The Short-Doyle Act, implemented in 1957, was designed to organize and finance community mental health services for persons with mental illness through locally administered and locally controlled community health programs. This basic structure was reaffirmed through the Bronzan-McCorquodale Act of 1991, also known as program realignment. The Department of Mental Health (DMH) in consultation with the California Mental Health Directors’ Association and the California Mental Health Planning Council, the Department of Mental Health (DMH) sets policy, standards and procedures for the delivery of community-based public mental health services statewide. DMH establishes priorities, standards and procedures; assists in, monitoring, reviewing and evaluating programs; and oversees any changes resulting from the evaluation and review process.

Counties are responsible for the providing community-based public mental health services to their residents. County Boards of Supervisors appoint a Local Mental Health Director (LMHD) who, in consultation with the Local Mental Health Board or Commission, assesses the needs of the county residents. The LMHD then enters into an annual performance contract with the DMH to provide a broad range of mental health services. These services include crisis evaluation and emergency care, 24-hour acute care, case management, rehabilitation services, and other supportive services.

Directed by realignment, public mental health services are funded by a dedicated portion of state sales tax dollars and vehicle licensing fees collected by the state and distributed to counties. This money is used, in part, as local matching funds for the Short-Doyle Medi-Cal program. The counties also receive funds from Medicare and other third party payers. County funds are also contributed to the mental health budget.

Individuals served by the public mental health system are persons with serious mental illness. This includes children and adolescents with severe emotional disturbance, and adults and older adults with serious and persistent mental illness. In addition, persons who require, or are at risk of requiring, acute psychiatric treatment because of a mental disorder with symptoms of psychosis, suicidality, violence or substantial deterioration are provided services.

In 1966, the State of California established the Medi-Cal program, known as Medicaid nationwide. The purpose of the program, as described in Cal. Welf. & Inst. Code § 14000, is to provide health care services to persons who lack sufficient income to meet the costs of health care, and whose assets are so limited that their expenditure on such care would jeopardize the person or family’s future maintenance or security.

There was minimal interaction between administrators of the Medi-Cal program and the Short-Doyle community mental health program for several years. Then, in 1972, Cal. Welf. & Inst. Code § 14021 was added in recognition of the fact that many Medi-Cal recipients were being treated by local mental health departments in the Short-Doyle system. This legislation added Short-Doyle community mental health services to the scope of benefits of the Medi-Cal program for the first time.

The result was the development of the Short-Doyle/Medi-Cal (SD/MC) program in addition to the Fee-For-Service Medi-Cal (FFS/MC) program for mental health services. The differences between these two programs are described below.

The SD/MC program provides cost-based reimbursement for a broad range of mental health services and a limited range of services for treatment of substance abuse. These mental health services are provided by the county or through a contract with the county.

The FFS/MC program provides reimbursement for a comprehensive range of health services and a limited range of mental health services. Services are reimbursed on a fee-for-service basis, or within managed care contracts. These mental health FFS/MC services are provided primarily by private hospitals and private practitioners.

With federal approval of the Rehabilitation Option in 1993, the SD/MC program has expanded the scope of benefits to include rehabilitative services. These services provide greater flexibility for providers to meet a broad range of client needs. In addition, the quality improvement system has been redesigned to encourage coordination of services with focus on outcomes rather than the amount of service delivered. This also facilitates involvement of the client and family as critical members of the service delivery team.

In O’Connor v. Donaldson, 422 U.S. 563 (1975), the Supreme Court found a constitutional right to liberty for mental health patients: "There is...no constitutional basis for confining such persons involuntarily if they are dangerous to no one." With this constitutional recognition, the practice of mental health law became a process of limiting and defining the power of the state to detain and treat.

In California, the Lanterman-Petris-Short Act, passed in 1969, specifies a number of rights and protections, including civil commitments procedures for mental health clients. The stated purposes of the Act include:

(d) To safeguard individual rights through judicial review;

(e) To provide individualized treatment, supervision, and placement services by a

conservatorship program for gravely disabled persons;

(g) To protect mentally disordered persons and developmentally disabled persons from criminal

acts. (Cal. Welf. & Inst. Code § 5001 (g))

Beginning in 1971, a series of cases established due process limitations on the civil commitment power much the same way as protections had developed earlier in the criminal context. As with many mental health law concepts, case law initiated the development of a complex set of procedures and standards for commitment of mental health patients.

Important changes have revised and expanded the LPS Act in the past 25 years, including the development of additional hearing procedures and the articulation of specific standards. A 1981 decision, Doe v. Gallinot, 657 F.2d 1017 (9th Cir. 1981) led to amendments requiring automatic, administrative commitment review hearings for all persons detained under 14-day certifications. Riese v. St. Mary’s Hosp. & Medical Center, 209 Cal.App.3d 1303, 1318, 271 Cal.Rptr. 199, 208 (1988) established all individuals subject to 72-hour holds and 14-day certification under the LPS have the fundamental right to make their own informed decision regarding antipsychotic medication absent an emergency or a specific judicial determination of incompetence.

An important case in mental health law is Wyatt v. Stickney, 325 F.Supp. 781 (M.D. Ala. 1971) (Wyatt I). The Wyatt case established that the reason for hospitalization is treatment, not simply custodial care. The case emphasized that patients have a right to treatment which is reasonably calculated to improve their condition. Treatment must have three components:

1. · Humane physical and psychological environment;
2. · Qualified staff in adequate numbers;
3. · Individual treatment planning.

In the follow-up case, Wyatt v. Stickney, 344 F.Supp. 373 (M.D. Ala. 1972)(Wyatt II), the court established a broad range of standards for mental health facilities.

In 1982, the United States Supreme Court addressed the right to treatment in Youngberg v. Romeo, 457 U.S. 307 (1982). The Court found that people institutionalized under civil commitment statutes have Constitutional rights to adequate food, shelter, clothing and medical care, the right to reasonable care and safety and the right to minimally adequate or reasonable training to ensure safety and freedom from undue restraint.

In two important appellate decision, Reenie v. Klein, 462 F.Supp. 1131 (D.N.J. 1978), the court found a qualified right to refuse involuntary administration of psychotropic drugs. In other cases throughout the country similar decisions found a right to refuse treatment based on procedural due process and privacy rights.

The right to participate in treatment decisions has been a consistent theme in legal developments in California. On an individual level, clinicians are increasingly required to secure client consent and involve the client in treatment planning and decision-making. On a system level, services are required to be client-centered and to be developed with the active participation of the client.

The least restrictive treatment means that deprivations of personal freedom should be limited to the minimum necessary to achieve the purposes of the intervention. Initially applied in the mental health field to challenge the appropriateness of institutionalization, the principle of least restrictive treatment has been extended in the courts to challenge the nature of the institution in which the patient is placed, the treatment modalities provided, and the limitation on patient liberties in the institution.

In 1980, Congress passed the Mental Health Systems Act containing a model bill of rights for patients and recommending advocacy services for patients. In California, patients’ rights have been specified in statute for the past quarter century. These basis protections are designed to minimize restrictions on patients’ freedom while in a facility providing mental health treatment.

In 1978 the California Legislature recognized that mental health patients have the same rights and responsibilities as all other Californians. With the passage and enforcement of the Fair Housing Amendments Act in 1988 and the Americans with Disabilities Act in 1990, advocates for mental health clients have increasingly framed arguments in antidiscrimination rather than entitlement language and have developed new and creative theories for improving community services.