Governor Gavin Newsom last week unveiled an ambitious-seeming plan to push more of the state's severely mentally ill into treatment. But forced psychiatric treatment requires locked wards and hospital beds that the state has been short on for decades, so how is this all going to work?
Setting aside the perennial debate about whether conservatorships, forced medications, and lengthy psychiatric holds are violations of civil rights, experts in the field say Newsom will have an uphill battle in implementing his plan for CARE Courts (short for Community Assistance, Recovery and Empowerment) in the state. Under Newsom's plan, civil court judges will be empowered to compel psychotic individuals into treatment under several circumstances. Individuals suffering from mental illness — specifically psychosis, whether meth-induced or not — could be brought before a judge either because they recently committed a crime, because an involuntary psychiatric hold is ending, or because they've been referred there by a family member or outreach worker for conservatorship.
The judge would then assign the person a case worker, and create a court-ordered treatment plan that would likely include medication — though Newsom's plan is careful to say that the person would still need to voluntarily take the medication. The person may be sent to meet with a psychiatrist or assigned to a board-and-care facility or other supportive housing. And if the person refused this treatment, then the judge could order conservatorship — or in the case of a crime having been committed, their criminal case would then proceed, and they'd presumably remain in jail.
Unlike regular conservatorships, participation in the CARE Court program would be time-limited to one year.
"This is a completely new strategy,” Newsom said at a press conference last Thursday. "And I hope that creates a space for a different conversation than we’ve had in the past."
But, it isn't all new. The state has had something called Laura's Law for 20 years, which compels certain severely mentally ill individuals into treatment. The law was enacted following the 2001 death of 19-year-old healthcare worker Laura Wilcox, who was fatally shot by a mentally ill man who had refused his family's attempts to get him into mental-health treatment. And since 1967, the state has had the Lanterman-Petris-Short Act, which establishes standards for involuntary psychiatric treatment.
Newsom noted last week that Laura's Law, which not all California counties participate in (San Francisco declined to use the law until 2015), only brought 218 individuals into treatment in a single year (FY 2018-2019), while the CARE Court plan could potentially serve between 7,000 and 12,000 patients per year.
The Chronicle's Heather Knight spoke this week to San Francisco emergency-room physician Dr. Scott Tcheng about Newsom's CARE Court plan, and he says he's "cautiously optimistic" that it may do some good. Tcheng says he sees many psych patients cycle in and out of emergency rooms, sometimes multiple times a day, straining the system and causing care to be delayed for other people with serious conditions ranging from heart attacks to strokes and more.
He tells one story about a guy who came in to an ER looking "like the Joker" with blood smeared all over his face and hands — and the guy had been seen eating a dead raccoon on the street. Tcheng says that one psychiatrist he had check out the patient said that he didn't qualify for a 5150 hold because the "gravely disabled" definition required includes the inability to find food for oneself — and the raccoon in the case counted as food?
What happened after that, Tcheng isn't too sure, but he did send the guy to get test for rabies. "Hopefully, he got some sort of psychiatric care,” Tcheng tells the Chronicle. "But knowing San Francisco, I doubt it."
SF Supervisor Hillary Ronen didn't weigh in on the CARE Court proposal, but she did tell Knight that in a pre-pandemic hearing with the Department of Public Health, the Board of Supervisors heard that the city likely needed at least 400 new psychiatric beds. Only 89 have been added in the two years since then.
Charlie Berman, a clinical social worker in the city, tells the Chronicle that the CARE Court plan is just "a political facade masking the ineffectuality of a rotten system." And he adds that it won't get very far unless the state invests heavily in locked psychiatric wards and more psych beds.
In an Examiner opinion piece, Gil Duran notes that San Francisco and other cities already fail to provide services and housing to the "low-hanging fruit" of mentally cogent homeless people who are seeking them out. So it's going to be a steep climb to suddenly provide beds or housing to the mentally ill.
"Homeless elderly people and patients in need of serious medical care get dumped on the streets in their wheelchairs because there’s apparently nowhere to put them," Duran writes. "This is the reality in The City named for St. Francis, and it’s the same in cities statewide."
But maybe there is political will and money enough this time to put a dent in the massive problem of mental illness on our streets — and start to improve the situation for San Francisco, which long ago gave up the Tenderloin and parts of the Mission to being an open-air insane asylum.
Oakland Mayor Libby Schaaf talked to Cal Matters last week about a mentally ill homeless woman whom she found surrounded by rats and freezing on the street during the city's biennial point-in-time homeless count. The woman fed the rats because they were her "chosen company," Schaaf said.
"She had been offered care, shelter, housing countless times but had been left to freeze on the pavement of our city,” Schaaf said. "It’s time that our Golden State stops walking by our greatest moral shame and faces it head-on with clarity and compassion."
But Newsom's plan still needs to pass the Legislature, and it will need a lot of funding for housing and services behind it — all it is right now is a policy framework.
Kevin Baker, director of governmental relations for ACLU California Action, tells Cal Matters that he's reserving judgment, but his comments point to where the ACLU will stand as this thing takes shape.
"The problem of homelessness is caused by the cost of housing, and we won’t solve homelessness, mental health or substance abuse problems in our communities by locking people up and drugging them against their will,” Baker tells Cal Matters. "New funding for housing and services would be good, if we also keep in mind that people don’t lose their civil liberties just because the government wants to help them, no matter how sincerely."