Assisted Outpatient Treatment Can’t Wait: It’s Time to Make Laura’s Law Work in California

RETHINKING THE LANTERMAN-PETRIS-SHORT ACT (LPS) – By Frank Woodard

"Primum non nocere" or "First, do no harm", a quote some authorities have attributed to a Roman physician named Galen.

The Lanterman-Petris-Short act (1969) in part set the rules for the involuntary treatment of mentally ill persons in California. Unfortunately, most of us who have a loved one suffering from a mental illness will probably at some time experience the shortcomings of the LPS act. Those shortcomings usually involve a loved one in a psychotic or irrational state, not fitting the criteria of an involuntary hold and refusing medical treatment.

“If you are not a danger to yourself or others and are not gravely disabled then you have the constitutional right to be psychotic”, is sometimes touted by advocacy groups that fight involuntary treatment by quoting the LPS act. The argument should be for the right to proper medical treatment before becoming a danger to self or others or reaching a state where the patient cannot take care of themselves. In fact, the stated legislative intent of the LPS act was to provide prompt evaluation and treatment of persons with serious mental disorders.

Nobody would argue against the need to balance the patient’s liberty with any potential use of involuntary treatment. The historic abuses of patients in mental hospitals are well documented and any advocacy group’s zealous stance against involuntary treatment is understood. But it is this author’s contention that because the LPS act was enacted before the medical community really understood the neurophysiologic basis of mental illness, biological conditions were not adequately considered. In fact, in the late 60’s when the LPS act came into being many medical authorities concluded that mental illness was the result of bad parenting, with some mental illnesses specifically focusing on the mother who was termed a schizophrenogenic mother. Any biological causes of mental illness and the resulting consequences were largely ignored or unknown at that time.

We now understand that mental illness is a disease of the brain, like cancer is a disease of the cells or diabetes is the result of the body not properly controlling the amount of sugar in the blood. But mental illness, being a disease of the brain, can impact the patient’s cognitive abilities creating a type of cognitive impairment.

Most blatantly the LPS act did not address the issue of the patient’s lack of understanding of their illness, medically termed as Anosognosia. Derived from the Greek “nosos” meaning disease and “gnosis” meaning knowledge, the term means to not know one’s own disease. Anosognosia is a neurological deficit, and is one of the cognitive impairments commonly seen in patients with mental illness. Some studies have shown that as many as 50% or more of those suffering from mental illness lack insight or awareness of their disease. This lack of understanding has resulted in needless suicide, homelessness, incarceration and the resulting revolving doors at jails and at psychiatric hospitals.

Legislatures need to enact new laws or modify existing laws when they have been based on faulty information or assumptions. The LPS act was intended to provide prompt evaluation and treatment of persons with serious mental disorders. But how is this going to occur if the patient does not believe they have an illness that needs treatment? Certainly this will not occur on a voluntary basis as logically a patient would not volunteer for the treatment of a disease they don’t believe they have. In order to properly evaluate and treat patients as the LPS act requires, highly trained and qualified medical personnel should make that decision for the patient before they become a danger to themselves or others, or are gravely disabled.

The nature and biologic causes of anosognosia were not clearly understood and therefore not considered at the time of the enactment of the LPS act. Believing anosognosia to be a choice, rather than a symptom of a disease, the legislature set the bar for involuntary treatment too high, resulting in some cases in harm to the very patients this act should be requiring to be evaluated and treated. It is time for the California Legislature to rethink the Lanterman-Petris-Short act in light of the current medical findings concerning mental illness and “First, do no harm”.

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