Rights of Mentally Ill Pitted Against Public, Patient Safety

When Julie Rodriguez drove herself and her two young children into the muddy depths of the Sacramento River last spring, she wasn’t the same person her parents had raised. She had become someone else, they say, someone distorted by illness and suffering.

William and Elvira Gonzalez couldn’t help her. The way they see it, they weren’t allowed to.

Rodriguez, 31, refused treatment for her deepening paranoia and psychosis. And despite her family’s pleas to counselors, doctors, children’s protective services officials and the police, no one felt able to force her into a hospital.

“They wouldn’t do [anything] unless she did something real drastic,” Elvira Gonzalez said. “I said, ‘Are you going to wait for a tragedy to happen? By then it will be too late!’ ”

Last May, Gonzalez was proved horribly right. Rodriguez, once a doting mother, ended three lives with the turn of a steering wheel. Efrain was 4, Priscilla 2.

Citing sensational crimes and lesser-known tragedies like these, as well as dramatic improvements in psychiatric medications, critics of California’s commitment law want to make it easier to force resistant mental patients into treatment.

“No one wants to go back to the days when it was too easy to hospitalize someone and throw away the key,” said Rosalyn Kalmar of Los Angeles, who has struggled to get care for her daughter. “But we’ve gone too far in the other direction.”

These reformers--mostly health care providers and families of the mentally ill--face a rock wall of opposition from patients rights groups and civil libertarians. They insist that the 1969 law and subsequent protections are in place for a good reason: to prevent any repetition of past psychiatric abuses.

At issue is the strict, complex set of rules that California has developed over the past 30 years governing detention and treatment of psychiatric patients against their will. Before they were enacted, patients could be hospitalized indefinitely after what critics considered perfunctory court hearings. Hospital staff determined how long they were held.

Now, people can be committed to hospitals for evaluation only if doctors find them dangerous to themselves or others, or so gravely disabled that they can’t care for their basic needs. A person can be detained for three days before a hearing must be scheduled.

In the name of public and patient protection, reformers want to allow involuntary commitment when patients’ conditions have deteriorated markedly, for example, or when their histories show poor judgment about their own care. Reformers also want to broaden use of outpatient commitments--court-ordered medication and monitoring in the community--so that care is not restricted to brief, expensive hospital stays.

Many patients, former patients and civil libertarians cringe at the very notion, recalling psychiatry’s sordid history of drastic, misguided treatments administered in the name of science: lobotomies, sterilizations, clitoridectomies and convulsive “therapies.”

Some have themselves been involuntarily hospitalized, placed in restraints, misdiagnosed and drugged repeatedly against their wills. To them, the freedom to refuse treatment is a fundamental right rooted in long-standing medical precepts and constitutional protections of life, liberty and the pursuit of happiness.

“Give me liberty or give me death!” said Sally Zinman, executive director of the California Network of Mental Health Clients, which has 1,115 members.

Retorts E. Fuller Torrey, a psychiatrist and national proponent of legal reform: “Being psychotic on the streets is not being free. You are imprisoned by your brain dysfunction.”

In California, the already raging debate appears destined to intensify during the next legislative session, when reform proposals are expected to be introduced.

Meanwhile, other states have forged ahead. New York legislators were shocked into action by two recent incidents in which unmedicated mental patients pushed strangers under subway cars. In August, the state passed a law named after one of the victims, Kendra Webdale, that makes it far easier for the courts to order outpatient mental treatment.

For the last 30 years, California has been headed mostly in the opposite direction, toward greater patient freedom. This state eagerly emptied state mental hospitals, and went on to pass the trailblazing Lanterman-Petris-Short Act, which built tough civil rights protections into mental health law. The protections were emulated throughout the nation.

Now that safer, more effective medications can treat and perhaps forestall illness, and patients don’t necessarily need to be hospitalized, the question is whether California will change its course.

In many ways, the battle pits the promise of science against the pain of history. It is a fight that many mental health advocates lament, even as they stake out strong positions, for it divides parents from children and usual allies from one another. It also distracts, some say, from their primary mission: enhancing services for people who desperately need them.

“We [California mental health advocates] have worked hard to really come together in a real partnership, and this will just destroy it,” said Zinman. But given what’s at stake, “we have to come out fighting.”

Concern for Public Safety Spurred Law

Last January, when 32-year-old Kendra Webdale was shoved from a New York subway platform into the path of a train, the nation shuddered.

What could be more terrifying than a sudden, unpredictable act of violence by an apparently psychotic stranger?

The alleged murderer, Andrew Goldstein, has become a harrowing symbol of what can happen when untreated mental illness explodes into random violence.

Actually, it doesn’t happen very often; about 4% of all violence is committed by mentally ill people, and much of it is against family members.

But concern for public safety was the key to passage of “Kendra’s Law” in New York. And, to the dismay of patients trying to de-stigmatize mental illness, advocates of stricter involuntary commitment often cite out-of-nowhere attacks on strangers as a logical outcome of leaving mental patients untreated.

Only after Webdale’s death did officials ask why Goldstein wasn’t kept on medications after his repeated hospitalizations and why no one followed up. Goldstein’s mother had been asking the same questions for some time.

Such headline-grabbing acts of violence have “set the stage” for discussing involuntary treatment reforms nationwide, said California Assemblywoman Helen Thomson (D-Davis), who plans to introduce changes in the commitment laws next year.

But she and others say quieter tragedies play out every day, year after year. The basic script hardly varies: Patients deteriorate and even die while their families struggle, often in vain, to help them.

Elvira Gonzalez did her best. In the years before her daughter, Julie, drowned her children and herself, Gonzalez was able to persuade her to go to a Sacramento County mental health facility just three times. Her efforts were wasted. Once, Rodriguez became impatient and left; twice, she refused treatment and counselors declined to detain her, presumably because she did not appear dangerous.

Though police were summoned to calm Rodriguez at least eight times, they never saw fit to seek a three-day hold in a psychiatric hospital, the first step in involuntary treatment.

Rodriguez continued to rant and laugh to herself, to fight with her husband and dig her nails into his arm. She drove her car all over the region late at night with the windows open and the children in tow. Sacramento County Children’s Protective Services workers came out once to her house, saw that it and the children were well-scrubbed and took no action, Gonzalez said.

“I think there’s a lot of people who might put someone into the hospital because they’re mean, but when a person loves their daughter or son, and they’re trying to get them good help, there should be something [done],” Gonzalez said.

Critics complain that it’s harder to get something done in California than almost anywhere else.

“The law right now just doesn’t work in the best interest of the patient, nor the families,” said Sen. Don Perata (D-Alameda), who is writing reform legislation with Thomson. “Why can’t we do it better?”

Perata’s frustration comes from experience. He couldn’t get his own schizophrenic sister into treatment until he deliberately provoked her to near-violence in front of police officers. “Had I not lived it, I would not have believed it,” he said.

The law is so loaded with protections of patients’ civil rights, critics say, that it fails to protect their lives. One critic counted at least 14 opportunities in the law for patients to challenge their detention or drug treatment.

“Over the years, [the law] has been piecemeal amended to make it one of the most adversarial, costly and difficult to administer involuntary treatment systems in the country,” wrote a private task force advocating changes in the Lanterman-Petris-Short law in a March report.

The law is nothing if not elaborate. The 72-hour hold for psychiatric evaluation is just the first step. After that, the law provides for 14-day holds, additional 14-day holds, 180-day holds, and temporary and long-term conservatorships in which another person is appointed to oversee a patient’s care.

Each step has its own legal criteria and requires at least one hearing. Still other hearings must be held if doctors want to medicate patients against their will.

The intricate process creates what critics call absurd scenarios. For example, a patient can lose a bid to leave the hospital but win a petition to refuse medication, tying the hands of treating psychiatrists. A patient detained for suicidal behavior can be released after 31 days--whether or not he is still suicidal--because after that, the “danger to self” criterion no longer applies.

From then on, patients generally can be held only if they’re “gravely disabled”--meaning that they can’t provide for their own food, clothing or shelter.

Advocates of changing the law want to expand the circumstances under which involuntary treatment is allowed, streamline procedures and combine medication and detention hearings.

Opponents say vague criteria such as “substantial deterioration” or “inconsistent judgment” leave psychiatrists and others free to decide anything they want, to curtail basic freedoms based on subjective impressions.

They offer horror stories of past abuses, some from personal experience.

“I was beaten by the doctor, and tied down to a bed after I tried to escape,” said Zinman, whose father had her placed in a private hospital in Pennsylvania during the early 1970s. “I was in a security room for three months, in my underwear . . . with a bucket for a bathroom.”

Ron Schraiber, consumer affairs director for the Los Angeles County Department of Mental Health, describes his hospitalization two decades ago in California as a form of persecution.

“I was paralyzed from the neck down by psychiatric medications,” he said. “Throughout history, every [oppressed] group has been denied rights based on differences that make them inferior. . . . When you say a group of people are qualitatively different, you can do things to them.”

New Drugs Offer Reasons for Hope

Whatever past misdeeds were done in the name of science, many researchers and clinicians say the future is bright: New medicines offer an unprecedented opportunity to free long-tormented patients from the prison of psychosis.

Although no one claims to have a cure for mental illness, some suggest that new drugs--such as Zyprexa, Risperdal, Seroquel and Clozaril for schizophrenia--can slow or stop its progression with a minimum of side effects.

The biggest problem is getting patients to accept the medications. Doctors once attributed this to “denial”--a reluctance to own up to a stigmatized illness--and to a fear of uncomfortable side effects.

But Columbia University professor Javier Amador came up with another theory that has gained currency in the last 10 years: The brain disorder itself keeps many seriously ill mental patients from recognizing that they are sick.

He likens the condition to that of stroke patients who cannot accept that they have lost the use of a limb, or certain blind patients who believe, against all evidence, that they can see.

“This unawareness is neurologically based,” he said. “Neuropsychiatric tests that are sensitive to the frontal lobes of the brain [show deficits] highly correlated with unawareness of illness.”

A schizophrenic person may believe, for example, that he can do everything he could do when he was 18, before his first psychotic break. It is as though he is “stranded in time,” Amador said, unable to “update his self-concept.”

Amador’s research on 400 schizophrenics suggests that more than half the people with the disease are not aware they are ill. Nationwide, that translates to more than a million people who are unaware. Amador and other scientists say this works against the kind of prompt treatment that can prevent repeated psychotic episodes and more severe brain damage.

Within five to 10 years, many schizophrenics become “persistently symptomatic,” said Dr. Jeffrey Lieberman, a University of North Carolina psychiatrist. “The best strategy is to treat patients early, [to] prevent progression or recurrence.”

He wades, reluctantly, into the social debate: “We don’t want to be overly paternalistic, but by not encouraging and doing everything possible to engage people with schizophrenia in treatment, we do them a great disservice that ultimately harms them and society as well.”

One broader social concern is public health. Some doctors say homeless mentally ill people often develop physical diseases--such as tuberculosis or AIDS--that pose a health threat to the wider community and act as a financial drain on health resources.

Opponents of involuntary treatment say that the promise of new drugs is overblown, that they don’t always work and still can cause serious side effects for some patients.

They draw some scientific support from disaffected researchers and clinicians.

“All the public mental health system can do is pass out drugs,” complained Dr. Loren Mosher, a former clinical director of the San Diego County Mental Health Department. “People run away from treatment because they experience it as personally uncomfortable and harmful.”

Neuroscientist Elliot S. Valenstein challenges the very notion that drugs are needed to treat so-called chemical imbalances in the brains of mental patients.

“We should not be all that reliant on drugs when their effectiveness is grossly exaggerated,” he said.

Solution to Conflict Is Not Expected Soon

A resolution to this conflict over legal reform is neither obvious nor easy. It has become increasingly--some would say distressingly--polarized.

“A great number of people see me as the enemy,” confided one deputy public guardian who handles conservatorship cases in Los Angeles County Superior Court. “I don’t want people to know where I live.”

In this charged atmosphere, subtleties and opportunities for compromise often get lost. There are patients who favor stronger commitment laws, for example, and families loath to change them, but their voices often don’t rise above the din.

There are also mental health advocates who believe a showdown over involuntary treatment is premature, given the dearth of treatment and services in the community for patients who ardently want them.

“In the long run,” said Rusty Selix, executive director of the Mental Health Assn. in California, “it doesn’t even serve [our] purpose to do . . . reform if we haven’t put in place the services people need.”

Some argue that for all the conflict over the letter of the law, many of the system’s flaws are practical snafus and matters of implementation that don’t necessarily require legislative remedies.

For example, in the mental health department of the Los Angeles County Superior Court, psychiatrists who work for private hospitals under county contracts sometimes don’t show up to testify about their detained patients. So the patients are released.

The problem is that the doctors often aren’t being paid for their time, by the county or anyone else. They resent waiting in court while their private patients go unattended.

When doctors and hospitals pursue the cases, Los Angeles County judges approve many more holds than they reject. In fact, jurists here don’t complain much about the law, even when they face a tough call.

Their main concern, they say, is the widespread neglect of the mentally ill that brings patients, often disheveled, desperate and bewildered, into their courtrooms.

That’s what supervising mental health Judge Harold Shabo preferred to talk about during a legislative hearing last year on reforming commitment laws: not how to detain more people, but how to fix the system that is supposed to be serving them.

“We have a mental health system which from my point of view is inconsistent, sporadic and fairly much in shambles outside hospitals,” he said.

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The Broken Contract

This series examines failings of the system of care for California’s more than 600,000 severely mentally ill residents.

Sunday: The mentally ill often hit bottom--or land in jail--before receiving consistent treatment.

Monday: A look at what happened to the last wave of patients forced out of state hospitals.

Today: The controversy over laws making it difficult to commit ill people into locked treatment centers.

Stories in this series are available on the Internet at www.latimes.com