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Public Education & Policy :: Position Papers AB 2357 - Why Oppose It AB 2357 extends the sunset deadline of AB 1421, the bill which codified outpatient commitment. It extends the sunset deadline of AB 1421 from 2008 to 2013. Extending the sunset deadline of AB 1421 will provide a viability to outpatient commitment which is antithetical to the transformation that is taking place in California through the implementation of the Mental Health Services Act (MHSA.) Give Voluntary Community Services (in the Mental Health Services Act) a Chance Voluntary enhanced services are the answer to the mental suffering that surrounds us, not the expansion of forced treatment. In 1999, when legislation to expand forced treatment was introduced in California, the perception of the need for increased involuntary services was an incorrect response to the lack of accessible mental health services. Today assessable voluntary community services are on the horizon with the passage of the Mental Health Services Act (MHSA.) Before resorting to the extreme measure of denying the rights of a whole group of persons, give these voluntary community services a chance. Deinstitutionalization did not fail; it was never completed. People with mental disabilities were never offered the full array of voluntary community mental health services they were promised, including medications, housing, job and benefits assistance, outreach teams and other alternative support for people in crisis, client-run and self-help services, such as peer counseling. The Mental Health: A Report of the Surgeon General states, "One point is clear: the need for coercion should be reduced significantly when adequate services are readily accessible to individuals with severe mental disorders who pose a threat of danger to themselves or others." The Little Hoover Commission agrees, and urges an "assessment of how improved access to voluntary treatment could diminish the need for involuntary treatment, before implementing options that would increase forced treatment". With the passage of Prop 63, the Mental Health Services Act, California is moving in the direction of making adequate services readily accessible to Californians with mental disabilities, of improving access to voluntary services. California is fulfilling a promise made 30 plus years ago when it closed so many of its institutions. Give this initiative a chance. The Surgeon General's Report further states, "Almost all agree that coercion should not be a substitute for effective care that is sought voluntarily". Making AB 1421 a viable program option by extending the sunset provision would substitute coercion for a mental health system based on effective care that is sought voluntarily envisioned in the MHSA. Outpatient Commitment is an Old Idea Whose Time Has Passed AB 1421 was an incorrect answer to an inadequate mental health system. In California, that system is now changing. The environment that created the perceived need for AB 1421 is changing. In fact, other States are beginning to reject outpatient commitment. In 2005, Outpatient Commitment was proposed in New Mexico, and died on the floor of the legislature. Transformation, promoted by the President's New Freedom Commission's Achieving the Promise: Transforming Mental Health Care in America, is now sweeping the country. Federal transformation grants have been awarded to States' mental health divisions. In California, the MHSA promises a transformation of our mental health system, with services that transcend outdated and stigmatizing reactions to people with mental disabilities. Outpatient Commitment is an outdated and stigmatizing reaction to people with mental disabilities; it looks backwards, not forwards. Whereas the traditional system has used coercion and force in its attempt to solve problems, a transformed system will create options that maximize client self-determination and autonomy, goals of the MHSA. The implementation of the MHSA supports a new direction for mental health services, not the same old - unsuccessful - answers. Making AB 1421 secure by extending the sunset clause supports the same old answers and is antithetical to the immanent changes throughout the country. Coercive treatment is ultimately ineffective. The expansion of forced treatment will not stop "treatment noncompliance," which is viewed as a problem that more forced treatment will solve. In fact, researchers have found that forced treatment causes noncompliance. The Well Being Project, a research project supported by the California Department of Mental Health, found that 55& of clients interviewed who had experienced forced treatment reported that fear of forced treatment caused them to avoid all treatment for psychological and emotional problems. Moreover, coercion seriously undermines the therapeutic relationship between a client and his/her therapist. Choice is Essential for Recovery Choice is so important a concept to human kind and human dignity, that medical interventions, with only the exception of psychiatric, are soundly based on choice, including extensive consent policies and procedures. Informed choice about treatment and control over one's own individualized path to health, is necessary for recovery. Treatment and civil rights are not antithetical to each other; in fact, good treatment can only occur in an atmosphere of choice and freedom. Introducing the Issue of Forced Treatment is Divisive The introduction of AB 2357 threatens to destroy the consensus of the mental health stakeholders that has been forged in the development, promotion and implementation of the MHSA. The MHSA has spurred a unique collaboration among mental health stakeholders. By focusing on what we all can agree on, voluntary community services, the MHSA has brought together the whole mental health community. In unity is our success in building a transformed mental health system; in divisiveness will lie our failure. AB 2357 threatens to tare apart the whole. The introduction of forced treatment is the one subject that will create dissension and animosity among stakeholders and county/state administrators. It is divisive at a time when we need to be working together and diversionary at a time when our energy needs to be focused on working toward the one goal of transforming the mental health system. MHSA Funds Can Not be Used for AB 1421 Programs. A rational for AB 2357 is that AB 1421 needs to become a secure option (through extending the sunset deadline) because of the funding opportunities that the MHSA provides it. In fact, MHSA funds cannot be used for AB 1421 programs. The services that provided the model for the MHSA, AB 34 and 2034, are designed to be voluntary, and require providers to follow a client-directed, culturally competent and recovery-based standard of service. The California Council of Community Mental Health Agencies, one of the lead advocates of the MHSA, writes that "the law (AB 34/2034 programs) describes a process of developing an individual personal services plan in which each client participates. These are voluntary community services programs. There is no authority for using Proposition 63 funds for any other type of program. The imposition of involuntary treatment precludes such standards." This is reiterated in the following DMH's Requirements for Community Services and Supports Programs. "Individuals accessing services funded by the Mental Health Services Act may have voluntary or involuntary legal status which shall not affect their ability to access the expanded services under this Act. Programs funded under the Mental Health Services Act must be voluntary in nature." California is Not New York State: Comparison to New York State's "Kendra's Law" The author of AB 2537 sites positive outcomes for Kendra's Law in New York City in her promotion of AB 1421. (There are no California outcomes because there has been no full implementation of AB 1421 in California. In addition, Kendra's Law outcomes are based almost entirely on the opinions of case managers and fail to provide a comparison with a control group of those who received a voluntary package of similar enhanced services. (From New York Lawyers for the Public Interest) In California, these kinds of positive outcomes have been achieved with voluntary community services alone such as the AB 34/2034 programs upon which the MHSA is based. The expectation is that with the implementation of the MHSA these positive outcomes will be repeated. For example, under the AB 34/2034 programs, the number of days hospitalized has decreased by 55.8&, the number of days incarcerated has decreased by 72.1&, the number of days homeless has decreased by 67.3&, the number of days employed (full time) has increased by 65.4&, and the number of days employed (part time) has increased by 53.1%. In analyzing New York's outcomes, it is important to know that New York State put millions of dollars into enhanced services for court ordered people. A 1998 study of outpatient commitment in New York City found that, when comparing a control group to persons court ordered to outpatient commitment, there was no difference in any qualitative or quantitative outcomes. The positive element with both the court ordered and non court ordered groups was the enhanced community services offered to both. It is not the court order, but rather the enhanced community services that lead to positive outcomes, an explanation inferred in a Rand Study that was commissioned by the California Senate Committee on Rules during the legislative course of AB 1421. Why deny a person's civil and human rights to achieve outcomes that have been proven to be achievable without this deprivation? It is also important to know that court-ordered treatment under Kendra's Law in New York has disproportionately targeted people of color, specifically, African Americans and Latinos. A recent analysis of state data by the New York Lawyers for the Public Interest showed that African American clients were nearly five times as likely as whites, and Latinos were twice as likely as whites, to be the subject of court ordered treatment under Kendra's Law. For California to implement a similar involuntary outpatient commitment law would invite a comparably discriminatory application of court-ordered treatment, violating the principle of cultural competence as well as civil rights. There is No Justification to Expand the Sunset Deadline of AB 1421 No County has chosen to implement AB 1421. The Health Committee analysis that AB 1421 was implemented in Los Angeles is incorrect. Los Angeles County implemented a diversionary program for incarcerated persons with mental disabilities under the "negotiated settlement" section of AB 1421; it ignored the rest of the law. Los Angeles County describes its program as a voluntary wraparound program, not an AB 1421 program. The RAND report commissioned by the Senate Rules Committee cites that one reason for the lack of implementation of outpatient commitment laws throughout the country is that mental health providers don't like it; they don't want to undermine their therapeutic relationship with coercion. Only one County is considering implementing AB 1421: Nevada County promised to implement the law as a lawsuit settlement with the Wilcox family over their daughter's death. Because there has been no implementation of AB 1421, there are no program outcomes to justify its continuance. There is no new money that can support AB 1421; the MHSA can not support involuntary programs. There is no rationale for continuing the sunset deadline beyond what is in the law. AB 1421 should die as we enter the 21st century and commit ourselves to transforming the mental health system. In a state that avowals client empowerment, a client driven system, and client inclusion in decision making, the fact that clients of the state overwhelming oppose increasing forced treatment is in itself a powerful reason to oppose making AB 1421 a permanent law. The people for whom this approach intends to help, whom the state professes should drive the system, oppose it. References
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