My piece on Laura’s Law – the involuntary outpatient commitment statute being implemented in California – is out in this month’s issue of Pacific Standard. There are two things that I want to note:
1) This is not a comprehensive or wholly unbiased take on involuntary outpatient commitment.
This is the story of one county — the county where the law originated — told from the perspective of the people who designed and implemented the actual program. So yes, they are strongly in favor. That’s not to say I didn’t report on the opposition’s case; I did. I think it boils down to two key points:
- Coercive therapy is inherently wrong no matter what the circumstance.
- The problems with our treatment of the seriously mentally ill in this country have mostly to do with a dearth of resources and a failure to prioritize.
For the record, I think that the latter point is completely valid but that the former point is not at all. Yes we need more resources for people with mental illness. But without compulsory treatment laws, those resources won’t ever reach the sickest of the sick.
The NYCLU, an organization I respect tremendously, came out strongly against Kendra’s Law, the New York statute upon which Laura’s Law is based. In a testimony to the State Assembly, attorney Beth Haroules wrote:
Kendra’s Law violates the fundamental freedoms of competent, non-dangerous persons with psychiatric disabilities who constitutionally could not be detained involuntarily in psychiatric facilities. Kendra’s Law prescribes for them involuntary and highly restrictive treatment programs and often forces them to take medications against their will. And, the most disturbing information provided by the New York State Office of Mental Health in its mandated final report to the Legislature on “Kendra’s Law,” reveals major racial/ethnic and geographic disparities throughout New York State in the implementation of “Kendra’s Law.”
I can’t speak to the NY experience directly, but my own reporting, on both Laura’s Law in California and Gregory’s Law in New Jersey, has led me to opposite conclusions. And at least some parsing of the Kendra’s Law data concludes that the charge of racial disparity does not hold up. I concede that each state is different, but I believe there are enough successes across the country to say that it’s possible to have effective IOC programs without racial bias or egregious civil rights violations. (For the record, I did reach out to the NYCLU for an interview, but did not hear back).
2) There was so much reporting that I didn’t get to include in the final piece.
I spent a week just sort-of hanging out at the mental health center in Grass Valley – talking to clients and caseworkers there and observing them as they interacted with each other. It’s an awkward kind of reporting, because everyone expects you to ask questions and conduct formal interviews, but your real job is to disappear into the background, and to quietly observe without interrupting things.
You end up with way more material than you have space for — incidents and exchanges that inform your perspective but never make it into the actual story. At Turning Point I found a whole community of clients and caseworkers who were meeting the chaos that often attends serious mental illness with resourcefulness and pluck. Kindness was systemic, reserves of patience were tremendous. Humor prevailed wherever it could.
What struck me most was how minute the crises could be that threatened to tip this client or that one over the edge. We talk a lot about the need for big systemic reforms to our mental healthcare system. But at the actual interface, between patients and providers, it comes down to some very basic things — medication reminders, rides to doctor’s appointments, someone to talk to on a regular basis.
Laura’s Law, the thing that was being vigorously debated across the state — and the thing that I had come to report on — was just a teeny tiny snippet of that larger picture. (In fact, for all the debate and controversy, Laura’s Law itself is actually pretty toothless – almost to the point of being inconsequential. Not only has the actual statute been written too timidly, but it only comes into play in a handful of cases anyway).
Below is a side-story that unfolded while I was reporting the main piece.
A thin column of black smoke curled up from just beyond the ridge of pine trees on the horizon as Carol pulled into the parking lot of Turning Point Providence Center in Grass Valley, California; two weeks had passed since the last rainfall and even that was just a drizzle.
It was barely 9:00 on Monday morning and Tyler, one of the center’s clients, was already waiting at the front door for her. He bounded across the lot as she stepped out of her car. He had fantastic news, he said. He’d be graduating to phase three of mental health court this week.
Would she come support him when it happened?
“Of course I will,” she said, patting him on the back. He put his arm around her and grinned.
“Will you be my mom?” he asked.
She laughed, unlocked the door, and ushered him inside along with the week ahead.
Mondays were always hectic. Turning Point, of which Carol was the executive director, served 90 area residents suffering from serious mental illnesses – mostly schizophrenia and bipolar disorder. During the week, those clients received constant support from Carol’s staff – rides to and from doctor’s appointments, group therapy sessions, and lots of help managing housing issues and roommate issues and family issues. But the center was closed on weekends, with just one caseworker on call, and there were always lots of emergencies. This past weekend was typical. One client landed in the ICU late Saturday night, where she tested positive for meth. Another went to the psychiatric hospital because he was struggling with delusions that involved talking insects.
A third client who had been released from a short term care facility late last week was found in a ditch with his head busted open and taken to the Emergency Room. His name was Don, and he was one of Turning Point’s (not to mention Nevada County’s) toughest cases: chronically homeless and almost constantly in crisis. He could usually be found wandering through town or hiding up in one of the ridge’s many nooks and crannies, unwashed and shouting at the top of his lungs. Invariably, the police would pick him up and take him to the emergency room, where nurses would inject him with a strong psychiatric sedative.
What happened next was anybody’s guess – he might end up in a short-term psychiatric hospital. But he might just as easily end up right back on the street. Don was so well-known, not just in Nevada county, but across the state, that a lot of facilities for which he was eligible wouldn’t accept him. He’d been violent in the past, and so they would use that that to screen him out. This past weekend was his tenth go-round in as many months. And patience everywhere – in the police department, in the emergency room, and among Carol’s staff – was wearing thin.
But Don was also smarter than people gave him credit for; and if the staff at Turning Point was frustrated by him they were also feeling protective. They had seen his softer side. They knew him to be spiritual, when he was well enough, and contemplative. “He just doesn’t want to be told what to do,” his caseworker Jeff would say. “You know, he’s like everyone else in that way.”
Recently, a plan had been hatched to try and break the cycle that Don was trapped in. There was one psychiatric hospital a few counties over – Curby Hill Medical – that might be willing to take him in, and to hold him for a full month. A month might just be long enough to stabilize him. In a month, he could be persuaded to take his meds. And once they kicked in, maybe he could be persuaded further, to accept housing. From there, a whole array of possibilities might open up. Maybe he’d join some groups, or find a part-time job. They’d seen it happen with so many other clients. Despite all evidence to the contrary, they couldn’t help but hope the same might be possible for him.
So Carol had spoken to Daryl, her counterpart in Behavioral Health, and Debbie had spoken with their contact in the police department. Let’s try to get Don into Curby Hill and see if they can keep him there a while. Now the two women were alerting their own staff. As soon as a bed opens up at Curby, we need to find Don, and get him committed there.
That of course would be trickier than it sounded. Not only would a bed have to become available, but the right police officers would have to receive the call, and Don himself would have to be exactly the right amount of agitated: enough to warrant involuntary commitment, but not so much that he would be deemed a danger to other patients. “We have to wait for all the stars to align,” Debbie explained to the group. “And then we have to move very quickly.”
On Wednesday, Don was discovered wandering through a housing complex with soiled pants, after having defecated on some outdoor furniture. The people in charge of the complex knew him, and did what they could to help. They called the police, then washed his clothes and tried convincing him to take a shower. Officer Lovelady, who was aware of the plan in place at Turning Point, responded to the call. He informed Daryl at Behavioral Health, who came and placed Don on a psychiatric hold, which enabled officers to take him to the emergency room for a psychiatric evaluation. Seth, the caseworker responsible for Don that day, went to the ER to offer what support he could.
Seth found Don in a bad way: furious, confused and struggling to process even the most basic information. The door to his room was open, and bits of conversation were filtering in from the hallway – about other patients in the E.R., about doctor’s schedules, about Don himself – adding to his confusion. A handful of nurses were cycling in and out of the room, trying to feed Don directions. They wanted him to put a gown on, and when he refused, they tried doing it for him.
In an effort to resist this onslaught, Don threw a cup of coffee at one of them. Actually, Seth thought, he threw it at the ground in front of her. He wasn’t really trying to be assaultive, Seth thought. He just wanted some space. None-the-less, a nurse injected Don, forcibly, with Haldol which sent him quickly and predictably into a deep sleep.
Seth figured that the injection was probably better than any physical restraint – because nobody wants hands on them when they’re in that state – but he was still exasperated by the entire scene. If the ER staff would give Don just a little more time, he might be able to put the gown on himself, or decide on his own to take an oral sedative. Why couldn’t the nurses put themselves in Don’s shoes? Poor guy was just pulled off the street, dropped into this hospital, and had almost no idea what was going on. He’d just been deemed gravely disabled. Did they think he was choosing to act this way? Didn’t they realize he couldn’t help it?
At the same time, though, Seth could just as easily see the other side of it. The hospital workers were trying to care for, say, a very sick child or someone who’d just been in a terrible car accident. They had people everywhere in need of really high-level medical attention. And this guy across the hall was just screaming at the top of his lungs. Most of them knew who he was. They were probably wondering how long he’d be stuck there with them; last time around it was nearly a week. Seth could see how that might not inspire patience or warmth. The nurses weren’t to blame, he decided. The whole system was just broken.
It was Thursday afternoon and the week was winding down at Turning Point. A half-dozen or so caseworkers were scattered about the computer room, doing paper work, and calling to check on various clients.
“Can you please remind Bill to pack a lunch everyday…” one caseworker was asking someone at the group home to which one of her clients had recently been transferred.
“… The owner is very upset about the breadcrumbs in back of the building,” another was saying to one of his clients. “They need to be gone by Friday.”
In the activity room down the hall, one of the center’s younger clients was listening to loud music and intermittently banging on the piano. He was experiencing a lot of auditory hallucinations lately, and the noise helped him drown them out. There had been talk of getting him some headphones, but it was decided that he had probably lost or broken many pairs over the years.
Outside the nurse’s station, Tyler was playing court jester for Lisa, the staff nurse. He was throwing a single orange up in the air and catching it.
“Look,” he said, grinning. “I’m juggling for you!”
“Dude you need two more oranges to juggle,” she said, teasing. “Right now you’re playing catch.” He put the orange on her desk and broke into a set of jumping jacks, then rolled onto the ground and began kicking his legs in the air.
“Tyler is wiiiiild,” Lisa said, smirking.
Almost 24 hours had passed and Don was still in the ER. Yes, there was still a bed open at Curby Hill, and yes, they were considering accepting him as a patient. But first, they wanted to make sure he was safe. If he could go a full 24 hours, unrestrained, without attacking anyone, they would admit him and keep him for a solid month as planned. But if he failed this impromptu test they would be forced to turn him away, for the sake of their other patients. Don’s caseworker Jeff relayed the update to Debbie. “He’s got to make it a few more hours,” he said. They both knew what that meant: Don might be back on the street by nightfall.
“Tell them we’ll go sit with him if need-be,” Debbie said. “I can go play cards with him myself.” She headed towards the hallway, then quickly turned around. “Call them back,” she added. “Tell them we’ll do whatever it takes.”