Skip Repetitive Navigation Links

Lanterman-Petris-Short Act
California Has Not Ensured That Individuals With Serious Mental Illnesses
Receive Adequate Ongoing Care

Report Number: 2019-119


Audit Highlights . . .

Our audit of the implementation of the LPS Act in three counties, highlighted the following:

Results in Brief

Millions of Californians experience mental illnesses, including nearly two million who experience mental, behavioral, or emotional disorders that substantially interfere with major life activities (serious mental illnesses). The consequences of these illnesses can be dire: for instance, people with serious mental illnesses are at increased risk of early mortality and experience significant rates of incarceration and homelessness. Treatment can help people cope with the symptoms they experience; however, individuals with serious mental illnesses may not always seek or receive treatment voluntarily, and as a result, they can sometimes pose a risk of harm to themselves or others. To address these risks and to reduce the use of restrictive, institutional mental health care, the Legislature passed the Lanterman‑Petris‑Short Act (LPS Act) in 1967. The LPS Act allows qualified treatment facility staff or other county‑designated professionals (designated professionals) to provide involuntary mental health treatment to people who, because of a mental illness, are a danger to themselves or others, or cannot provide for their basic personal needs of food, clothing, or shelter. Specifically, the LPS Act establishes three main stages during which people can be treated involuntarily: short‑term holds of up to 72 hours, extended holds that generally last up to 14 days, and conservatorships of up to one year during which courts appoint outside parties, such as county officials, to assume responsibility for individuals’ care. This audit focuses on the implementation of the LPS Act in three counties—Los Angeles County (Los Angeles), San Francisco County (San Francisco), and Shasta County (Shasta)—and how the act functions within those counties’ broader mental health systems.

Some organizations have expressed concerns that the criteria in the LPS Actfor involuntary treatment are inadequately defined and that counties have inconsistently applied those criteria, preventing some individuals from receiving necessary involuntary treatment. However, based on our review of 60 short‑term involuntary holds and 60 conservatorship cases in the three counties we examined, we found that the LPS Act’s criteria appropriately enabled the designated professionals and courts to place people who needed involuntary treatment on LPS Act holds or conservatorships. Further, the designated professionals in the three counties generally interpreted and applied LPS Act criteria similarly when making decisions about involuntary treatment. Expanding the LPS Act’s criteria to add more situations in which individuals would be subject to involuntary holds and conservatorships could widen their use and potentially infringe upon people’s liberties, and we found no evidence to justify such a change.

However, just because the LPS Act’s criteria for involuntary holds and conservatorships are sufficient to meet the intent of the Act does not mean the State is adequately caring for Californians with serious mental illnesses, and we identified other significant issues related to that care that we believe warrant action. For example, when we looked at the availability of treatment options for individuals on conservatorships, we found that people who were on the waitlist for specialized care in state hospital facilities had been waiting an average of one year to receive that care because of a shortage of available treatment beds. While they waited, some of the individuals received other care that did not fully meet their needs and did not fully protect them or others around them. Similarly, at the county level, Los Angeles and Shasta reported that they have a shortage of available treatment beds for a variety of types of care. However, only Los Angeles showed a robust understanding of its current capacity and need for additional treatment beds. Neither Shasta nor San Francisco has taken the steps necessary to ensure that they fully understand their needs for additional resources.

Additionally, in Los Angeles and San Francisco individuals exiting involuntary holds have not been enrolled consistently in subsequent care that could help them live safely in their communities. Specifically, of almost 7,400 people in Los Angeles who each had been placed on five or more short‑term holds from fiscal years 2015–16 through 2017–18, only 9 percent were enrolled during fiscal year 2018–19 in full‑service partnerships or assisted outpatient treatment—the most comprehensive and intensive methods available to all counties for providing community‑based care to individuals with serious mental illnesses. In San Francisco, the proportion was even lower. The LPS Act is intended to stabilize individuals who are experiencing crises because of their mental illnesses. Thus, people leaving LPS Act holds often need continuing mental health services; in particular, individuals who have experienced several short‑term holds represent a high‑need population that should be connected to counties’ most intensive community‑based care. However, Los Angeles and San Francisco did not always identify individuals who had been on multiple short‑term holds or ensure that these individuals received the ongoing care they needed. One reason for this gap in care is that counties do not have access to confidential state‑managed data about the specific individuals who have been placed on holds in the past.

Moreover, fewer than a third of California’s counties have adopted assisted outpatient treatment, even though it is an effective treatment option that could help prevent individuals from cycling through involuntary holds and conservatorships. Assisted outpatient treatment allows individuals to remain in their communities while still receiving the critical care they need, either voluntarily or by court order, depending on their circumstances. Nonetheless, only 19 counties have adopted such programs since California authorized them in 2003. The eligibility criteria that state law establishes for assisted outpatient treatment are one barrier to wider use of this treatment approach. For example, the criteria effectively exclude those leaving or recently on conservatorships from participating in this program. However, about one in four individuals placed on conservatorships whose cases we reviewed cycled back to restrictive settings, despite having successfully recovered their abilities to provide for basic needs at the time their conservatorships ended. In other words, a population of individuals who would likely benefit from assisted outpatient treatment are effectively ineligible to receive that continuing treatment. Further, with respect to involuntary assisted outpatient treatment, state law does not explicitly allow courts to order medication in an individual’s treatment plan despite the importance of medication to some individuals’ ability to live independently. Addressing these issues by changing the law would allow counties to better care for people with serious mental illnesses.

The treatment that individuals receive through the LPS Act is only one part of a much larger, county‑based mental health system in which California invests billions of dollars each year. Despite the magnitude of that investment, policymakers and other stakeholders do not have the information they need to understand the extent to which these funds affect people’s lives. The State’s current public reporting related to mental health programs and services relies on disjointed and incomplete tools—a result of multiple funding sources with different requirements and levels of transparency. For instance, we did not identify consistent public reporting of funds that the State distributed when it transferred its responsibilities for providing mental health services to counties—which totaled nearly $3 billion in fiscal year 2018–19—or to the outcomes counties produce for individuals with serious mental illnesses through those services. The Mental Health Services Act (MHSA) contains the most comprehensive public reporting requirements of the major mental health funding sources, but this reporting is still insufficient for understanding the full range of counties’ mental health spending. Further, current MHSA reporting requirements make it difficult for stakeholders to assess the balances of counties’ unspent funds.

Given these issues, an overhaul of mental health reporting requirements is necessary. We outline in this report a possible framework for this overhaul that includes capturing comprehensive spending information as well as outcomes for counties’ specific programs and for the State’s overarching mental health system. Because it already oversees MHSA reporting—the reporting closest to our proposed model—the Mental Health Services Oversight and Accountability Commission (Oversight Commission) is best suited to oversee a new approach to reporting on spending and outcomes. Without such a framework for consolidating information about the full range of mental health services, the State will remain unable to fully understand the impact of its mental health investments and the changes it could make to better serve those coping with mental illnesses. Further, we identified immediate changes the Legislature should make to direct MHSA funds toward people leaving LPS Act holds to ensure that they receive effective, community‑based care.

Summary of Recommendations


The Legislature should amend state law to do the following:

San Francisco and Shasta

By August 2021, San Francisco and Shasta should conduct assessments to determine the number and type of treatment beds that they need to provide adequate care to individuals receiving involuntary treatment. Once the assessments are complete, the counties should adopt plans to develop the needed capacity.

Los Angeles and San Francisco

By August 2021, Los Angeles and San Francisco should adopt systematic approaches to identifying individuals placed on multiple involuntary holds in their county‑designated facilities, obtaining information about those individuals, and connecting them to services that support their ongoing mental health.

Agency Comments

Los Angeles and San Francisco both disagreed with our conclusion that the LPS Act’s involuntary hold criteria are sufficient. Both counties agreed with our recommendation to provide counties access to information about LPS Act holds. Los Angeles expressed strong disagreement with our recommendations related to mental health care spending and outcome tracking, while San Francisco agreed with those recommendations. Shasta chose not to respond to our report.

Back to top