For years, former Mountain View resident Jeffrey Middlebrook said he watched his son crumble after returning home from military service.
Suffering from severe post traumatic stress disorder (PTSD), he said his son Kenneth attempted suicide multiple times, grappled with drug addiction and simply could not stick to a treatment regimen that would get his life back together. Things bottomed out in 2014, when his son was arrested after an erratic episode in which he kidnapped two women.
Looking back, Middlebrook said he believes the court system failed his son and that the loose, voluntary nature of his son's mental health treatment plan was doomed to fail. There was no way his son was going to comply without a stronger push.
"None of this would have happened had the treatment programs for guys like my son been court-mandated," Middlebrook said.
Over the next two months, Santa Clara County's Board of Supervisors will debate whether to implement Laura's Law, which could drastically change the way the county treats residents suffering from severe mental illness. The state law allows counties to compel a small subset of the mentally ill into mandatory treatment — with a court order if necessary — using intensive outpatient services.
Supporters of the law say it's about time and that Laura's Law would offer a real path to recovery for patients who have been failed by the county's mental health system. They point to homeless people on the street, many of whom are suffering from a mental illness and unable to care for themselves, as visible proof that the change is sorely needed.
Others caution that Laura's Law is not a panacea for the state's mental health woes, and that taking away the civil liberties of patients who could be served by voluntary programs is a critical drawback.
Advocacy groups including the Law Foundation of Silicon Valley say the real problem is a fragmented mental health care system and a lack of housing for the people who need it most. Coercion, they say, is not the solution.
The emotionally charged back-and-forth has already caused a rift at the county level. Behavioral health officials say the county should stay the course and not implement Laura's Law, calling it unnecessary and potentially ineffective. But at a meeting last month, two county supervisors said they are keeping an open mind.
"The system is still not working for too many folks in the community," county Supervisor Joe Simitian said. "I see too many folks out there who we're still not able to help."
A long-ignored law gains traction
The California Legislature passed Laura's Law in 2002 following a groundswell of support from mental health advocates who worried that the status quo was untenable. People without care who were psychotic could not be forced into treatment unless they posed an immediate threat to themselves and others — a high bar that was tantamount to waiting until the problem gets worse.
The law is named after Laura Wilcox, a 19-year-old woman who was shot and killed by a schizophrenic man at a mental health clinic, where she volunteered as a receptionist. It sought to create a middle ground between voluntary treatment and a short-term emergency psychiatric hold, compelling patients into what's called assisted outpatient treatment (AOT) that can be mandated by a court judge.
The law closely mirrors Kendra's Law, which went into effect in New York in 1999, with one key difference. Counties in New York were required to implement Kendra's Law and provide assisted outpatient treatment, whereas California counties have a choice. Los Angeles was the only county to even attempt to implement Laura's Law in the first five years after its passage, and to date, a majority of California counties still do not provide assisted outpatient treatment.
A new state law is looking to change that. Assembly Bill 1976, passed last year, will automatically require counties to implement Laura's Law unless they explicitly decline through a resolution that gives a clear rationale for the denial. State Sen. Susan Eggman (D-Stockton), who authored the bill, said it's obvious that too many people who need help are refusing treatment. The proof is right there on the streets, she said.
"I don't think anyone can drive around and say things have not changed drastically in the last 20 years, in what mental health and homelessness look like," Eggman said. "It looks like a crisis on our streets."
Eggman, who had a career in social work before joining the state Legislature, said the problem is personal to her. She had an aunt who was bipolar and was psychotic, and her family tried desperately to get her help. But in California, the idea of compulsory mental health treatment has fallen out of favor: State psychiatric hospitals have shuttered, and people tend to bristle at the idea of involuntary commitment.
"We used to lock people up, and now we went so far to the other side that we aren't providing care to the people who need it," she said.
Johnny Khamis, a former San Jose councilman, has relentlessly pushed the county to adopt Laura's Law for years, and said the unwillingness to implement court-mandated treatment amounts to sending sick people out onto the street. Families have loved ones who aren't getting the intervention they need, he said, while businesses have to tolerate verbal and physical assaults by people suffering from severe mental illness.
"The fact of the matter is the people who are running into traffic and hitting their heads into a wall are not making good decisions for themselves to begin with," Khamis said. "I think it's a lack of compassion not to use Laura's Law."
Walking away from treatment
Kenneth Middlebrook served more than two years in the U.S. Army before being discharged in June 2012. During that time, he suffered a traumatic brain injury and returned with PTSD that required residential treatment. Four months after his return, he jumped off the roof of a three-story building.
Jeffrey Middlebrook said his son has been haunted by his experiences in Iraq, including an incident in which an improvised explosive device blew up his vehicle and decapitated members of his group. Since his return, he became addicted to drugs including methamphetamine, has been arrested several times and fell in and out of homelessness.
It was clear that his son's situation was deteriorating, but it felt impossible to do anything about it, Middlebrook said. He laments that the courts failure to commit his son to rehab while he was only facing misdemeanor drug offenses.
In April 2014, Kenneth Middlebrook approached a 19-year-old Alviso woman and asked for a ride to Mountain View, according to court records. When they arrived, Middlebrook reportedly got agitated, grabbed her phone and threatened to snap her neck, according to the victim's statement. He demanded that she drive them both to Palo Alto, and while en route the victim intentionally crashed into another car in order to get help, court records said.
Later that day, he entered the home of a 61-year-old Mountain View woman and forced her into the passenger seat of her car before driving the vehicle out to the city of Ione, 40 miles southeast of Sacramento, according to court records. He got out of the vehicle and wandered off.
The episode led to two felony convictions and sparked three years of fruitless referrals for mental health treatment. Santa Clara County Superior Court records show he was released to Red Road Recovery in San Jose for treatment and walked away after just one day. He attempted treatment at the San Francisco Adult Rehabilitation Center later that month and walked away after five days. He was offered treatment by Veterans Affairs in San Francisco but refused.
"Kenneth has walked away from three programs, failed to engage in treatment, and has not reported to offices of adult probation," probation officer David Villalon wrote in January 2018.
After two years in jail for the 2014 felonies, Middlebrook was released but unstable, getting arrested and taken into custody every few months due to probation violations. The cycle abruptly ended in November 2018, when he was arrested and later convicted for possession of child pornography. He remains in state prison, with possible release in 2022.
Jeffrey Middlebrook said he would emphatically support Laura's Law in Santa Clara County and that it was "non-stop frustration" to get his son to stay in any VA treatment programs, which he said make the false assumption that every veteran is mentally capable of making the right decisions for themselves.
"None of this would have happened had the treatment programs for guys like my son been court-mandated. It blows my mind that the VA doesn't realize that guys like my son need to be forced into treatment programs," Middlebrook said. "The system failed my son miserably."
Early success with outpatient treatment
While Santa Clara County remains steadfast in its opposition to Laura's Law, other Bay Area counties have warmed up to the idea in recent years. San Francisco launched its assisted outpatient-treatment program in 2015 and found participants were more likely to stick with a treatment regimen and less likely to end up in a hospital or in jail.
San Mateo County has provided assisted outpatient treatment for the last five years through the nonprofit Caminar, which has a cadre of mental health professionals and social workers helping roughly 50 clients at a time. Fewer than 1% of have been incarcerated or admitted into an inpatient psychiatric hospital since enrolling in the program, said Mark Cloutier, Caminar's chief executive officer.
Cloutier said that Laura's Law, despite being conflated with a loss of autonomy, is actually a last-ditch effort to save someone's civil liberties. Without intervention through assisted outpatient treatment, people with severe mental illness who are not getting treatment could very well end up in a conservatorship, which would shatter all pretenses of personal liberty by putting treatment decisions in the hands of someone else.
"It's important to think of AOT as an extra level of protection for clients that gives them an opportunity for compliance before the possibility of being conserved," Cloutier said.
Laura's Law is also written with precise language that tightly limits who can be forced into treatment. They must be an adult with a severe mental disorder and be "unlikely to survive" in the community without supervision. They also have to demonstrate a history of failing to comply with voluntary treatment and that their illness has resulted in one or more serious or violent incidents in the last two years.
It's a narrow approach, yet Cloutier said he worries some advocates think that Laura's Law will clean up the streets or somehow eliminate homelessness. While there is an overlap between homelessness and mental illness, most will not qualify.
"For policy makers or the public who think AOT is going to solve homelessness, that's not how it works," he said. "The problem with homelessness is much more complicated than what a program like this can actually do."
The law, AB 1976, requires Santa Clara County officials to decide whether to opt into Laura's Law by July 1, reviving a debate that has spanned nearly two decades. Santa Clara County has long held that assisted outpatient treatment is redundant and that existing programs reach far more people than Laura's Law ever could. In a report last month, county behavioral health staff also suggested that people of color could be disproportionately subjected to court-mandated treatment, which has been the subject to scrutiny in New York.
Eggman said claims of possible inequity don't hold water.
"I think the data shows the majority of people who have been treated are Caucasian men between the age of 26 and 46," she said. "The data doesn't hold up to the emotional argument."
Becky Moskowitz, an attorney with the Law Foundation of Silicon Valley, said it's the treatment services that assisted outpatient treatment provides — rather than the compulsory element — that leads to all the positive results reported out of counties like San Francisco and San Mateo and that county supervisors should not confuse the two. At a Feb. 17 committee meting, she argued that those with mental illness would be better served by stable housing, which is a key part of the recovery process.
Cloutier said housing is a serious barrier to treatment in San Mateo and that no real clinical progress can be made for those who are insecurely housed. Housing subsidies are available for those participating in assisted outpatient treatment over its two-year period, but all that progress is at risk once they expire. Of the people who have gone through the program, 23% are homeless.
"Once you've stabilized someone and they lose their housing, they are likely to go back to the circumstances that had them referred to AOT in the first place," he said.
Though Eggman has advocated for Laura's Law, she said the intent of her bill is to force counties who have opted out to at least take a hard look at reconsidering, which is exactly what Santa Clara County is doing today. She said assisted outpatient treatment won't be a cure-all and will only affect a small population, which is exactly the point.
"When it comes to mandating something against peoples' will, it should be used very sparingly," she said.