One year ago, San Francisco and eight other California counties launched CARE Court, a new treatment program for people with specific mental health diagnoses. Now the rest of the state’s counties are rolling out the program — and they’re looking to SF and other early adopters for lessons.
But San Francisco doesn’t have many lessons to share for a couple of reasons. Only a few dozen people have been referred to its CARE Court, and officials refuse to say how many of them have begun a treatment program.
“San Francisco [has] some similar challenges that we will face,” says Judge Sandra Bean, who is helping run Alameda County’s CARE Court rollout, which began this month. “Not only do a lot of our potential participants have severe mental illness, but they also have severe substance abuse issues. But I can’t compare because I really don’t have enough information.”
When San Francisco’s pilot kicked off in October 2023, SF behavioral health officials estimated that 1,000 to 2,000 people would be eligible for CARE Court. (It stands for Community Assistance, Recovery and Empowerment.) So far, 47 people have been referred to the court, according to the San Francisco Superior Court.
Some of the larger counties that also joined the CARE Court pilot a year ago have been more forthcoming. Officials in San Diego, Riverside, and Los Angeles counties have shared data not just on how many referrals, also known as petitions, their courts have received, but also how many people are getting treatment.
CARE Court supporters are eager to know more. They see the court as a way to make a dent in SF’s overlapping mental health and homelessness crises by steering people with psychotic disorders, including those compounded by drug or alcohol use, into as much as two years of treatment — and ideally helping them avoid hospitals, the criminal justice system, or homelessness.
“I was curious to see what they would be able to do with it,” says Sup. Rafael Mandelman, an early supporter. “But we’re certainly due for an update.”
San Francisco’s health officials could not be reached for this story, but DPH provided a statement through a spokesperson: “San Francisco has continued to be a leader in advocating for modernizing outdated laws that no longer meet the acute needs of the populations we serve, as well as being at the forefront of implementing all the tools available to us despite their limitations. We recognize the difficulty that families face and do everything we can to compassionately provide options.”
Update 12/19/24: The Chronicle reported in October that out of 42 petitions, half were dismissed, and five people had entered care plans. When The Frisc asked for confirmation of those numbers, an SF Superior Court spokesperson said, “We are not providing any additional information at this time.”
The first year of CARE Court came during a tumultuous time in San Francisco, with two 2024 elections that highlighted voter anger over public safety, drug use, and homelessness.
San Francisco has similar challenges that we will face. But I can’t compare, because I really don’t have enough information.
alameda county superior court judge sandra bean
On the campaign trail, Mayor-elect Daniel Lurie promised better mental health and drug treatment services, including 1,500 more emergency shelter beds during his first six months in office and 2,500 temporary housing units in his first year.
“I’m building a team rooted in accountability, service and change to tackle the city’s historic challenges,” Lurie said via email to The Frisc. “We must turn around a failing behavioral health system to end the despair on our streets and attract the new businesses and jobs that are critical to our economic recovery.”
When asked to comment specifically on CARE Court, Lurie declined. In August the Bay Area Reporter cited his support of the program to get people into treatment.
The lack of information also fuels critics, some of whom say CARE Court is coercive, and others who say it can’t provide the treatment it promises. “There are a lot of people out there who need something like CARE Court,” says Nicholas Rosenlicht, a clinical professor of psychiatry at UCSF. “But if you put them in the system, you’re butting somebody out. They just don’t have the resources to provide that sort of comprehensive intervention that these people need.”
How it’s supposed to work
CARE Court is meant to help people with psychotic disorders by allowing a family member, medical professional, first responder, or other official to file a petition – a formal request – for court-ordered treatment. A judge then reviews the petition.
If it meets several criteria, the local health department takes over and creates either an agreement or plan (there’s a difference) that includes up to two years of treatment and housing.
A CARE agreement, considered less restrictive, is a voluntary settlement between the health department and the participant to set up treatment and services outside the court process. In a CARE plan, the court can order services and require the participant to attend hearings. According to Alameda’s Judge Bean, a judge will order a CARE plan only when the court can’t agree with county health officials on which services to provide.
Samuel Jain, a senior attorney with Disability Rights California, says even a less restrictive CARE agreement is coercive because a judge must approve the arrangement and can make changes. Bean disagrees: “I think there’s a lot of misconception about what the CARE Act does. It does not order the participant to do anything.”
Another criticism is that similar programs already exist. For example, San Francisco offers assisted outpatient treatment, or AOT, that provides treatment and housing to a similar population. But to be eligible for AOT, a person must have had “prior negative outcomes,” such as two or more instances of hospitalization or incarceration.
In other words, CARE Court fills a niche that other programs don’t, according to Dr. Angelica Almeida, who used to oversee San Francisco’s AOT program. Almeida told The Frisc last year that CARE Court is “upstream” from AOT because it seeks to keep people out of hospitals and jails.
The new court adds more treatment options, but what if there’s no place for the participants to go? UCSF’s Rosenlicht says he struggles to find available hospital beds for his patients who “desperately want care” unless they are violent or suicidal. “The places are full,” says Rosenlicht.
With budget crises at the local and state level and a Trump White House that could well be hostile to California, promises of more beds, homes, and services (like Lurie’s during the mayoral campaign) could bump up against fiscal realities.
According to a 2023 survey by the county behavioral health director association and UCSF’s healthforce center, county behavioral health departments are running 25 to 30 percent below full staff capacity, the Chronicle reported.
Attitude shift
A common narrative is that the past year or so has marked a shift toward less leniency and more punishment for drug use and crime. California’s Prop 36, which allows felony charges for certain drug and theft crimes, passed 68 to 32 percent in November. (The backing in SF was nearly as strong at 63 percent.)
With record numbers of drug overdoses, SF voters in March approved drug screens for welfare recipients and more police powers. And for some time, there’s been a push for more “sober” recovery housing where drugs and alcohol aren’t permitted.
Voters have also said yes to more funding. In March, state Prop 1 passed by a hair’s breadth, authorizing more than $6 billion in bonds for more behavioral health treatment and housing. Critics like the ACLU, which also opposes CARE Court, argued Prop 1 forced mental health, housing, and substance use programs to compete for funding.
In Oct. 2023, the state also passed SB 43 to expand the population of people that are eligible for conservatorship. Mayor London Breed pushed SF to take full advantage. Similar in some ways to CARE Court, conservatorship allows a judge to appoint a person or organization to manage the affairs of someone considered “gravely disabled” with a mental health disorder.
SB 43 expands the definition of gravely disabled beyond mental health to include those with a substance use or co-occurring substance use disorder. The Chronicle reported last month that the city is struggling to provide enough resources to help people being conserved.
From Orange to Glenn
As of Nov. 25, the San Francisco Superior Court, which holds CARE hearings, had received 47 petitions. That’s one petition for every 17,212 SF residents.
Some early adopter counties with large populations have had fewer petitions per capita, and some have had more.
San Diego County has a population about four times larger than San Francisco and has seen 221 petitions filed, one for every 14,796 people. In Los Angeles, the state’s most populous county, 323 petitions have been filed, one for every 29,916 people.
In Orange County (1 petition for roughly every 30,000 residents) officials want to use CARE Court only “when absolutely necessary,” says assistant deputy director of health services Frank Congine at the Orange County healthcare agency, told The Frisc.
Glenn County, the smallest of the pilot group, had only received two petitions as of Nov. 18. (One was dismissed.) Chris Ruhl, court executive officer with the Glenn County Superior Court, told The Frisc that they expected more petitions to come in, and he sees the court as a good way to avoid criminalization.
Across the bay, Alameda County opened its CARE Court two weeks ago and has received three petitions. “I was hoping we would have just an onslaught when we opened the doors,” says Judge Bean. “But I think that was overly optimistic, because people still are not sure exactly what it is and what to do.”
Even with the one-year pilot in SF and eight other counties, Bean and other county officials emphasize that it’s still early. According to the state’s Department of Healthcare Services, 557 petitions have been filed statewide, with more each quarter and expected to keep rising.
The program is expected to cost the state about $25,000 a person per year. While some detractors say it’s a waste of money no matter what, others on the fence want to ensure treatment and services will be there for those who take part in CARE Court. “We need to add carrots to the sticks,” says UCSF’s Rosenlicht. “It’s the humane thing to do.”
