It's an argument that has raged for more than 50 years, since California dismantled its involuntary hospitalization policy. The landmark 1967 Lanterman-Petris-Short Act strengthened patients' rights by requiring a judicial hearing for involuntary hospitalization. But while Lanterman restored civil liberties and curtailed abuses, it had some consequences that communities across the state still contend with today.
Between 1969 and 1970, 45,000 people formerly under state care for inpatient services and 120,000 people receiving state outpatient services were shifted to counties' care, the National Alliance on Mental Illness (NAMI), an advocacy group, notes on its website. Santa Clara County's Agnews State Hospital alone released more than 3,800 people on June 30, 1972, creating a "mental health ghetto" overnight, NAMI noted.
New medications developed in the decades since that era have made it possible for severely mentally ill people to live in the community, but the idea of compelling treatment, outpatient or otherwise, for people who do not want to accept it continues.
A move toward public conservatorship of mentally ill persons has slowly been growing.
A 2002 state statute, Assembly Bill 1421, "Laura's Law," allows families and some law-enforcement and medical professionals to ask a county's mental health director to petition the court to have a person involuntarily treated.
Any petition to the court must satisfy a strict set of criteria, including evidence that the person has been repeatedly hospitalized and is a danger to self or others or be mentally deteriorating. Persons who do not comply with the court order can be put on a 72-hour hold and potentially sent to an institution.
Laura's Law is named for Laura Wilcox, 19, a mental health clinic employee who was one of three people killed by a mentally ill man, Scott Harlan Thorpe, on Jan. 10, 2001, in Nevada County. Thorpe was said to have refused medication. A court later found him incompetent to stand trial.
Counties that adopt Laura's Law must create and fund comprehensive mental health services, which include housing, evaluations, medical treatment and therapy.
There hasn't been a serious discussion in Santa Clara County about implementing it, officials said.
Santa Clara County Supervisor Joe Simitian voted in favor of Laura's Law during his tenure in the state legislature. But he said that funding for a strong, countywide outpatient system would go a long way to reducing involuntary treatment and commitments.
"To some extent, if you put more resources into outpatient care, more mental health infrastructure mitigates the need to some degree for Laura's Law," he said.
Ostensibly, Laura's Law would catch people earlier in their mental illness and prevent hospitalization or crises. But some mental health professionals and patients' rights advocates say the law is a wrong step.
"I do not favor Laura's Law," said former Palo Alto mayor Vic Ojakian, a member of the county's Mental Health Board. "It singles out a class of individuals because of the actions of a few and may cause undue harm to them. Also, it may not solve the issue it is trying to address. For me, ultimately I do not believe forced treatment is a successful approach."
Dan Brzovic, associate managing attorney with the advocacy group Disability Rights California, said the standards for compelling involuntary treatment outside of Laura's Law are adequate.
"Laura's Law is barking up the wrong tree. It will lead to frustration. If treatment is voluntary, people are likely to continue. If they are forced, as soon as the force is removed they may not continue receiving treatment. Involuntary treatment can destroy trust. We have a significant number of patients who prefer not to have anything to do with the system because of bad experiences," he said.
Disability Rights takes the position that Laura's Law could extend involuntary treatment to people who are not a danger to themselves or others, or who are not gravely disabled.
"We want to see legal treatment standards that avoid speculation if someone will become dangerous. We can't predict future dangerousness or future grave disability," Brzovic said.
So far, only Nevada County is fully implementing Laura's Law. Los Angeles County has adopted a modified version. Two years ago, the San Francisco Department of Public Health started the San Francisco Community Independence Placement Program, which Mayor Ed Lee called "San Francisco's version of Laura's Law."
Since Nevada County's implementation in 2008, the courts have ordered 27 people to undergo outpatient treatments and mandated institutionalization for three or four people, according to Michael Heggarty, Nevada County director of health. Most of the other 72 people who were evaluated since 2008 voluntarily accepted treatment.
The county has tracked the program for five years.
"We've had very good outcomes," Heggarty said. "We've had a large reduction in psychiatric hospital stays and a large reduction in the number of days spent in homelessness We have reduced the number of days in jail and emergency department visits."
The county has used funds from Proposition 63, the state's Mental Health Services Act, to develop its programs. Although comprehensive services are expensive, the costs are significantly lower than emergency care, ambulances, prosecution for crimes and incarceration, he said.
Outpatient services cost the county about $16,000 per patient per year, compared to inpatient care or incarceration in jail, which costs $20,000 to $25,000, he said. In the first 31 months, the county saved a net $503,000 after expenses of the program — about $1.81 for every $1 spent.
But the savings are significantly greater, he said. The evaluation did not include emergency room visits, the costs for law enforcement, prosecutors, public defenders and judges, excessive 911 calls, child abuse and neglect, he said.
Heggarty thinks the law has benefits for people with severe mental illness.
"It's much less restrictive than sending people to institutions. They can come and go and live at home; they don't lose all of their rights," he said.
"The law can give you a way to reach people. Part of the illness for some people is they don't believe they are sick. (Without Laura's Law), for those people we don't have a way to treat them. Conservatorship is very complicated," he said.
Nevada County has not had any legal challenges since implementing Laura's Law, he said.