Signed by Gov. Gray Davis last year, the law, Assembly Bill 1421, allows judges to order assisted outpatient treatment for the seriously mentally ill who don't understand the gravity of their condition.

These are people who desperately need care but do not meet criteria for involuntary hospitalization.

Assisted outpatient treatment is intensive oversight of mental patients akin to what they would receive in a mental hospital. Instead of merely giving patients medication for a week or a month and sending them on their way, workers follow up with home visits, checking patients regularly and even observing to make sure they take their medications.

The program under the law "looks for people who are severely deteriorating and are not able to manage their own treatment."

Laura's Law was named in memory of Laura Wilcox, a 19-year-old high school valedictorian who was killed Jan. 10, 2001 by delusional and paranoid Scott Harlan Thorpe, a Northern California man who had repeatedly refused treatment and medication.

Thorpe, who was 41 at the time, was found incompetent to stand trial and was sent to Atascadero State Hospital. He was later transferred to California's Napa State Hospital.

Though a grand jury brought murder indictments against Thorpe, in March, several psychiatrists found that Thorpe was still incompetent to stand trial.

The crusade for a law to thwart another act of violence by the mentally ill in California began about three years ago with Assembly Bill 1800, an earlier more comprehensive version of AB 1421.

Thomson, whose term expired in November, was elected to the Yolo County Board of Supervisors.

"I won't say who was behind it, but it got buried in the Senate committee," Stanley said.

The nearly toothless version, AB 1421, was introduced later.

Originally, $300 million was earmarked for its implementation but California, already financially strained because of the energy crisis, didn't have money to fund it.

The bill was reintroduced with no money to put it to work and relies on counties to underwrite costs.

"It doesn't have a lot of teeth," Stanley said. "A second weakness is that individual counties have a choice on whether to implement it."

They have to get creative.

To fund Laura's Law, Los Angeles County officials subtracted from the number of inpatient psychiatric beds the county "buys" from the state Department of Mental Health each year.

"The plan is that people who would have otherwise used these beds could go into this program and therefore decrease our need for those beds," Shaner said. "It's fairly complex, but that's what has allowed us to do this."

Last year, Los Angeles County purchased about 325 psychiatric hospital beds from the state.

Los Angeles County reduced the number of psychiatric beds reserved for it by 10, freeing about $1 million to implement its Laura's Law program. It hopes to serve about 35 people.

"The law basically states that an individual can receive assisted outpatient treatment with proper investigation and court approval," Shaner said.

"A person can be released from a restricted setting on the condition that they continue with the treatment. It carefully specifies what services will be offered."

Thomson said that New York has already seen more people staying on their medications because of the law.

In addition, New York's mental health department has seen an increase in people taking advantage of housing and vocational services, she said.

"People are returning to more normal living quicker," Thomson said.

Other California counties are talking about Laura's Law and looking at creative ways to fund it, Thomson said.

Mostly, everyone's awaiting results from Los Angeles County.

So far, fewer than 10 people have been placed in its program, which started earlier this year.

"Even though this program is small now, we see this as an opportunity to help us determine other steps in the future," Shaner said.

Laura's Law is a California state law that allows for court-ordered assisted outpatient treatment. To qualify for the program, the person must have a serious mental illness plus a recent history of psychiatric hospitalizations, jailings or acts, threats or attempts of serious violent behavior towards self or others. A complete functional outline of the legal procedures and safeguards within Laura’s Law has been prepared by NAMI San Mateo.

The law was named after Laura Wilcox, a young woman who was killed by a mental patient who had refused treatment. Modeled on Kendra's Law, a similar statute enacted in New York, the bill was introduced as Assembly Bill 1421 by Assemblywoman Helen Thomson, a Democrat from Davis. The measure passed the California Legislature in 2002 and was signed into law by Governor Gray Davis. The statute can only be utilized in counties that choose to enact outpatient commitment programs based on the measure. As of 2010, Nevada County has fully implemented the law and Los Angeles County has a pilot project. In 2010 the California Supervisors Association chose Nevada County to receive its Challenge Award for implementing Laura’s Law.

Background

Laura Wilcox, a 19-year old sophomore from Haverford College, was working at Nevada County's public mental health clinic during her winter break from college. On January 10, 2001, she and two other people were shot to death by Scott Harlan Thorpe, a 41-year old mental patient who resisted his family's attempt to seek treatment.

Thorpe was found incompetent to stand trial and was sent to Atascadero State Hospital and was later transferred to California's Napa State Hospital. After the incident Laura’s parents chose to advocate for treatment of individuals with mental illness

Implementation at county discretion

The law is only operative in those counties in which the county board of supervisors, by resolution, authorizes its application and makes a finding that no voluntary mental health program serving adults, and no children's mental health program, was reduced in order to implement the law.

In 2004, Los Angeles County implemented Laura's Law on a limited basis. Since the passage of the MHSA [see below Prop. 63] Nevada County fully implemented Laura's Law in May 2008 and several other counties are discussing it, notably San Francisco County, San Mateo County, San Diego County, Marin County and others.

In those counties that adopt outpatient commitment, an AB 1421 program will ensure individuals are provided the services and medical treatment (including medication) that will enable the person to have a good chance to recover. Nevada County Director Michael Heggarty bests describes it as part of the recovery movement.

Proposition 63 impact

In November 2004, California voters passed Proposition 63. When the California Department of Mental Health (DMH) released its draft plan requirements for county mental health administrators on February 15, 2005, they contained a provision that would allow MHSA funds to be used for "involuntary services" if certain criteria were met. Nevada County's Laura's law program and Los Angeles County's AOT pilot project are utilizing MHSA funding for services.

Assisted outpatient treatment eligibility criteria

As stated above the patient must have a serious mental illness plus a recent history of psychiatric hospitalizations, jailings or acts, threats or attempts of serious violent behavior towards self or others. The recipient must also have been offered an opportunity to voluntarily participate in a treatment plan by the local mental health department, yet fails to the point that, without a Laura’s Law program, he or she will likely relapse or deteriorate to the point of being dangerous to self or others. "Participation in the assisted outpatient program is the least restrictive placement necessary to ensure the person’s recovery and stability." While a specified group of individuals may request an investigation to determine is a person qualifies for a Laura’s Law program, only the County mental health director, or his or her designee, may file a petition with the superior court for a hearing to determine if the person should be court ordered to receive the services specified under the law.

A person may be placed in an assisted outpatient treatment if, after a hearing, a court finds that the following criteria have been met. The patient must:

• Be eighteen years of age or older

• Be suffering from a mental illness

• Be unlikely to survive safely in the community without supervision, based on a clinical determination

• Have a history of non-compliance with treatment that has either:

1. Been a significant factor in his or her being in a hospital, prison or jail at least twice within the last thirty-six months; or

2. Resulted in one or more acts, attempts or threats of serious violent behavior toward self or others within the last forty-eight months

• Have been offered an opportunity to voluntarily participate in a treatment plan by the local mental health department but continue to fail to engage in treatment

• Be substantially deteriorating

• Be, in view of his or her treatment history and current behavior, in need of assisted outpatient treatment in order to prevent a relapse or deterioration that would likely result in the person meeting California's inpatient commitment standard, which is being:

1. A serious risk of harm to himself or herself or others; or

2. Gravely disabled (in immediate physical danger due to being unable to meet basic needs for food, clothing, or shelter);

• Be likely to benefit from assisted outpatient treatment; and

• Participation in the assisted outpatient program is the least restrictive placement necessary to ensure the person's recovery and stability.

If the court finds that the individual meets the statutory criteria, the recipient will be provided intensive community treatment services and supervision by multidisciplinary teams of highly trained mental health professionals with staff-to-client ratios of not more than 1 to 10, and additional services, as specified, for persons with the most persistent and severe mental illness. The law specifies various rights of the person who is the subject of a Laura’s Law petition as well as due process hearing rights. The bill also provides for voluntary settlement agreements as an alternative to the hearing process

Debate over bill's efficacy and propriety

Supporters

Passage of the bill was supported by organizations such as the California Treatment Advocacy Coalition (an affiliate of the Treatment Advocacy Center), the California Psychiatric Association, the Police Chiefs Association, and the National Alliance on Mental Illness (NAMI). In an editorial endorsement of the law, the Los Angeles Times touted then-Governor Gray Davis's support, while limiting its comments on opponents to mentioning that "a subgroup of the Church of Scientology, which opposes virtually all psychiatric treatments, sponsored a rally at the Capitol against Laura's law."

The San Francisco Chronicle and The San Francisco Examiner have published positive articles on the topic. The Los Angeles Times won a Pulitzer Prize, in part for its coverage of Laura’s Law.

Opposition

MindFreedom International and the California Network of Mental Health Clients (CNMHC), along with allies in the psychiatric survivors movement, also fought the measure and its earlier versions, accusing such legislation as a regressive and reprehensible scheme to enforce coerced drug treatment regimens against the will of patients. The Church of Scientology also gained attention as an opponent of the new law.

Evidence of Efficacy

Studies on Kendra's Law

Many of the studies on the efficacy of assisted outpatient treatment (AOT) are done on Kendra's Law (on which Laura's Law is based). Two notable studies were released in 2005 and in 2009. These studies were very important as they revealed the inaccuracies in many of the arguments critics of assisted outpatient treatment were making. A good briefing of these and other studies was prepared by The Treatment Advocacy Center.

The 2005 study found:

Specifically, the OMH study found that for those in the AOT program:

• 74 percent fewer experienced homelessness;

• 77 percent fewer experienced psychiatric hospitalization;

• 83 percent fewer experienced arrest; and

• 87 percent fewer experienced incarceration.

Comparing the experience of AOT recipients over the first six months of AOT to the same period immediately prior to AOT, the OMH study found:

• 55 percent fewer recipients engaged in suicide attempts or physical harm to self;

• 49 percent fewer abused alcohol;

• 48 percent fewer abused drugs;

• 47 percent fewer physically harmed others;

• 46 percent fewer damaged or destroyed property; and

• 43 percent fewer threatened physical harm to others.

As a component of the OMH study, researchers with the New York State Psychiatric Institute and Columbia University conducted face-to-face interviews with 76 AOT recipients to assess their opinions about the program and its impact on their quality of life. The interviews showed that after receiving treatment, AOT recipients overwhelmingly endorsed the program:

• 75 percent reported that AOT helped them gain control over their lives;

• 81 percent said that AOT helped them to get and stay well; and

• 90 percent said AOT made them more likely to keep appointments and take medication.

Additionally, 87 percent said they were confident in their case manager's ability to help them—and 88 percent said that they and their case manager agreed on what is important for them to work on. AOT had a positive effect on the therapeutic alliance.

In 2009, an independent study by Duke University into alleged racism found "no evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings."

A 2010 study on Kendra's Law by Gilbert et al showed that "the odds of arrest for participants currently receiving assisted outpatient treatment (AOT) were nearly 2/3 lower (OR .39, p<.01) than for individuals who had not yet initiated AOT or signed a voluntary service agreement."

Another 2010 study from Swartz et al tracked Medicaid claims and state reports for 3,576 AOT consumers from 1999-2007. They found that "the likelihood of psychiatric hospital admission was significantly reduced by ~25% during the initial six-month court order (odds ratio [OR]=.77, 95CI=.72-.82) and by over 1/3 during a subsequent six-month renewal of the order (OR=.59, CI=.54-.65) compared with the period before initiation of the court order. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals (OR=.80, CI=.78-.82, & OR-.84, CI=.81-.86, respectively)."

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