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San Francisco Mayoral Candidates and Mental Illness

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The San Francisco Chronicle asked the mayoral candidates whether or not they support Laura's Law. Laura's Law lets courts order a very small group of severely mentally ill (only those with a past history of violence, arrest, or multiple hospitalizations) to stay in treatment as a condition for staying in the community. It's been hugely successful wherever it's been used at keeping patient and public safer, while simultaneously saving money. Even those in the program overwhelmingly support it.

Candidates Jeff Adachi, Michela Alioto-Pier, Bevan Dufty, Tony Hall, Joanna Rees, Dennis Herrera, Phil Ting, and Leland Yee fully support the law and therefore deserve the support of San Franciscans who want to improve care for people with mental illness, those who want to keep the public safer, and those who want government to spend less.

John Avalos opposes Laura's Law because of alleged expense and impact on other public health services. He is wrong on both counts.

David Chiu claims to support the intention, but not the law because he is following the lead of former San Francisco public health director, Mitch Katz, who opposes the law.

But when it comes to treating people with severe mental illness, mental health directors are notoriously unreliable. Leaders of mental health departments prefer to cherry-pick the easiest to treat for their programs. That is why in California there are 3.8 times as many mentally ill in prisons and jails than psychiatric hospitals and why San Francisco has so many homeless people with severe mental illness foraging dumpsters for food. Mental health officials prefer to serve large numbers of people with mental "health" issues rather than people with severe mental "illness" because that gains them larger political clout. This "mission-creep" sends the severely mentally ill to the end of the line, shelters, jails and morgues, while the worried-well crowd them out at the front. So it is not surprising that Mr. Katz is not a supporter of Laura's Law. What is surprising is that candidates Avalos and Chiu defend the staus quo, rather than express a desired to improve it.

Following are some of the myths surrounding Laura's Law.

MYTH: If there were more voluntary services, Laura's Law would not be needed.
REALITY: Voluntary programs and AOT currently serve two mutually exclusive populations. Voluntary programs serve those who 'voluntarily' accept services. Laura's Law by definition is for those won't accept voluntary services. Laura's Law does not preclude anyone from accepting voluntary services.

MYTH: Existing community programs serve the same people who would be served by Laura's Law
REALITY: Laura's Law is the only community program that serves people who refuse treatment. San Francisco has no other program that can accomplish this.

MYTH: Laura's Law doesn't work because it doesn't allow forced medication. REALITY: Nevada County's experience with Laura's Law found it does work. Per Judge Anderson it saves people from severe mental health deterioration, increases voluntary participation in mental health care, increases stability, decreases crisis. Studies of the NYS version of Laura's Law show it
  1. Helps the mentally ill by reducing homelessness (74%); suicide attempts (55%); and substance abuse (48%).
  2. Keeps the public safer by reducing physical harm to others (47%) and property destruction (43%).
  3. Saves money by reducing hospitalization (77%); arrests (83%); and incarceration (87%).

MYTH: Laura's Law will lead to a roundup of mentally ill individuals who will be forced into treatment.
REALITY: Laura's Law's narrowly-focused eligibility criteria, stringent multi-layer administrative requirements, independent judicial review and strong due process protections protect against misuse. Nevada County and Orange County estimate less than 1 in 25,000 individuals (.00004) of the population would be allowed into the program. This is consistent with NYS findings.

MYTH: Laura's Law is unconstitutional and infringes on civil liberties.
REALITY: Versions of Laura's Law have survived constitutional challenges in multiple states. A 2009 NYS study of their version of Laura's Law found:

(I)t is now well settled that Kendra's Law is in all respects a constitutional exercise of the states police power, and its parens patriae power. Further, the removal provisions of the law have withstood constitutional scrutiny.

AOT also cuts the need for incarceration, restraints, and involuntary inpatient commitment, allowing individuals to retain more liberties.

MYTH: Laura's Law will frighten consumers away from seeking voluntary services. REALITY: A study in Psychiatric News of involuntarily treated discharged psychiatric patients found that 60 percent retrospectively favored having been treated against their will. A 2005 NYS study of consumers in their version of Laura's Law found:
  1. 75% reported that AOT helped them gain control over their lives;
  2. 81% said that AOT helped them to get and stay well;
  3. 90% said AOT made them more likely to keep appointments and take medication.
The 2009 independent study found:

"On the whole, AOT recipients and non-AOT recipients report remarkably similar attitudes and treatment experiences. That is, despite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their mental health treatment experiences than comparable individuals who are not under AOT."

MYTH: Assisted Treatment forces people to take medications.
REALITY: There is no provision for forced medication in Laura's Law. But it works anyway in counties where it is used. This is called "The Black Robe" effect. Going in front of a judge is enough to convince most to stay in treatment.

MYTH: Mental Health Commissioners support Laura's Law
REALITY: This is generally true after the program is implemented, but not before. (See misleading report by Orange County officials). Many (not all) mental health commissioners oppose Laura's Law before implementation because they fear losing the ability to cherry-pick the easiest to treat for admission to their programs. Currently mental health policy is to send the most severely ill individuals to shelters and jails and use the 'savings' to fund services to a larger number of people ("mission-creep").

MYTH: Prop 63/Mental Health Services Act money can not be used to fund Laura's Law
REALITY: Both Los Angeles and Nevada County use MHSA money (plus Medicare, Medicaid, private insurance, and patient fees) to fund Laura's Law. San Francisco can too.

MYTH: Voluntary programs have to be cut to fund Laura's Law
REALITY: Per California Department of Mental Health, voluntary programs that provide services (ex., medication, case management, housing, CSS, etc.) may also serve individuals under court orders. There is no need to close these programs, merely open them up to people under court orders.

Myth: Laura's Law is expensive.

REALITY: Nevada County found they saved $1.81 for every $1.00 invested. The Mental Health Director found it decreases hospitalizations, length of hospitalizations, and use of 911, arrest, trial, incarceration and parole; and can be funded with existing sources.

Clearly San Francisco should implement Laura's Law. With hundreds, perhaps thousands of mentally ill inmates about to be released as a result of Plata v. Brown, a mechanism to keep people with mental illness safe is needed now more than ever. Laura's Law helps everyone. Some mayoral candidates know that. Others don't.