PPAC’s Friday Blast – 10.30.2020

Grave disability. “Grave disability: A condition in which a person, as a result of a mental health disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter.”

Forgotten. This week a cataclysmic election bears down, potentially changing the character of our nation for decades to come. In an all too common counterpoint a young severely mentally ill black man was gunned down in Philadelphia in a confrontation with white police officers. An event overshadowed by, but no less important than, the national political news.

Themes. A lot of themes intersect here for psychiatry. National political turmoil. Structural racism. Health inequities. Untreated mental illness. Police training. Crisis response models. Lack of treatment resources. Treatment laws acting as barriers to treatment. And the political will to make fundamental, lasting changes.

Not resting on laurels. The fate of mental health policy in California, fortunately, is mostly up to California. The legislative year 2020 was a resounding year for the enactment of new policies, not the least of which was a requirement that all counties adopt court-supervised intensive treatment programs (AB 1976, Laura’s Law) addressing the dual crises of growing homelessness and incarceration. Psychiatrists can be proud of sponsoring that bill. Also, a new national model for assuring that the promise of mental health insurance parity is secured – something that I worked very hard to pass on your behalf (SB 855). The coming year promises more of the same.

Another Call for Help. The violent death of Walter Wallace, Jr, a young black man with bipolar disorder, at the hands of white police officers in West Philadelphia raises a lot of questions, many of which will also be raised in the 2021 legislative session in Sacramento. For example: The West Philadelphia officers responding to the call for help apparently had no de-escalation training leaving them ill-equipped to deal with psychiatric crises; the shots that killed Wallace may have been impelled by the implicit bias of racism; It’s been reported that police had prior knowledge of Wallace’s mental condition and been called three times the same day Wallace was killed.

Inadequate. Entire communities suffer because of the sheer number of gravely disabled individuals living and dying on our streets. With treatment, some could, in fact, manage their illnesses and remain safe. However, in California, they are within their rights to refuse treatment due, in large part, to a 53-year-old law. Years ago (1967) when the Lanterman Petris Short Act was enacted, the current definition of grave disability replaced “in need of treatment” as the basis for commitment of individuals not dangerous to themselves or others. This change reflected the legislature’s intent to add more precision to the definition. The “need for treatment” standard was meant to be more constitutionally adequate.

Unprotected. The current Gravely Disabled Standard states that a person (presently) “unable to provide for his or her basic personal needs for food, clothing or shelter” because of a mental health disorder qualifies as gravely disabled. In reality, this definition, intended to be more precise, is, in fact, more narrow and exclusionary than the definition it replaced. The result is a dramatic increase in the numbers of individuals with a mental disorder languishing on the streets. The current definition contains serious ambiguities and has invited multiple interpretations. And, importantly, it denies individuals equal protection under the law – a quite different constitutional conundrum.

Redress. This is an issue that will be addressed in 2021. Conservatorship reform is one applicable context. Another is introducing a stronger, more explicit standard that takes into account the capacity of the individual to make decisions and act on their own behalf. Another is to add health conditions as a basic personal need, including health conditions with food, clothing, and shelter as part of the litmus test for grave disability.

Proposal. Add this essential condition to the existing definition of Grave ‘Disability: A condition in which a person, as a result of a mental health disorder, is unable to provide for his or her basic personal needs for food, clothing, shelter, and health.’ Including just the word “health” covers the individual’s ability to stay safe and address medical and personal health needs. This clarification, and perhaps others, will be on our 2021 advocacy agenda.