Two weeks ago, an ambitious and controversial plan by Gov. Gavin Newsom for a new mental-health court system received near-unanimous support from California lawmakers. Newsom signed it Wednesday, putting San Francisco on the clock as one of seven counties that must roll out a Community Assistance, Recovery and Empowerment Court — or CARE Court — by October 1, 2023.
That’s about 12 months away. CARE Court aims to address one of the city’s thorniest issues: People, often living on the streets, with mental health disorders so severe they are unable or unwilling to get help.
Yet city officials, advocates, and others with a stake in the rollout can only offer, at best, a vague idea of how the court system will come together.
“Folks in our Department of Public Health have to spend a fair amount of time in the next few months figuring out how and whether we can use this,” Sup. Rafael Mandelman, a top local backer of the idea, said in a recent interview. “We’re likely to have hearings with the Board of Supervisors on how implementation is likely to work and what we’re hoping to accomplish. I think it’s all too soon to tell.”
The idea is to create an alternate judicial branch where people with schizophrenia and other mental health disorders, be they housed or unhoused, would get a court-ordered treatment plan, with the aim of avoiding the criminal justice system. The governor’s office estimates up to 12,000 people a year statewide could be eligible, according to reports.
Given the pace of city government and official deliberation, however, 12 months could be a squeeze to craft a local version and fit it into San Francisco’s existing web of legal and health services.
Multiple city agencies, nonprofit providers, and specialists will be involved. “We need a substance use disorder specialist, a mental health specialist, a developmental specialist, a trauma specialist, and that’s just the providers,” Kara Chien, who leads the SF Public Defender’s Office’s mental health unit, told The Frisc. “It’s not like the court [alone] can fix it just because the court orders it and the judge wears a black robe.”
Chien is deeply skeptical that SF will have the resources, including housing and healthcare workers, that the new system will need. In a recent op-ed, Chien called CARE Court a “referral system to nowhere.”
Like Mandelman, Chien indicated the city’s Department of Public Health (DPH) would take the lead, but that’s as much insight into structure and planning that anyone would give. When asked about preparations for CARE Court, a DPH spokesperson sent a lengthy statement describing who could be eligible and other parameters for participants, without mention of how the city will put it together and fund it.
Could SF’s CARE Court become one of San Francisco County Superior Court’s collaborative courts, which serve as alternatives to traditional criminal justice? Emails to the director, Allyson West, went unanswered. When asked if planning has begun for CARE Court, Superior Court communications director Ken Garcia emailed this answer: “It is far too early to see what impact the CARE program will have on California’s courts. Maybe in a year or so we will be able to assess its impact.”
If San Francisco or the other six counties in the initial rollout can’t meet the state’s demands, the state can levy hefty fines. Glenn, Orange, Riverside, San Diego, Stanislaus, and Tuolumne are also part of the first wave. The other 51 California counties must launch their courts by December 2024.
Mandelman said the threat of fines, if done right, could work in SF’s favor, forcing other counties to treat their own residents and carry “their fare share of the burden.”
What is CARE Court?
To respond to the overlapping crises of homelessness, mental health and substance use disorders, the CARE Act requires a new court in every California county. (San Francisco is both a city and county.) People considered at risk of harming themselves or others are going to the focus, and especially those suffering from schizophrenia spectrum disorders. People can be referred to the court by social workers and first responders, as well as by family members.
Once in court, represented by a legal aid worker or public defender, a person will receive a care plan of up to two years, which can include housing, mental health and substance use treatment. In addition to legal representation, a participant will have an advocate to ensure they understand what’s happening and that they’re making their own informed decisions.
If participants don’t stick to their plans, the court can threaten conservatorship or involuntary hospitalization.
CARE Court received significant opposition from the ACLU — which tweeted yesterday “we expect to see legal challenges” — as well as Human Rights Watch, SF’s Coalition on Homelessness, the Western Regional Advocacy Project, and other advocates who see it as another arm of a carceral system that punishes people for having mental health disorders or being homeless. Counties also opposed the idea until the state delayed the rollout and promised more money, according to CalMatters.
Yet it ultimately sailed through the state legislature, totalling 100 of 102 possible votes across both chambers. “Passage of the CARE Act means hope for thousands of Californians suffering from severe forms of mental illness who too often languish on our streets without the treatment they desperately need and deserve,” Newsom said in a statement.
Sharing $26 million
The Newsom administration says the nearly $30 billion budgeted for homelessness, housing, and mental healthcare staffing will create plenty of support for CARE Court participants. The bill itself, however, provides $26 million that SF and the other six counties in the first rollout must share to establish the courts and train staff.
San Francisco’s mental health workforce has been short-staffed in recent years. DPH is SF’s largest department and currently has over 700 vacancies, according to a spokesperson, despite a raft of new hires spurred by Mayor Breed’s emergency declaration in the Tenderloin. The Behavioral Health Services Division alone has 88 vacancies.
The state’s budget promises don’t assuage some skeptics. “There is a subsection of people with mental illnesses for whom this might be really helpful and might prevent incarceration,” Beth Phoenix, a UCSF School of Nursing professor, told The Frisc. “I think the issue is mandating services in an environment of very scarce resources without doing anything to address that scarcity other than threatening to fine counties that don’t implement this,” she said. “I just don’t see that as being tremendously workable.”
Phoenix also worries about adding to the bureaucratic web of services and providers that folks needing help must navigate.
Sup. Hillary Ronen, who coauthored the 2019 reform of SF’s behavioral health services called Mental Health SF, also said the state must fund more resources: treatment beds, supportive housing, skilled nursing facilities, and more.
In a statement provided by staff, Ronen was even blunter about the bureaucratic overlap. “We already have CARE Court in San Francisco,” said Ronen, and noted the Superior Court’s diversionary Drug Court and Behavioral Health Court.
There is a difference, however. The “diversion” courts are for people who have been charged with a crime. (The district attorney’s office decides whether to refer people for diversion.) CARE Court is ostensibly meant to help people before they reach the criminal justice system — or the emergency room. Ronen’s staff did not respond to follow-up questions about this difference.
Another tool
Mandelman says the city should embrace another “tool in the toolbox.” “If the state is going to give us CARE Courts,” he said, “we should take a serious look at how to maximize that tool to get people into care.”
Decades ago, people were involuntarily committed, “but in getting rid of the state mental hospital, we seem to have given up on trying to get mental health care to people who need it and don’t recognize they need it,” Mandelman said. “They aren’t getting longer term care, which is the problem, and CARE courts can help solve that.”
Legal fights might be brewing, but now that CARE Court is law, at least some local critics are also thinking about how to make it work. Jennifer Friedenbach, executive director of the SF Coalition on Homelessness, echoed concerns about the lack of services, but she’s optimistic that in building the court DPH will give advocates a seat at the table.
“We can try to make sure that there’s coordination with the different systems,” said Friedenbach, who also sits on a committee that oversees hundreds of millions of dollars in homelessness spending. “We can try to make sure that the people impacted by it who have mental health challenges have a voice in what happens.”
Daniel Lempres is a reporter based in the East Bay. He has contributed research and reporting to the New York Times, USA Today, KQED, the Humboldt Times-Standard, the Los Angeles Times, The Markup, California Magazine and the East Bay Express.