In 1993, Alice Fiddian-Green’s father experienced a psychotic break. Richard Fiddian-Green, Oxford and Harvard educated, was a professor of general surgery at the University of Massachusetts Medical School in the 1980s. According to Alice Fiddian-Green, now a University of San Francisco public health professor, her father’s diagnosis, paranoid delusional disorder, led him to homelessness.
In 1995, she and other family members made the tough decision to admit him into treatment out of desperation. “I still feel really guilty,” Fiddian-Green told The Frisc. “We were hopeful that treatment would be effective and beneficial.”
Ultimately her father spent the rest of his life on the streets, and died in London in 2014.
In San Francisco — often seen as a microcosm of America’s larger struggle to address mental health disorders, drug use, and homelessness — officials just launched on Oct. 1 yet another program designed to deal with, and hopefully prevent, these compounding crises.
The new program, called the Community Assistance, Recovery and Empowerment, or CARE Court, is required in every county by the state of California. It is designed for a narrow population of people diagnosed with schizophrenia or other psychotic disorders: to get them treatment and, if they’re homeless, to find them housing — or if they’re already housed, to stay housed and avoid the criminal justice system.
Although Gov. Gavin Newsom signed CARE Court into law last year with near-unanimous support from state lawmakers, some advocates are wary of potential civil rights violations, while some local officials say it requires resources, such as treatment beds and staff, beyond what the city can provide.
There’s yet another complaint: It isn’t necessary.
‘We don’t have the attention span’
San Francisco already has numerous services and programs, including Mental Health SF, Assisted Outpatient Treatment, and Treatment on Demand. Some officials worry that yet another program could stall their progress rather than strengthen the overall system.
“Every time they [the Department of Public Health] take three steps forward, it almost feels like they take a couple steps back,” Sup. Hillary Ronen told The Frisc. Ronen was a coauthor of Mental Health SF, a system of coordinated care that addresses homelessness. “We present a vision, then we don’t have the attention span or the wherewithal to see it through, because every six months some politician somewhere wants to look like they’re solving the crisis of the day.”
According to Ronen and others, CARE Court is particularly similar to Assisted Outpatient Treatment, or AOT, a program that the Department of Public Health launched eight years ago, also to address the city’s interconnected crises. There’s enough overlap that the department’s AOT specialist, Dr. Angelica Almeida, is now one of the officials leading SF’s CARE Court rollout.
This is another intervention to try to support people to live healthy and safe lives in the community rather than deteriorate and meet higher and more restrictive levels of care.
Dr. Angelica Almeida, SF Department of Public Health
Another key official working on CARE Court acknowledged the confusion. “There’s always questions like, ‘Why aren’t we combining this with AOT? How is this different from conservatorship? Doesn’t this already exist in some purview?” said Melanie Kushnir-Pappalardo, director of SF’s Collaborative Courts, a specialty court system which also includes drug court and family court. “And we just don’t know yet.”
Kushnir-Pappalardo is right that there are still many unknowns — CARE Court has been in practice less than a month, and SF’s version is one of seven pilots around the state — but there are comparisons worth noting to help understand what this new, controversial initiative could do that AOT is not set up to do. We have laid out several similarities and differences below.
Who is eligible? In some ways, CARE Court is narrower than AOT. In other ways, it is not
To be eligible for AOT, a person must have had “prior negative outcomes,” such as two or more instances of hospitalization or incarceration within a 36 month period, or one or more serious attempts or acts of violence against oneself or others in the previous four years.
CARE Court does not require this kind of negative track record. Officials emphasize that CARE Court is “upstream” from AOT — an effort, via a court-ordered plan, to connect people to housing and up to two years of treatment before hospitalization, incarceration, or homelessness. “This is another intervention we can use to try to support people to live healthy and safe lives in the community rather than deteriorate and meet higher and more restrictive levels of care,” Almeida said.
But CARE Court is also designed only for individuals who suffer from a schizoid disorder. Individuals with a dual diagnosis such as a drug use disorder, which is common, can also receive services. People with a drug-induced psychotic disorder but not underlying schizoid disorders are not eligible. In San Francisco, officials estimate between 1,000 and 2,000 people will be eligible.
“I think it is special that it’s focused,” Kushnir-Pappalardo told The Frisc. “It’s going to create an environment where the social workers or case managers can truly focus on becoming experts in one area.”
She noted another benefit: Placing people with drug-induced psychosis in the same program as those with mental health disorders could lead to improper care.
A wider range of people can refer patients to CARE Court than to AOT. CARE Court also allows for more support once in the system
A person who refers someone into a mental health program is called a petitioner. Both CARE Court and AOT require a petition to be filed, and both allow friends and family to be petitioners. However, CARE Court allows a broader range. For example, first responders can file a petition on behalf of someone; they cannot do so with AOT. Officials hope the expansion will prevent more people from cycling in and out of hospitalization.
Once in the CARE system, participants can choose a supporter who will advocate for them throughout the process. This person could be a friend, family member, social worker or other individual of the participant’s choice. (AOT does not let participants choose supporters.) If a CARE participant doesn’t identify a supporter, the court can ask the Mental Health Association of San Francisco to provide one. “Having them be a part of it is going to keep the process as honest as possible in not criminalizing mental illness, which we don’t want to do,” Kushnir-Pappalardo said.
Both AOT and CARE Court are supposed to point participants toward treatment and housing. Neither system is a guarantee, though
San Francisco has a notorious shortage of beds, social workers and funding for treatment. While Newsom has pledged billions more dollars for mental health, CARE Court is receiving initial funding for the administrative set-up and a $32 million grant for some transitional housing.
All this means that CARE Court participants, if a judge creates a treatment plan for them, might have to wait in line. Because of SF’s shortages, the only people who get priority for treatment or housing are those leaving the hospital and need “acute diversion” into a hospital alternative where they can be held for up to 24 hours.
There’s hope that CARE participants can get into bridge housing — a transitional step toward permanent housing — more quickly, especially if they can stabilize in a treatment program first, but with shortages it’s still not guaranteed.
Kushnir-Pappalardo said that while housing and treatment is a crucial aspect of CARE Court, a participant shouldn’t be allowed to jump in front of someone who’s been waiting: “That’s why people aren’t prioritized based on their status, and I get it. I wish everyone was prioritized, there just aren’t the beds.”
She added that hotels, which reduced health risks for homeless San Franciscans during the pandemic, might become a shelter option for CARE Court participants who could benefit from better sleep and services as they make decisions about their treatment.
Samuel Jain, senior attorney with Disability Rights California, criticized the city and state for the housing shortage: “You can get caught up in CARE Court, go through this coercive process, and then if you’re unhoused, you’re not actually provided any housing.”
SF officials acknowledge the pressure. DPH’s Almeida said the city could be fined for not providing court-ordered services, including housing. When CARE Court launched a month ago, the city had 2,550 beds, with 50 more in the pipeline.
AOT takes place in a traditional courtroom, CARE Court does not
This might seem like a minor difference. CARE Court supporters say it isn’t. By using a private conference room and removing other traditional trappings — the judge won’t wear a robe or bang a gavel — CARE hopes to avoid traumatic associations or paranoia that participants might have with the government or justice system.
At hearings, the court will also offer gift cards for stores like Walgreens so participants can buy items for their basic needs. Kushnir-Pappalardo said building trust and relationships is going to be the first and perhaps most important step. Public health officials elsewhere are also thinking creatively about building trust. Kushnir-Pappalardo noted how Riverside County is purchasing two wifi-enabled vans that will locate eligible individuals and give them the option to attend hearings on the spot.
It remains to be seen if people in an agitated state will be willing to step inside a van, but Kushnir-Pappalardo said she appreciates the creative thinking.
Part of it is showing up
CARE Court backers emphasize the program is voluntary, and to bring participants along they’re relying on a delicate balance: not feeling too much like a court, yet having enough “symbolic weight,” as Almeida put it during a September hearing, to encourage individuals to accept treatment.
If participants do not attend hearings or accept treatment or medication, officials say there is no penalty. However, should someone fail to complete the steps mandated in CARE Court, their decision could be used as evidence in a conservatorship hearing — which makes civil rights advocates question whether CARE Court is actually voluntary.
In a conservatorship, a judge appoints a guardian to manage the personal or financial affairs of someone deemed gravely disabled, or incapable of making decisions for themselves. And Newsom recently signed SB 43, which expands the standards for grave disability to include individuals whose mental illness or substance use disorder inhibits their ability to keep themselves safe.
“We’ve seen a number of bills moving through the legislation, with very little opposition, eroding the civil rights of people with mental health disabilities under the guise of addressing homelessness,” said Disability Rights California attorney Jain. “All of these complex court processes like CARE Court, like AOT before it, are just taking away money from the core services that we need to provide.”
When asked about CARE Court’s prospects, USF’s Fiddian-Green acknowledged the complexities, and leaned on her professional and personal experience. She expressed hesitancy about programs that use some level of coercion, yet also applauded attempts to separate mental health from criminal justice. As for her father, she said, “After mandating him into treatment” and seeing his severe mental illness never remedied, “I would not make that choice again.”
Leaving people on the street to fend for themselves — or waiting until “negative prior outcomes” eventually, perhaps tragically, qualify someone for more help — isn’t working either. “The thing that we found across big, small, red and blue counties is that we all have the same issues, which are not enough housing, not enough social workers, and too many drugs,” said Melanie Kushnir-Pappalardo. “And that’s all over California, and really all over the country.”