Improving Mental Health Guardianship

From Prevention to Treatment

Published in: Psychiatric Services (2021). doi: 10.1176/

by Amy L. Shearer, Elizabeth Bromley, Curley Bonds, Connie Draxler, Dmitry Khodyakov

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The authors sought to identify the most promising strategies for improving the mental health guardianship process in Los Angeles County for adults with mental illness who are gravely disabled.


In May and June 2019, 56 experts, working in hospitals or outpatient facilities or representing legal, advocacy, policy, or forensic organizations, participated in an online modified-Delphi panel, rating the ethical appropriateness, impact on care quality, efficiency, and feasibility of nine strategies for improvement of mental health guardianship. Agreement was determined with the RAND/UCLA appropriateness method, and comments were thematically analyzed.


The strategy ranked highest by the participating experts was improving the administrative functioning and judicial processes of entities involved in mental health guardianship proceedings—it was the only strategy that achieved agreement among panelists and was rated highly on all four criteria. Other preferred strategies were enhancing the ability of assertive outpatient mental health teams to serve individuals before they experience a crisis and expanding the continuum of unlocked residential treatment settings.


Opportunities exist to improve all stages of the mental health guardianship process. Experts favored strategies that streamline administrative processes, facilitate community integration into treatment, and ensure fidelity to best practices. Improving the mental health guardianship process has the potential to speed up delivery of services, better manage resources, and increase access to treatment for individuals with mental illness who are gravely disabled.

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