Many severely mentally ill Californians are cycling in-and-out of forced psychiatric holds due to a lack of treatment options when they’re released, according to a report this week from the state auditor.
The report looks at the Lanterman-Petris-Short Act, the California law that governs involuntary mental health treatment for people deemed a threat to themselves or others, or who cannot meet their own basic needs due to a mental illness.
This treatment can entail a short-term hold of up to 72 hours, an extended one of up to two weeks or a one-year conservatorship, where a government agency or family member becomes responsible for someone’s care.
County officials, law enforcement agencies and mental health groups throughout the state have been waiting for the audit for months. Many hoped the auditor would suggest changing the criteria for who is considered “gravely disabled,” to allow for more people to be compelled into treatment.
In his February State of the State address, Gov. Gavin Newsom suggested lowering the threshold as a way to better connect homeless individuals to care.
But the idea has faced resistance from advocates who feel involuntary treatment is a violation of civil liberties.
The auditor determined there was no reason to change the Act, and instead focused on the issue of people exiting involuntary holds and not immediately getting connected to follow-up services.
“People leaving LPS Act holds often need continuing mental health services,” the audit summary reads. “In particular, individuals who have experienced several short‑term holds represent a high‑need population that should be connected to counties’ most intensive community‑based care.”
When that care isn’t available, these individuals might end up incarcerated, on the streets or back in on a “5150 hold,” another term for a 72-hour involuntary stay in a facility.
The report looked at Los Angeles, San Francisco and Shasta counties. It found that, of nearly 7,400 people who experienced five or more short-term involuntary holds between 2015 and 2018 in Los Angeles County, only 9% were enrolled in assisted outpatient treatment or full-service partnerships in 2018-19. These are two strategies designed to keep people in their communities by providing them with housing, therapy, transportation or anything else they might need.
Kathy Day, a Sacramento-area caregiver for a family member with schizophrenia, said right now there’s no “step-down” from the hospital for mental health patients.
“We do that for people who have leg surgery or something like that — we put them in the skilled nursing facility for wound care, and then maybe physical rehabilitation or an at-home nurse,” she said. “The system needs to be held accountable for working with the patients.”
Counties are already required to run full-service partnerships to care for severely mentally ill people. But these programs can be expensive, because they deliver a wide array of resources to individuals, said Toby Ewing, executive director of the Mental Health Services Oversight and Accountability Commission, which monitors county mental health spending.
“We do know of scenarios where families are saying it’s too hard to get into a full service partnership,” he said. “There’s a range of barriers. It could be that capacity is limited.”
The report also points out that counties don’t have a way to track when someone comes off an involuntary hold, which can make it difficult to find them and get them into services.
The auditor recommends legislative action to give counties access to that information, and directs them to use money they receive from the state’s Mental Health Services Act revenue to connect people to help.
Mchelle Doty Cabrera, executive director of the California Behavioral Health Directors Association, says the audit doesn’t address people who get mental health help through Medi-Cal or a private plans after being discharged from a hold.
“It's sort of like it was designed to be fairly narrow,” she said of the state audit. “And there are so many other systems and elements that play into what our outcomes are ... It really wasn’t part of a comprehensive conversation.”
And the recommendations only address a sliver of the state’s mentally ill adults, added Sacramento Mayor Darrell Steinberg, who as a state lawmaker authored California’s Mental Health Services Act.
“The audit did not look at the tens of thousands of people on the street who would meet the definition of grave disability who never get help in the first place, who never get the 5150 designation or who don’t have any access to any system of care, whether it be voluntary or involuntary,” he said. “How do we get people into care in the first place?”
Los Angeles County said in a response to the audit that they rely on involuntary treatment to “ensure that every person in need is guaranteed access to the services to improve their quality of life,” but that the Act doesn’t give law enforcement enough latitude to compel people into care.
“We are mandated as a humane society to provide both surrogate decisions and requisite resources to those whose chronic illness and inability to accept resources due to their illness prohibits their ability to live safely in community,” the county wrote. “In order to realize such a commitment, modifications to the LPS Act and the definition of grave disability are necessary for individuals who are unable to live safely in the community.”
But some mental health advocates say that’s the wrong strategy.
“Coercion should never take the place of voluntary services that are available and accessible to people,” said Sally Zinman, executive director of the California Association of Mental Health Peer Run Organizations. “Meeting people where they’re at, providing services for the whole person, integrates them into the community.”
Over the years, efforts to expand the state definition for who can be forced into treatment have largely failed in the Legislature. The audit found “no evidence to justify any changes to the criteria” under the Lanterman-Petris-Short Act.
Still, some groups are pushing to change it.
The California Psychiatric Association is currently sponsoring a bill that could allow doctors to keep patients in a hold for an additional 14 days if they meet certain medical criteria.
“There is room for improvement in the legal standards that are over 50 years old and sometimes serve to thwart care to critically ill individuals. The LPS has not been updated in significant respects and should be,” Randall Hagar, a legislative advocate for the association, wrote in an email.
Some advocates have pointed out that people who are not aware of their own condition may never be convinced to voluntarily seek help.
Day says her family member with schizophrenia has never acknowledged his hallucinations as symptoms of an illness. He thinks they’re his superpowers.
For years, she says he cycled in-and-out of acute psychiatric facilities, where he was held for 72 hours, or sometimes longer. But the stays did little to improve his health in the long-term.
“He would just isolate in his room and pretend to sleep, he would get medications and had three meals a day,” she said. “And other than that, he paced the halls a lot.”
She ultimately gained conservatorship for him, and now he’s in a long-term residential treatment facility.
But many advocacy groups say the ultimate goal should be to keep people out in the community, connected to the care they need.
“Let’s not look at expanding the act, but instead let’s make sure we’ve got systems and structures and services available for individuals,” said Curt Child, legislative director for Disability Rights California. “Services need to be available upfront, to avoid any length of time of needing an involuntary hold.”
The Mental Health Services Oversight and Accountability Commission is working on a number of strategies to try to prevent severe mental illness, from investing in ways to identify psychosis early in life to strengthening the role of people who’ve lived with mental illness in delivering services.
“It would be really important for the state and the counties to collectively establish a goal of reducing reliance on involuntary care,” Ewing said. “The auditor is correct in suggesting we have to improve the way in which we serve people who are at high risk, but we need to look at this more through a prevention lens. The fifth time you’ve had an LPS hold, that’s too late.”
The auditor is also calling on the state to improve how it tracks county spending of mental health dollars, and whether that money is providing helpful services to mentally ill individuals.