On LPS Reform, Fears and Hopes May Be Overstated

In my previous post, I asked whether involuntary treatment actually helps people, and concluded that the evidence in general is mixed and for long-term conservatorship basically inexistent (both for its harms and its benefits, in fairness). Here, I’m considering a question closer to my own research, which is not whether involuntary treatment “works” but whether reforming involuntary treatment laws does anything. I’m more confident in saying in this post that both advocates for and against LPS reform are vastly overstating the practical effects that changing the law will actually have. Building more beds might have a greater impact, and there’s some evidence in favor of doing so.

The real drivers of changes in civil commitments in the last 50 years were factors other than the law.

Some advocates claimed that the dramatic changes to civil commitment laws in the 1960s and ‘70s, of which LPS was a spearhead, would virtually bring to an end involuntary treatment.1 The results of a flurry of subsequent studies were surprising: as Paul Appelbaum wrote in a widely-cited review in the 1990s, “the difficulty researchers have had in demonstrating a clear effect of the new statutes in restricting admissions is impressive” in light of the breadth of reform.2(p37)

Researchers advanced two core explanations for this paradox. First, studies in California3–5 and elsewhere in the U.S.6–8 found that new legal protections mattered little because judges and attorneys largely agreed with psychiatrists that the people whose commitments they were reviewing needed to be in the hospital. Contemporary research also finds similar deference of legal to medical professionals, despite popular narratives to the contrary.9–11 Appelbaum concluded that professionals continued to act based on a “need for treatment” standard even when that standard had been changed by legislation. It appeared that “when the law goes against the grain of popular opinion concerning the legitimate scope of commitment, the law gives way.”2(p56)

Other studies found that “grave disability” served as a catch-all category that swept up people that were not “dangerous.”2,3,12,13 In my own research, I found that grave disability is now seen as the hardest of the LPS criteria (compared to danger-to-self and danger-to-others) to use. What has changed is not the law, but the available resources. As hospital beds closed, psychiatrists focused on keeping patients at imminent risk of harm. Police and outpatient clinicians have adapted by using grave disability less.

These practices will not be changed by re-wording grave disability. On the other hand, these studies suggest that if California had more locked beds, the interpretation of LPS would probably change to fill them.

Comparative data also emphasize factors other than the law as the driver of civil commitment rates.

Another type of data also suggests the limited impact of changed civil commitment laws. Two cross-national studies found that there was no relationship between countries’ statutes and the actual number of commitments.14,15 Within the U.S., there’s no clear correlation between the types of laws and how they are used.16 For example, in one study of 25 states, the states with the highest numbers of civil commitments were Florida, Colorado, Massachusetts, and South Dakota, which received a “D”, “C-“, “F”, and “C-“ respectively for the quality of their commitment laws from the Treatment Advocacy Center (which wants to see states have looser laws).17 California’s “D-” has not stopped it from having the highest rate of medium-length commitments of eight states for which data was available.17

Studies have instead argued that rates of involuntary commitments are a result of the overall functioning of the mental health system.18 For example, an evaluation found that California’s Mental Health Services Act, which put money into intensive voluntary services in the community, did not reduce 72-hour 5150s but did reduce 14-day 5250s, suggesting that it created new options for discharging patients but was less effective in preventing crises that precipitate involuntary treatment.19  

In short, organizational and resource factors play a much greater role than the law in determining rates of civil commitments.

The is limited support for key proposed components of LPS reform.

Most states’ laws on civil commitments have some provision for involuntary treatment of substance use disorders.20,21 This includes California, where the LPS Act provides for conservatorship for people gravely disabled as a result of chronic alcoholism. In my own research, I have not found a single recent example of this provision being used. This mirrors a national pattern: these laws are generally applied very rarely.20 Nonetheless, proponents of reform have worked to expand civil commitments for SUDs, particularly meth use, through a pilot program in San Francisco. This, again, mirrors a national expansion.

Evidence for the effectiveness of compulsory drug treatment outside of criminal justice system is scant. Two reviews found that most studies showed no impact.22,23 In my own research, I found that many mental health professionals believe that—despite the ubiquity of co-occuring disorders—addictions are not their specialty, and thus are reluctant to admit people with SUDs into psychiatric settings where forced treatment could be applied.

I could not find any published studies analyzing whether adding “medical needs” to the grave disability tryptic of food, clothing, and shelter is needed or likely to be impactful. Dozens of Public Guardians and judges I interviewed told me that they already incorporated someone’s ability to take care of their physical health into evaluations of grave disability where appropriate. However, because there are so few facilities willing to serve people with co-morbid medical and psychiatric needs, they were resistant to conserving them.

Some studies suggest having more hospital beds would be a good idea, but their methodological approach is not always sound.

The evidence in support of modestly more psychiatric beds is somewhat consistent. Studies have claimed that areas with greater inpatient capacity have a lower homicide rate24 and fewer deaths by suicide.25 On the other hand, the closure of public hospital beds is associated with an increase in homelessness26 and admissions to jails,27,28 although this explains only a small proportion of the dramatic rise of both in the United States. These studies are vulnerable to the “ecological fallacy”; they show correlations within geographic zones but cannot show that the people going to jail are actually the people who would be hospitalized if there were more beds.

A different, somewhat more surprising association, is between the number of beds and involuntary care. In both France29 and the United Kingdom, as psychiatric inpatient capacity has declined, there has been an increase in the absolute number of involuntary admissions and as a proportion of all hospital admissions30,31 (although some sub-national studies contest this link32). In my research, I have generally encountered the assumption that if California had more beds, they would quickly be filled through LPS. This research suggests that more beds might be filled with voluntary patients, because professionals could propose a hospitalization before waiting for a crisis to worsen to the point that a person is no longer able or willing to consent. People also might be willing to go to a hospital if they could stay long enough for it to help them (although, of course, the evidence in favor of longer hospital stays is mixed33–35).

Although some psychiatrists have called for “bringing back the asylum,”36 none of this remotely shows that interning hundreds of thousands of people a year is a good idea. On the other hand, the fear that building more beds will crowd out community-based solutions may be overstated. Generally, as my collaborator Isabel Perera has shown, countries with more robust inpatient care also tend to have more robust systems of outpatient care.37

The LPS Audit in 2020 did provide good evidence around the need for reform.

The last truly thorough statewide evaluation of LPS was published in 1972—three years after it went into effect.38 Advocates I spoke to eagerly awaited a review of LPS from the CA State Auditor which was published in 2020. It considered proposals to “expand the LPS Act’s criteria to include additional situations in which individuals may be involuntarily treated” and concluded there was “no evidence to justify such changes.”39 I would argue that the audit actually found no compelling evidence either way.

The audit’s methodology was flawed. It only reviewed documentation for 5150s and permanent conservatorships, offering no review of what happens at many, many other steps (hospital admissions decisions, 5250s, probable cause hearings, and temporary conservatorships, to name a few). Its retrospective review only showed that clinicians do a good job filling out paperwork justifying their decisions, which is unsurprising given that clinicians spend about a quarter of their time doing paperwork.40 It tells us nothing about cases of people who were not 5150ed or for whom a conservatorship petition was not filed but might have needed it.

The weaknesses of the audit—which are disappointing given the enormous access and resources at the Auditor’s disposal—go on. It did not analyze the work of Public Guardians, who serve as conservators the vast majority of the time, at all. It did not tell us anything meaningful about who goes on conservatorship, where they are (in locked or unlocked settings, for example), or what clinical or social outcomes they have. It only covered three counties and did nothing to address the pathetic fact that state government cannot even say how many people are conserved at a given point in time and whether that number is going up or down.

The fervor of the debate over reforming LPS has overstepped its likely impact.

For many families and clinicians, it is obvious that involuntary treatment works. For a significant proportion of consumers and advocates, whether it works is often irrelevant because involuntary treatment is ethically wrong and discriminatory against people with psychiatric disabilities. For both sides, reforming LPS would be—for better or for worse—symbolically enormous. In practice, the likely impacts are less clear.

Literature Cited

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6.         Bursztajn H, Gutheil TG, Mills M, Hamm RM, Brodsky A. Process Analysis of Judges’ Commitment Decisions: A Preliminary Empirical Study. Am J Psychiatry. 1986;143(2):170-174.

7.         Hiday VA. Reformed Commitment Procedures: An Empirical Study in the Courtroom. Law Soc Rev. 1977;11(4):651-666. doi:10.2307/3053176

8.         Hiday VA. Representing Respondents Under New Civil Commitment Statutes: An Analysis of Counsel’s Role In and Out of the Courtroom. Law Policy. 1983;5(4):438-454. doi:10.1111/j.1467-9930.1983.tb00308.x

9.         Morris GH. Let’s Do the Time Warp Again: Assessing the Competence of Counsel in Mental Health Conservatorship Proceedings. San Diego Law Rev. 2009;46:283-342.

10.       Player CTL. Outpatient Commitment and Procedural Due Process. Int J Law Psychiatry. 2015;38:100-113. doi:10.1016/j.ijlp.2015.01.013

11.       Zetterberg L, Sjöström S, Markström U. The Compliant Court—Procedural Fairness and Social Control in Compulsory Community Care. Int J Law Psychiatry. 2014;37(6):543-550.

12.       Cleveland S, Mulvey EP, Appelbaum PS, Lidz CW. Do Dangerousness-Oriented Commitment Laws Restrict Hospitalization of Patients Who Need Treatment? A Test. Psychiatr Serv. 1989;40(3):266-271. doi:10.1176/ps.40.3.266

13.       Monahan J. Empirical Analyses of Civil Commitment: Critique and Context. Law Soc Rev. 1977;11(4):619-628. doi:10.2307/3053174

14.       Salize HJ, Dressing H. Epidemiology of Involuntary Placement of Mentally Ill People Across the European Union. Br J Psychiatry. 2004;184(2):163-168. doi:10.1192/bjp.184.2.163

15.       Sheridan Rains L, Zenina T, Dias MC, et al. Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative study. Lancet Psychiatry. 2019;6(5):403-417. doi:10.1016/S2215-0366(19)30090-2

16.       Werth JL. U.S. Involuntary Mental Health Commitment Statutes: Requirements for Persons Perceived to be a Potential Harm to Self. Suicide Life Threat Behav. 2001;31(3):348-357. doi:10.1521/suli.31.3.348.24247

17.       Lee G, Cohen D. Incidences of Involuntary Psychiatric Detentions in 25 U.S. States. Psychiatr Serv. 2021;71(1):61-68. doi:10.1176/appi.ps.201900477

18.       Gandré C, Gervaix J, Thillard J, Macé JM, Roelandt JL, Chevreul K. Involuntary Psychiatric Admissions and Development of Psychiatric Services as an Alternative to Full-Time Hospitalization in France. Psychiatr Serv. 2017;68(9):923-930. doi:10.1176/appi.ps.201600453

19.       Bruckner TA, Yoon J, Brown TT, Adams N. Involuntary Civil Commitments After the Implementation of California’s Mental Health Services Act. Psychiatr Serv. 2010;61(10):1006-1011. doi:10.1176/ps.2010.61.10.1006

20.       Christopher PP, Pinals DA, Stayton T, Sanders K, Blumberg L. Nature and Utilization of Civil Commitment for Substance Abuse in the United States. J Am Acad Psychiatry Law Online. 2015;43(3):313-320.

21.       Williams AR, Cohen S, Ford EB. Statutory Definitions of Mental Illness for Involuntary Hospitalization as Related to Substance Use Disorders. Psychiatr Serv. 2014;65(5):634-640.

22.       Jain A, Christopher P, Appelbaum PS. Civil Commitment for Opioid and Other Substance Use Disorders: Does It Work? Psychiatr Serv. 2018;69(4):374-376. doi:10.1176/appi.ps.201800066

23.       Werb D, Kamarulzaman A, Meacham M, et al. The Effectiveness of Compulsory Drug Treatment: A Systematic Review. Int J Drug Policy. 2016;28:1-9. doi:10.1016/j.drugpo.2015.12.005

24.       Segal SP. Civil commitment law, mental health services, and US homicide rates. Soc Psychiatry Psychiatr Epidemiol. 2012;47(9):1449-1458.

25.       Kaboli PJ, Augustine MR, Haraldsson B, et al. Association between acute psychiatric bed availability in the Veterans Health Administration and veteran suicide risk: a retrospective cohort study. BMJ Qual Saf. Published online August 10, 2021. doi:10.1136/bmjqs-2020-012975

26.       Markowitz FE. Psychiatric Hospital Capacity, Homelessness, and Crime and Arrest Rates. Criminology. 2006;44(1):45-72. doi:10.1111/j.1745-9125.2006.00042.x

27.       Yoon J. Effect of increased private share of inpatient psychiatric resources on jail population growth: Evidence from the United States. Soc Sci Med. 2011;72(4):447-455. doi:10.1016/j.socscimed.2010.07.023

28.       Yoon J, Domino ME, Norton EC, Cuddeback GS, Morrissey JP. The impact of changes in psychiatric bed supply on jail use by persons with severe mental illness. J Ment Health Policy Econ. 2013;16(2):81-92.

29.       Robilard D, Jacquat D. Rapport d’information En Conclusion Des Travaux de La Mission d’évaluation de La Loi N° 2013-869 Du 27 Septembre 2013 Modifiant Certaines Dispositions Issues de La Loi N° 2011-803 Du 5 Juillet 2011 Relative Aux Droits et à La Protection Des Personnes Faisant l’objet de Soins Psychiatriques et Aux Modalités de Leur Prise En Charge. Assemblée Nationale; 2017.

30.       Allison S, Bastiampillai T, Fuller DA. Should the Government change the Mental Health Act or fund more psychiatric beds? Lancet Psychiatry. 2017;4(8):585-586. doi:10.1016/S2215-0366(17)30290-0

31.       Keown P, Weich S, Bhui KS, Scott J. Association between provision of mental illness beds and rate of involuntary admissions in the NHS in England 1988-2008: ecological study. BMJ. 2011;343:d3736. doi:10.1136/bmj.d3736

32.       Weich S, McBride O, Twigg L, et al. Variation in compulsory psychiatric inpatient admission in England: a cross-classified, multilevel analysis. Lancet Psychiatry. 2017;4(8):619-626. doi:10.1016/S2215-0366(17)30207-9

33.       Babalola O, Gormez V, Alwan NA, Johnstone P, Sampson S. Length of hospitalisation for people with severe mental illness. Cochrane Database Syst Rev. 2014;(1). doi:10.1002/14651858.CD000384.pub3

34.       Fuller DA, Sinclair E, Snook J. Released, Relapsed, Rehospitalized: Length of Stay and Readmission Rates in State Hospitals – A Comparative State Survey. Treatment Advocacy Center; 2016.

35.       Wanchek TN, Bonnie RJ. Use of Longer Periods of Temporary Detention to Reduce Mental Health Civil Commitments. Psychiatr Serv. 2012;63(7):643-648. doi:10.1176/appi.ps.201100359

36.       Sisti DA, Segal AG, Emanuel EJ. Improving Long-term Psychiatric Care: Bring Back the Asylum. JAMA. 2015;313(3):243-244. doi:10.1001/jama.2014.16088

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38.       ENKI Research Institute. A Study of California’s New Mental Health Law.; 1972.

39.       California State Auditor. LantermanPetrisShort Act: California Has Not Ensured That Individuals With Serious Mental Illnesses Receive Adequate Ongoing Care.; 2020.

40.       Department of Mental Health. The TRIESTE Project: True Recovery Innovation Embraces Systems That Empower. Los Angeles County; 2019.

One thought on “On LPS Reform, Fears and Hopes May Be Overstated

  1. Thank you for your ongoing research on these issues and your keen insights. I’m working on a cost-benefit analysis and will attempt to show that continuing to put resources ($) into band-aid nonsolutions and incarceration is not only harmful but more expensive than supplying the missing infrastructure to treat mental illness, just like any other illness, with healthcare provisions and supports to improve and maintain a seriously mentally ill patient’s condition to their optimal functional capacity. Incarceration, homeless encampment sweeps, emergency crisis responses, revolving-door ER visits, lawsuits for wrongful deaths at the hands of police, etc., are incredibly costly to all of society. If it isn’t enough to convince our society to address the inhumane and illegal response to Americans with disabilities due to SMI (accommodations are required under the ADA), then maybe focusing on how much money continues to be wasted on responses that only make things worse, compared to projected costs for expanding evidence-based models of care that result in better outcomes, can educate and sway public opinion to opt in and at least increase psychiatric beds. California ranks last in the nation, way short of the required psych beds needed for the SMI, according to the California Hospital Asociation. Thousands of Californians are deteriorating in jails without proper care due to lack of facilities to send them to for treatment, even when they are incompetent to strand trial and the law requires that they be admitted to a State Hospital within 28 days.

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