Laura’s Law has been an option for counties in California since 2003, but only in recent weeks have three of the most populous ones — Los Angeles, Orange and San Francisco — voted to implement it. The law — like another one in New York, Kendra’s Law — allows families or officials to ask the courts to order outpatient treatment for the seriously mentally ill.
Will it help? A decade ago, Tom Burns, a psychiatrist and professor of social psychiatry at Oxford University, was among those arguing ardently for the British version of Laura’ Law — “community treatment orders,” or CTOs. Now, he says, the most thorough research — including his own — shows these laws don’t accomplish much: Compulsion added to otherwise decent care makes no difference. But note the qualification: “otherwise decent care.”
You say the best research shows that legally forcing the mentally ill to get outpatient treatment doesn’t change overall outcomes. That would indicate that Laura’s Law won’t do much good.
You’ve got three [randomized] trials in the world on CTOs; two are in America, and there’s our study. All three have the same results: CTOs don’t make a difference.
We looked at two groups of similarly ill people in the British healthcare system who’d been judged by their psychiatrists to need CTOs. One group received CTOs and one not, and we found that there was absolutely no difference in the outcome, with or without compulsory treatment. About a third of both groups relapsed and required hospitalization over the following 12 months.
I was depressed by those results. I worked for more than 20 years to get the CTO law passed. I thought such laws were going to make a difference, but they don’t.
I don’t know the answer, but they don’t. We know what does keep patients well, and our experience is that adding compulsion does not appear to make it work better. Care is better than no care; it doesn’t say care with compulsion is better than care.
What does work?
The long-term treatment of very severely mentally ill people — consistent, steady, low-grade outreach which is flexible and which goes on for months and years and which is based on ensuring the person gets their medicine, ensuring their social life is stabilized as best we can — that reduces the rate of relapse substantially. We’ve now tried to add compulsion to it and it hasn’t improved the outcome. So I think the effort should go into making sure that everybody gets access to basic treatment.
So you found CTOs don’t prevent the mentally ill from getting worse as a group, but are there any good outcomes from them?
If you look at high-quality research evidence, you could say there is no evidence patients are benefited by CTOs if they are getting decent care otherwise. We were careful in our Lancet article to say that in well-coordinated mental health services, compulsory treatment has nothing to offer. If you have semi- to nonexistent services, then you don’t know whether compulsion is helping the patient or whether treatment is helping the patient. I think treatment helps patients.
It may be that getting the care you are describing would require, in this country, compulsion.
I don’t think it does. One of a doctor’s biggest skills is in forming a trusting relationship with scared, frightened, shy, anxious individuals, and through that encourage them, nag them, to get them to treatment. I’m shameless at it! And most of my colleagues are too. I had hoped that adding compulsion would move the proportion who do well up, but the evidence is stubbornly consistent that it doesn’t.
It sounds as if Britain has better basic mental health services than the United States.
Even in impoverished bits of Europe like Portugal, any psychotic patient will be able to see a psychiatrist and psychiatric nurse ad infinitum. Someone will go see them at home, make sure they get their meds, etc. [If] with Kendra’s Law in New York, or Laura’s Law in California, most disabled patients will get treatment because the law allows us to force services or at least pay services to give that treatment, I can see something beneficent about that. At least let’s try to target the few resources we’ve got on the most at-risk.
The United States is one of the richest countries in the world, it’s not short of trained mental health staff, there’s no shortage of resources. There’s no political will to deploy them. You could argue that selecting out some very high-profile patients to give what by most international standards is fairly average treatment is not a benign advance but a sort of fig leaf to let politicians off the hook.
Many families of the mentally ill support Laura’s Law because they are desperate for some recourse. In California, involuntary hospitalization requires that a patient be dangerous or “gravely disabled.” Laura’s Law is seen as a way to help, short of that standard and short of hospitalization. Patients must recently have been violent, hospitalized or jailed, among other criteria.
That’s utterly understandable. Seeing young people’s lives ruined by mental illness is very difficult to watch. And most families like this law because it makes them feel safer, just as you could argue it makes [medical] staff feel safer. [Laura’s Law was named for Laura Wilcox; she and another mental health clinic staffer were killed by a man whose family had tried and failed to force him to be treated.] I think there’s an ethical issue. If you’re going to use compulsion to make me feel better about my job, the compulsion should be on me, not the patient.
There’s a profound conceptual difference in the approach to mental health care between America and Europe. European laws often state “danger to self or others,” but danger in Europe is almost always interpreted very broadly — and you might think paternalistically — to include the patient’s mental health. If I have a seriously ill schizophrenic patient who is neglecting himself, not taking his medicine, and I know he’s going to get worse, I can say that’s a “danger” to his health. My understanding is that in many states in America, it’s got to be an imminent physical risk. People who are actively and immediately dangerous — they probably shouldn’t be out of hospital.
As Laura’s Law takes effect, what would you tell us to look for?
Don’t expect it to make a big difference. If people are going to evaluate it, then evaluate it in a way that’s sufficiently rigorous to distinguish differences in access to better treatment from the effects of compulsion.
This interview has been edited and condensed.