A New Intervention in California’s Mental Health Crisis

A New Intervention in California’s Mental Health Crisis

A New Intervention in California’s Mental Health Crisis

Proposed mental health courts under the CARE program would mandate treatment for severely impaired people.

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Earlier this year, California Governor Gavin Newsom proposed setting up mental health courts in every county in the state. They would be known as CARE courts, with the acronym standing for Community Assistance, Recovery, and Empowerment; and they would create both an obligation on the part of the county to provide seriously mentally ill homeless residents with needed treatments and services, and also an obligation on the part of the mentally ill to participate in mandated treatment.

California is staggering under a homelessness crisis of unprecedented scale. More than 160,000 people were homeless on any given day as of 2020, and when data is released from the recently complete point-in-time count, it almost certainly will show that that number has gone up—despite the $12 billion that Newsom put toward solving the homelessness epidemic last year.

California’s homeless crisis has many causes, which I have written about in the past: vastly inflated rent and real estate prices, the release of tens of thousands of people from prisons over the past decade, wildfires that have destroyed numerous homes in recent years, escalating levels of opioid addiction, and a growing mental health crisis, at least in part exacerbated by the pandemic and all the stresses that accompanied it.

The challenge of helping profoundly mentally ill people not in treatment and living on the streets isn’t the only story here, but it is a core part of the narrative. In 2019, reporters for the Los Angeles Times examined 4,000 answers to questionnaires given out to homeless residents as part of the point-in-time count; the newspaper’s interpretation of the answers was different from that of the Los Angeles Homeless Services Authority, which tends to underplay the numbers of seriously mentally ill homeless. The Times found that 67 percent of respondents either had severe mental illnesses or were addicted to drugs. A year later, the Treatment Advocacy Center found that one-third of California’s homeless were seriously mentally ill. In 2021, U.S. News & World Report reported that 37,000 seriously mentally ill people in the state were pinballing between ERs, prisons and jails, and the streets.

Given this data, and the extraordinary level of dysfunction that anyone who lives in a California city can see on a daily basis, one would think pretty much everybody ought to be able to coalesce around the idea of supporting CARE courts, or at least acknowledging that in some cases it’s appropriate for the courts to mandate treatment.

But that’s not the case. Over the past week, as the legislation creating these courts has begun its journey through the state legislature in Sacramento, both the mental health advocacy community and groups such as the Western Center on Law and Poverty have come out strongly against the concept of these courts. Dozens of organizations signed a letter highlighting their objections and urging legislators to vote down the bill. Their concern is that it injects an element of coercion into the process, by imposing penalties on seriously mentally ill people who don’t accept the need for treatment.

That’s true: The courts would, under the plan Newsom hopes to sign into law come June, in certain circumstances have the power to order that a person refusing treatment be held in a psychiatric facility. They also would be able to appoint conservators who could make medical decisions on behalf of people deemed incapable of doing so on their own behalf. But why do advocates automatically conclude that these are inherently bad ideas, and that the motives of those proposing them are suspect?

I’m torn here. On the one hand, the organizations that signed onto the letter of opposition include many groups that I have nothing but admiration for, and which I have written about many times in the past. I respect their arguments, but on this particular issue I don’t entirely agree with them.

Of course it’s wrong to stereotype the mentally ill; and of course it’s wrong to simply assume that all seriously mentally ill people are inherently criminal or inherently violent. But anyone who has spent time talking with people living in California’s sprawling encampments will have seen that there are a vast number of people living on the streets of the Golden State who are dangers to themselves or others. To deny this is to place ideology before reality. It’s also to deny the current truth that vast numbers of seriously mentally ill people have essentially been abandoned by the state, by the counties, and by the cities, to fend for themselves in brutal, cruel shantytowns. Without at least a degree of enforcement, thousands of those men and women will remain in those shanties, their illnesses left untreated and their condition deteriorating.

I don’t like it when conservatives ignore what’s plainly visible—witness the ongoing efforts to deny legitimacy to Biden’s election win in November 2020, despite the mountain of evidence that the result was genuine and above-board. I don’t like it any better when progressives are the ones ignoring the hard facts.

Newsom’s plan certainly isn’t perfect. But at least it’s an acknowledgement that the streets of California’s great cities are at risk of becoming, if they aren’t already, open-air bedlams. In Los Angeles, San Francisco, Oakland, San Diego, and countless other cities, thousands of seriously mentally ill now reside in shantytowns, where untreated serious mental illness are allowed to fester.

Housing-first advocates argue that most of these problems can be managed once a person is provided housing. They suggest that Newsom’s efforts should be focused simply on the brick-and-mortar challenge of building homes. That might well be true for someone whose mental illness is situational—say, anxiety brought on by the ghastly realities of living on the street. But for someone like the man I saw the other day in downtown Sacramento who, screaming obscenities to himself as he walked, rushed into a kids’ play area near the basketball arena violently kicking at the toys and sports equipment, while the kids ran in horror—how on earth will simply giving them the keys to a home solve their, or society’s, problems?

The CARE courts clearly won’t work without massive investments in housing and wraparound social services at the same time. But to reflexively dismiss the concept because it includes a degree of compulsory enforcement is to do a disservice to the seriously mentally ill as well as to the broader community.

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