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Lanterman-Petris-Short Act California Has Not Ensured That Individuals With Serious Mental Illnesses Receive Adequate Ongoing Care Report Number: 2019-119

Introduction

Background

According to federal and state data, millions of Californians experience mental illnesses, including nearly two million individuals who experience one or more mental, behavioral, or emotional disorders that substantially interfere with major life activities (serious mental illnesses). ¹ For the purposes of this report, we define serious mental illnesses to include serious mental illnesses in adults as well as serious emotional disturbances in children. We use the term mental illness to encompass mental disorder and other similar terms used in state law. Serious mental illnesses can include schizophrenia, post‑traumatic stress disorder, bipolar disorder, and severe major depression. The consequences of these illnesses can be dire: individuals with serious mental illnesses have shorter life expectancies than the general population and experience significant rates of incarceration and homelessness. Treatment can help people cope with the symptoms of serious mental illnesses, which can include hallucinations, delusions, and disorganized thinking; for example, medication and psychotherapy can help individuals manage those symptoms. However, without treatment, people with serious mental illnesses can sometimes pose a risk of harm to themselves or to others.

California has a largely county‑based system for providing mental health care to those living with mental illnesses, including serious mental illnesses. In general, counties’ public mental health systems have both involuntary and voluntary components, as we illustrate in Figure 1. The Lanterman‑Petris‑Short Act (LPS Act), which the Legislature added to state law in 1967, generally governs the involuntary treatment components. Specifically, it outlines the circumstances under which county‑designated treatment facilities (treatment facilities) can hold people involuntarily in order to provide mental health evaluation and treatment, as we discuss in more detail below. This report focuses on people treated under the LPS Act in three counties—Los Angeles County (Los Angeles), San Francisco County (San Francisco), and Shasta County (Shasta)—as well as the services available to those individuals and others within the counties’ broader mental health systems.

Figure 1
The LPS Act Governs Only One Part of Counties’ Broader Mental Health Systems

The State’s Approach to Serving Individuals With Serious Mental Illnesses Has Changed Over Time

The Legislature passed the LPS Act amid a broader effort to deinstitutionalize mental health care, as we show in Figure 2. Over the past several decades, the federal government and California have taken steps to limit involuntary and institutional mental health treatment and to assign responsibilities for mental health treatment to counties. The LPS Act was an important part of these changes; it placed certain restrictions on involuntary treatment and assigned responsibilities for involuntary treatment to California’s counties. According to a report from the federal Substance Abuse and Mental Health Services Administration, the LPS Act also served as a model for other states that revised their own involuntary commitment laws.

Figure 2
California’s Approach to Mental Health Treatment Has Changed Over Time

As the State has increasingly moved toward a county‑based system for providing mental health care, its own role in administering and overseeing such care has changed. For instance, California has closed several of its state hospital facilities, which generally provide intensive treatment in locked settings for those with serious mental illnesses. As a result, the number of people treated in state hospital facilities has declined significantly; although state hospital facilities treated more than 37,000 individuals in 1959, they were treating only slightly more than 6,000 individuals in November 2019. Further, the State dissolved its Department of Mental Health in 2012 and assigned its responsibilities to several different agencies, some of which we list in the text box. Currently, these agencies hold the primary oversight responsibilities for the State’s public mental health system.

The LPS Act Permits Involuntary Treatment for People Experiencing a Mental Health Crisis

In certain circumstances, involuntary mental health treatment is necessary to stabilize people and prevent harm. In some cases, people with serious mental illnesses experience symptoms that cause them to lack insight into their illnesses. In other words, they may not be able to recognize or acknowledge that they have a mental illness or its extent. Individuals with these symptoms may not voluntarily seek treatment, and involuntary treatment may be the only way they receive care. To provide involuntary treatment under the LPS Act, qualified treatment facility staff or other county‑designated professionals (designated professionals) generally must determine that the individuals meet specified criteria: that as a result of mental illness, they are dangerous to themselves, dangerous to others, or gravely disabled—meaning that they are unable to provide for their basic personal needs for food, clothing, or shelter. ² The LPS Act also permits designated professionals to provide involuntary treatment to individuals who meet these criteria because of substance abuse or chronic alcoholism. Because the cases we reviewed almost exclusively identified individuals’ mental illnesses as the reasons they met the LPS Act criteria, we focus our report on those aspects of the LPS Act.

Because the stated legislative intent of the LPS Act is to end the inappropriate, indefinite, and involuntary commitment of people with mental illness, it includes several protections of the rights of those subject to such treatment. The LPS Act generally establishes three stages of involuntary treatment, which we depict in Figure 3. These stages automatically expire and require those advocating for additional involuntary treatment—designated professionals or the county public guardian (public guardian), which is generally an agency designated by a county government to provide conservatorship services—to justify the need for further treatment. The LPS Act requires those providing treatment to assess whether they can properly serve individuals voluntarily before initiating involuntary treatment, and it also requires that treatment providers release individuals from involuntary holds if at any point they no longer need involuntary treatment. Further, the stated legislative intent of the LPS Act is for individuals to receive treatment in the least restrictive setting appropriate for their needs, and the LPS Act allows individuals to receive their involuntary care at a range of treatment facility types based on their needs, as we indicate in Figure 1.

Figure 3
The LPS Act Outlines a Process That Generally Involves Three Stages of Involuntary Treatment for Mental Illness

The first type of LPS Act hold is the shortest—lasting no more than 72 hours—and the most common. Because these short‑term holds are typically an individual’s first encounter with LPS Act treatment, they represented a vast majority—nearly 80 percent—of the LPS Act holds that occurred in fiscal year 2018–19 in the three counties we reviewed. The LPS Act allows responders to bring individuals to county‑designated treatment facilities for evaluation and treatment if the responders have probable cause to believe that the individuals meet the criteria for an involuntary short‑term hold. These responders can receive alerts from the communities they serve about individuals potentially in need of care; for example, family members may contact the police for help when they are concerned about a relative’s behavior. In our analysis, these responders were either from county behavioral health services or mobile crisis teams, law enforcement, or medical professionals. Once responders have brought individuals to a designated facility, designated professionals assess them to determine whether they will be held for up to 72 hours to receive treatment. Individuals placed on short‑term holds must receive whatever treatment their conditions require, which may include medication. Designated professionals can end a short‑term hold before the 72 hours have elapsed only if the treating psychiatrist determines that the person no longer requires evaluation and treatment under the hold.

If, at the conclusion of a short‑term hold, the designated professionals in a treatment facility believe a person continues to meet the requirements for evaluation and treatment, they can place the individual on an extended involuntary hold of up to 14 days. Unlike short‑term holds, the LPS Act requires a legal review process for extended holds to ensure that continued involuntary treatment is justified. Specifically, the act requires that an official—generally a medical or legal professional, such as a court‑appointed commissioner—conduct a hearing to review the extended hold within four days of when the treatment facility initiates the hold. The act also requires an attorney or patient advocate to meet with the patient to answer their questions and assist them in preparing for their hearing.

If the designated professionals believe that after an extended hold, the individual continues to be gravely disabled—that is, unable to provide for their basic personal needs and unwilling or incapable of accepting treatment voluntarily—the designated professionals can recommend that the public guardian begin proceedings to establish a conservatorship of up to one year. ³ The LPS Act includes another definition of grave disability that applies to people who have been found incompetent to stand trial on certain criminal charges and who represent a substantial physical danger to others as a result of mental illness. In this report, we focus on the definition of grave disability as the inability to provide for food, clothing, or shelter as a result of a mental illness, which was the definition applicable to the majority of the conservatorship cases we reviewed. The decision to establish a conservatorship requires significantly more legal involvement than earlier stages of LPS Act involuntary treatment, and conservatorships are relatively rare compared to these other holds, as Appendix C details. Unlike the process for placing the two shorter holds, a public guardian must petition a superior court to establish a conservatorship following an investigation. The public guardian investigates the need for conservatorship and, if appropriate, assumes responsibility for the care of the individual placed on conservatorship. When the public guardian seeks a conservatorship, the individual—who is represented by a public defender or other court‑appointed attorney—can either accept the conservatorship or contest it through a trial. The purpose of a conservatorship trial is to allow the contesting individual to offer evidence against establishing a conservatorship and challenge the testimony of doctors and others recommending conservatorship.

The LPS Act requires a high burden of proof in order to place someone on conservatorship. The county must prove the need for a conservatorship beyond a reasonable doubt—the same burden of proof as needed to convict someone in a criminal proceeding. This burden exists because courts have determined that conservatorship proceedings under the LPS Act threaten individual liberty and personal reputation no differently than the burdens associated with criminal prosecutions. People placed on a conservatorship can lose certain rights, including their right to refuse medication for their mental illnesses. Their court‑appointed conservators—who can be public guardians but can also be suitable private parties, such as relatives of the people placed on conservatorship—are permitted to place them in treatment facilities and require them to receive treatment.

Finally, in addition to involuntary holds, the LPS Act allows counties to adopt assisted outpatient treatment programs, which provide intensive treatment services in community settings—such as psychological or psychiatric services coordinated by a personal case manager. Counties that establish assisted outpatient treatment programs can compel treatment using the court system if individuals are unlikely to survive safely without supervision, have histories of lack of compliance with treatment, and meet other criteria specified in the LPS Act. Counties with assisted outpatient treatment programs must also make these programs available for individuals to participate in voluntarily.

Counties Annually Receive Billions of Dollars in State and Federal Funding to Provide Mental Health Services

Counties received billions of dollars from state and federal sources to fund their mental health systems in fiscal year 2018–19, as Figure 4 details. The counties’ single largest source of funding for mental health services is Medi‑Cal, a state‑run system through which the counties receive federal reimbursements for treatment they provide to eligible Californians. Medi‑Cal is the State’s version of Medicaid, and it covers a range of mental health services that include some crisis stabilization services, inpatient care, and residential treatment. Counties also receive state funds to manage certain mental health programs—such as inpatient care, community‑based services, and services for youth—that the State realigned by transferring its responsibilities to counties in and around 1991 and 2011 (realignment funds). Counties generally have flexibility over their spending of realignment funds. Additionally, in 2004 California voters passed the Mental Health Services Act (MHSA), which funds certain county mental health services—mainly for those with serious mental illnesses—by levying an annual tax on the portions of people’s taxable incomes that exceed $1 million.

Figure 4
Counties Receive Billions in State and Federal Funds That They Can Use to Support Their Mental Health Systems

Because the LPS Act encourages the full use of existing public funds to accomplish its objectives, counties generally fund their treatment and services associated with the LPS Act from the funding sources in Figure 4 as well as from local funds. However, restrictions prevent counties from using certain funds for those purposes. For example, state regulations establish that MHSA funds cannot pay for long‑term hospital or institutional care, which limits counties’ ability to use those funds to provide such care under the LPS Act. Nevertheless, counties can use any of the funding sources we depict in Figure 4 to fund voluntary services that may benefit those treated under the LPS Act as well as others with mental illnesses.

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