lanterman-Petris Short.

“We considered everything under the sun,” Elliott said. “And we settled on CARE Court as the path forward. . .We’re certainly engaged in substantive policy discussions with opponents of CARE Court, [but] I don’t anticipate that we’ll earn the support of entrenched activists.” And, despite county indignation about potential sanctions, the administration is not backing down on a plan that could result in stiff penalties against counties that don’t comply.

“Laura’s Law was one of the best tools we had, as an option to conservatorship.” — Karen Larsen

Elliott disputes widespread criticism that the plan entails “forced” treatment. “There is a court-ordered care plan,” he said. “There is not a locked door.

“Those who are opposed will say you’re forcing people into a carceral (incarceration) system that takes away their rights, and I say no, with respect, that’s the system that has existed in California for decades. CARE Court is trying to take people out of that system, to divert people out of the in-custody system and get them the care they need.”

Although often viewed as involuntary court-ordered treatment, the 20-year-old civil-court Laura’s Law program on which CARE Court is based, is usually voluntary.

“We rarely had to go to court,” said Karen Larsen, former director of the Yolo County Health and Human Services Agency, now CEO of the Steinberg Institute, the mental health policy nonprofit founded by Sacramento Mayor and former state Senate President Darrell Steinberg, who was the author of major mental health legislation spanning decades, including the 2004 Mental Health Services Act.

“Laura’s Law was one of the best tools we had, as an option to conservatorship,” she added. “I understand the distrust and fears of coercion [in the CARE Court proposal], but I just don’t see any evidence in this bill, or the potential for it.”

Santa Clara County Superior Court Judge Stephen Manley — whose Mental Health Courts have diverted thousands of defendants from the criminal court system and is widely praised as setting the “gold standard” for such courts in California and throughout the country — strongly supports the governor’s proposal. He joined Newsom on the podium during a March 3 press conference to announce the plan at a mental health facility in San Jose.

Manley is also critical of opposition to the proposal.

“If we don’t try new approaches and keep complaining that things aren’t working, we’re really not moving forward,” he said in one of several recent interviews with Capitol Weekly. “CARE Court will take the most difficult clients with the greatest challenges, who are seriously mentally ill, and give them support and monitoring by the court. It will demonstrate that they can in fact be helped in the community.

“We need to stop trying to fix a failed system. We are rapidly moving back to where we were 100 years ago, where the answer for the mentally ill was simply to incarcerate them in a hospital and keep them there until they die.

“Mental health is a real crisis in our court system, and mental illness is not a crime.”
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Editor’s Note: Sigrid Bathen is a Sacramento journalist and former Sacramento Bee reporter who taught journalism at Sacramento State for 32 years. She has long covered mental-health issues, for several publications, and her writing has won numerous awards. She has covered health care, education and state government for Capitol Weekly since 2005. Her web site is www.sigridbathen.com. She can be reached at [email protected].