The Nevada County Experience with Laura’s Law

Prepared by California Treatment Advocacy Coalition and
Below are answers to sometimes posed questions related to the implementation of Laura’s Law from those with firsthand experience in California
Judge Tom Anderson, Presiding Judge of Nevada County
Carol Stanchfield, Program Director for Nevada County’s Laura’s Law Program
Michael Heggarty, Nevada County Director of Behavioral Health

Question: Are the legal procedures within Laura’s Law complex, requiring substantial effort or expense to implement?

Answer: No. The legal procedures are quite simple.
Presiding Judge Tom Anderson: The legal procedures are quite simple: 1) A request is made for a LL investigation; 2) An assessment is conducted; 3) If appropriate a Petition is filed with the court and 4) A hearing is scheduled and held. That is the whole program from a legal perspective.
The impact of LL is connecting the person/patient with services. The practical experience, here and everywhere, is that when a LL-type outreach occurs, the patient most always accepts services and becomes the participating, engaged patient we want them to be. Thus by utilizing the LL process we save patients from decompensation, additional costs to the agencies and further serious harm to the patient.
The success of LL comes not from the number of court orders issued but by the number of court orders that do not have to be issued because of the intervention allowed by LL.
Program Director Carol Stanchfield: The steps are fairly straight forward. Once the county identifies a person who may meet the criteria, the person is referred to the licensed mental health therapist by the “county access team.” In Nevada County, AOT is facilitated by a contractor (Turning Point) through an existing full service partnership, implementing Adult Assertive Community Treatment (a wraparound approach).
Director of Mental Health Michael Heggerty: Several steps are needed for a policy and procedure manual, because you need to address many situations, which may or may not ever occur. In our example, we use only a few of these steps, and many of the steps have never been used. Most individuals either agree to voluntary outpatient treatment or enter into a Settlement Agreement. Court Ordered treatment under this statute is rare in Nevada County.

Question: Is it burdensome to the Director of Mental Health to investigate referrals for petitions to Laura’s Law?

Answer: No. The process is actually much less burdensome than those for other statutes.
Judge Tom Anderson: The law requires that the Director or his/her representative investigate. That means that the Director is responsible to appoint a mental health professional to investigate requests. IF it is determined that a Petition needs to be filed, then a Petition is filed and a hearing is scheduled. The process is actually much less burdensome than current procedures {for 5150} because is permits direct contact with a person who, by definition, is decompensating and not engaged in services. Thereby avoiding the current process of waiting until the person deteriorates and commits a criminal offense or their behavior becomes so outrageous or dangerous to themselves or others that they have to be involuntarily committed to either jail or an institution. LL is designed specifically to avoid thatlevel of decompensation and prevent those dangerous situations (and the extreme expenses to the county that results from not implementing LL).
Program Director Carol Stanchfield: This is delegated to the contracted Licensed Mental Health Therapist who investigates. If the client meets criteria and an AOT petition is justified, the Director of MH is notified, appropriate documents are prepared and sent to County Counsel to prepare the petition. The Director, or his representative reviews the documents and signs the petition, with minimal time involved by the Director of MH.
Director of Mental Health Heggarty: I delegate the majority of the investigation to subordinate staff, a Program Manager, A Supervisor, and a psychotherapist. I review the initial request for a petition, which takes me 10-15 minutes. I also review the results of the completed investigation prior to filing the petition, which takes another 15 minutes. Signing the petition takes 5 minutes tops.

Question: Is it burdensome to maintain records to submit the annual report to the State Department of Mental Health
Answer: No. The department is required to keep records regardless and those records are computerized.
Judge Tom Anderson:The department must keep records, the department has computers, it is not all that burdensome. And that is part of the department’s job.
Program Director Carol Stanchfield: The contractor is responsible for maintaining these records and forwarding information to the county for the state report.

Director of Mental Health Heggarty:
I delegate record maintenance to the service provider. Whenever I need them, it takes me 5-10 minutes to request summary updates and forward them to DMH or other interested parties.

Question: Are clients who are currently enrolled in a public case management program, but not compliant, eligible for Laura’s Law?

Answer: Yes. Clients already enrolled in programs but who are not engaging in the program are eligible for Laura’s Law if they meet the criteria and are deteriorating from that lack of compliance.
Judge Tom Anderson: If someone who is enrolled in a case management program is not compliant, they are not “accepting services” by description. They are eligible.
Program Director Carol Stanchfield: This refers to a client’s willingness or ability to engage in services. The pattern of not engaging in treatment that leads to a minimal number of incarcerations and/or hospitalizations (in a specific time period) {or} “with a history or assault, or threat of assault” is the focus. Not everyone who refuses to engage in treatment would meet those criteria.Clients who might voluntarily agree to treatment, but are not adhering to treatment may be eligible if their condition is deteriorating and all other criteria are met.
Director of Mental Health Heggarty: This involves a personal judgment on a case by case basis. The law is somewhat vague regarding making this decision. I am reluctant to move forward on a petition if the individual is participating even marginally in treatment. The Director and the Judge would need to assess and analyze the definitions of ‘refusing treatment’, ‘accepting mental health services’, and ‘compliance’, then decide on the merits of each case.

Question: But, wouldn’t a public defender immediately make the point that the person is enrolled in a current program and thus not eligible for LL?

Answer: Perhaps, but that is the client’s right to due process.
Judge Tom Anderson:Due process demands that the public defender represent their client. The public defenders try to do what is in the best interest of their clients. And simply because an attorney makes a motion, does not mean that the motion is granted.
Program Director Carol Stanchfield: If the criteria are met, the petition is signed by the MH Director, “reasonable likelihood” has already been established that the petition can be proven through AOT hearing process. The public defender ensures the AOT criteria are met and supports the candidate in understanding the proceeding. If criteria are not met the application should be dismissed. This is due process and protects the rights of the candidate.
Director of Mental Health Michael Heggerty: Yes. Possibly. That is the beauty of due process, is it not? That is why we need judges to evaluate the arguments on both sides of the case and make a judgment. For us, the statute can make a bigger impact on individuals who have no current involvement in the mental health system.
Question: Is it a problem that there is no way to force medication in the community under Laura’s Law?
Answer: No. Other laws—and good medical practice—require that forcible administration of medications can only happen in a licensed medical facility

Question: Does Laura’s Law go far enough to be truly helpful?

Answer: Yes. Laura’s Law has been proven to be effective in engaging people in treatment.
Judge Tom Anderson: The impact of the current LL and the similar programs in other communities definitively demonstrate that these programs are more successful than any other programs currently in use. LL provides a means to intervene to prevent serious brain injury, to prevent extreme crisis, to encourage cooperation and in doing so saves money for the taxpayers. As to Laura’s Law compliance issue, while the treatment provider can not force medication, the court can order a person to comply with their treatment plan. LL is one of the few programs that includes a means (however minimal) to hold the service providers accountable as well as the patient. Perhaps the statute could be modified to ‘go farther” but in its current form, LL has proven to be remarkably effective.
Program Director Carol Stanchfield: AOT does not force medication. Medication is only one part of treatment. The relationship between to provider and the client is the main agent of change here, along with the structure and persuasion of the court if needed. AOT is a preventative measure that starts out as an invitation to voluntarily accept services…… supports that can improve the quality of life for the individual.Most people want to stay out of the hospital and/or jail and reestablish relationships with family or friends. This gives them an opportunity to choose. Sometimes this intervention is all that’s needed to support an AOT candidate with steps recovery without going to court.Court is often persuasive and can be a helpful structure for people {previously} struggling with frequent hospitalizations.
Director Michael Heggerty: A weakness in the {other} law, agreed. But, the Judge can still order an inpatient evaluation, where medications can be ‘forced’ if needed. And, following appropriate techniques of outreach, engagement, and persuasion, most of our individuals do agree to medications and eventually and voluntarily take their recommended medication. It is still ‘better’ for an individual with an untreated mental illness, to be participating in the outpatient mental health system, whether or not they are taking their prescribed medication. We still have the opportunity to engage the person, monitor whether they might be slipping into 5150, etc. Compared to the same person living isolated and alone in the community.

Question: Since Nevada County (pop. 97,751) has only had to do one direct court order {versus settlement orders}, does this mean Laura’s Law is ineffective?

Answer: No. Laura’s Law is effective and specifically designed to help the person start engaging in their own treatment. The Settlement order was legislated to help the person take that first step to engagement.
Judge Tom Anderson: The need for limited {direct} court orders overwhelmingly demonstrates the success of the LL process. By allowing intervention through LL with patients before they decompensate, to the point of being 5150’d, patients have shown a willingness to comply with treatment. Whether this is a result of outreach by a mental health professional or coercion by the court or a combination of the wrap-around efforts, it works. It works so well that the ultimate use of the authority provided by LL does not have to be utilized it the majority of cases.
Program Director Carol Stanchfield: The success of AOT is in the preventative nature of the law. That there have been 22 referrals and only six hearings is evidence of its effectiveness. The outcomes in Nevada County’s program measure the level of engagement and recovery among those referred. Most candidates with a history of lack of compliance with treatment are {now} stable and succeeding with housing, relationships, community involvement and on a path to recovery.There will always be a few that struggle; but supports remain in place to reduce the risk of higher level of restricted placement.
Director of Mental Health Michael Heggarty: 44 states have enacted laws using Assisted Outpatient Treatment. Data gathered from controlled studies indicate that AOT is effective and reduces hospitalization, arrests, homelessness, victimization, and improves substance abuse treatment. Furthermore, AOT laws in California require the use of the Assertive Community Treatment model, which is an established evidenced based practice.
Judge Tom Anderson COMMENT:
LL provides an effective tool to help people who are in serious danger of being involuntarily hospitalized or incarcerated or worse. The impact of LL interventions has been proven to save people from severe mental health deterioration, increase voluntary participation in their own mental health care, increase personal and social stability, decrease the need for crisis intervention and saving of lots of taxpayer money. There is no good reason to not implement LL. In fact, under the current circumstances (considering the budget issues and standards of care) the failure to utilize LL might be considered negligent.
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Prepared by California Treatment Advocacy Coalition and