KELLY ALATORRE is the product of the nation’s broken mental health system. People who suffer from untreated serious mental illness are extremely vulnerable to premature death, suicide, and abuse, but state laws err on the side of protecting civil liberties. People like Alatorre can refuse services and treatment when they have little capability to help themselves. They often land in jail or on the streets.
What’s happening to Alatorre is happening across the nation. Many police department heads throughout the country advocate reforming the country’s mental health system because law enforcement officers usually respond first to psychiatric emergencies. Many departments now train their officers in crisis intervention—recognizing signs of mental illness and de-escalating tension.
One of the most significant changes taking place nationwide is the expansion of assisted outpatient treatment (AOT), a court-ordered, community-based treatment for certain seriously mentally ill individuals who have already experienced multiple episodes of homelessness, arrest, incarceration, or hospitalization. Currently 47 states, including California, allow AOT, thanks to federal grants and studies that show high rates of success. But implementation can be inconsistent or inadequate, and AOT critics say it violates civil liberties and leads to heavy use of psychiatric drugs.
Meanwhile, family members tell me they feel unheard, unprioritized, misguided, and even blamed for a loved one’s disintegration. They run into HIPAA complications, lack of psychiatric beds and mental health professionals, and state laws that make it hard to get their loved ones professional care.
MORE THAN 150,000 people experience homelessness on any given day in California. In Los Angeles, about three homeless people die on the streets each day. Most leaders and advocates focus on poverty and the lack of affordable housing, both vital issues. But addressing those issues doesn’t address the mental illness component of homelessness. Official statistics say about one-third of the homeless have SMI and/or report substance abuse, but a Los Angeles Times analysis found that figure to be underreported: The paper’s analysis determined that about 51 percent of those living on the streets in LA County currently suffer from mental illness.
The spike in homelessness dates several decades back to the late 1950s when California, in the name of compassion, led the national movement to push mentally ill patients out of state mental hospitals. By the time Ronald Reagan became governor, California had already drained half its hospitals. Then in 1967, Reagan signed into law the landmark Lanterman–Petris–Short (LPS) Act, which prohibited involuntary hospitalization except under certain extreme circumstances. The LPS Act’s goal was to release patients into more humane, less restrictive “community care,” which never fully materialized.
The LPS Act recognized that individuals have the right to determine their own lives. But problems arise when they lack the mental competency to do so. Under the LPS Act, a patient can only be involuntarily hospitalized for up to 72 hours. If doctors say the patient is “still a danger to others or themselves, or is gravely disabled,” the LPS Act allows an additional 14-day hold and, if still necessary, a 30-day hold. Schizophrenia can’t be fixed in three or 30 days. Families tell me they’ve seen doctors, citing the LPS Act, discharge someone who’s still delusional and treatment-resistant.
That’s what happened to Alatorre: In 2015 alone, she was involuntarily placed in a hospital 15 times. The day they met in Skid Row, Aguirre convinced her daughter to check herself into a behavioral health facility that had just opened a 32-bed voluntary inpatient unit. Alatorre stayed for two weeks. She was diagnosed with schizoaffective disorder (schizophrenia with a mood disorder).
Meanwhile, Aguirre sought to get her daughter conservatorship, a legal arrangement in which a judge appoints a responsible adult (often the county’s public guardian) to manage the personal care or financial matters of an impaired adult. If Alatorre is conserved, the guardian can force her into long-term treatment.
The LPS Act imposes very strict criteria for conservatorship: An individual with SMI must first undergo both an initial involuntary hold and a 14-day hold. Next, a treating psychiatrist must sign a conservatorship request to the Public Guardian office. For her to be conserved, doctors and the county must determine that Alatorre is “gravely disabled,” which state law defines as someone no longer able to provide for her own food, clothing, or shelter because of a mental health disorder. But the law also says an individual is not considered gravely disabled if a willing third party—a family member, a kind stranger, or shelters—are providing food, clothing, or housing. Psychotic behaviors or delusions are not enough to prove someone is “gravely disabled.”
What’s more, each of California’s 58 counties interprets the definition of “gravely disabled” differently. Given that counties will bear much of the treatment costs—and many lack the necessary services—most counties are reluctant to pursue conservatorship. In 2019, California passed two bills creating pilot programs in three counties to grant conservatorship to more people. Those bills faced fierce criticisms from powerful organizations such as the ACLU and Disability Rights California, which say the bills violate civil liberties. So far, only the city of San Francisco has decided to implement the program, but conditions to qualify for conservatorship are still so narrow that it only applies to about 50 people in San Francisco (out of more than 8,000 homeless in the city).