San Francisco Chronicle, Heather Knight, March 3, 2022

The misery experienced on San Francisco’s sidewalks has long offered a case study in the failure of California’s mental health care system. Now, the dire situation is inspiring a proposal for a sweeping overhaul.

Gov. Gavin Newsom’s plan, to be unveiled Thursday, seeks to tackle two big flaws in the system: the shortage of desperately needed care and the strict limitations on compelling treatment for people who are too sick to understand they need help.

His proposal, called Care Court, would create a mental-health-focused arm of the civil courts in every county. For the first time, the state would require counties to provide comprehensive treatment to those suffering from debilitating psychosis — and risk sanctions if they don’t. The people in the program, in turn, would be obligated to accept the care.

In an exclusive interview Wednesday, Newsom grew visibly angry as he discussed his hometown — the city he presided over as mayor more than a decade ago — which prides itself on its so-called compassion as it lets people wither and die on its streets.

Previous efforts to compel treatment have often run into opposition from mental-health advocates who worry about a return to institutionalization, and say governments should focus on expanding voluntary care. But the governor said there’s no more time to debate people’s civil rights as they endure degradation, and no more time to argue over how to fund the much-needed help.

“There’s no compassion with people with their clothes off defecating and urinating in the middle of the streets, screaming and talking to themselves,” Newsom said. “There’s nothing appropriate about a kid and a mom going down the street trying to get to the park being accosted by people who clearly need help.

“I’m increasingly outraged by what’s going on in the streets,” he said. “I’m disgusted with it.”

Newsom, who has battled homelessness and mental illness in his official capacities for two decades — and has faced pressure to do more — sounded optimistic that this proposal could yield dramatic change.

Under his vision, people suffering from psychosis — whether from a mental illness such as schizophrenia or triggered by severe drug addiction — could be brought before a Superior Court judge under three scenarios: Either they are suspected of a crime, an involuntary hold in a psychiatric emergency room is ending, or a family member or outreach worker believes they cannot care for themselves. A public defender would represent them.

A county clinical team would create a care plan with input from the person and their “supporter,” a county case manager who would help them navigate the process and make decisions.

The plan would likely include clinical services such as visits with a psychiatrist, prescriptions for medications and housing such as at a board-and-care facility. The person wouldn’t need to be homeless to qualify. If a judge ordered the plan, the county would be mandated to provide what’s needed and the person would be required to accept it.

If the person suffering from psychosis refused at any point to participate, their criminal case would proceed. If no crime was committed, they could face the existing state process, in which people who are gravely disabled or deemed to be a danger to themselves or others are placed under involuntary holds and eventual conservatorship. Medication could be court-ordered, but would not be forcibly given.

Failure to take mandated medications could mean the person reverts to the criminal court or eventual conservatorship. The idea is to help people long before either of those outcomes is necessary.

Care Court would need legislative approval, which Newsom hopes to secure by June for implementation in January. The legislative process will include debate over how much additional money to provide to the courts.

A loud contingent has fought increases in involuntary treatment and conservatorship for years — and may fight the governor’s plan, too. They include advocates for homeless and disabled people who say forcing people to accept treatment is cruel, as well as some politicians and mental health clinicians who say increasing the number of conservatorships without far more treatment beds and staff isn’t viable.

Newsom brushed off those concerns Wednesday, saying the status quo is intolerable.

It’s unclear whether his sweeping, expensive idea will pan out, but what’s certain is that the current system is failing miserably.

Every week in San Francisco seems to bring new, horrifying stories of people suffering because they are experiencing crippling mental illness or drug addiction. Last week, a homeless woman and mother of three whose ex-husband said she suffered from severe drug addiction, and whose friend said she had behaved erratically, died in a fire while taking shelter from the cold under a freeway overpass in Glen Park.

On Sunday, Leonard Krubner was riding a Muni train when another passenger shoved him, screamed about him being in the FBI, called him anti-gay slurs and brandished a switchblade. Krubner darted off the train and reported the incident to a Muni agent — who said a similar report had been made the night before.

“Hello! Somebody, do something!” Krubner said in an interview. “I try to be sympathetic to people with problems. Nevertheless, we just can’t have them coming onto public transit and brandishing knives.”

On Saturday, a group of seven women and girls were celebrating a birthday at Ocean Beach when a man who they said seemed profoundly ill or high approached them, grabbed their food and threw it into the sand. He then grabbed a can of soda and hurled it into the face of Karla Flemmings, one of the celebrants, who passed out.

“I laid there and I literally asked, ‘God, am I dying today?’” Flemmings, 50, said. “Then I thought I’d lost my eye. I didn’t think it was even still there.”

A man sitting nearby called 911. Police responded and booked a 46-year-old man on suspicion of felony assault with a deadly weapon and misdemeanor vandalism. He remains in jail.

Flemmings was diagnosed with a concussion and multiple fractures in her nose. Her face was severely swollen and her eye was shut for days. She spoke compassionately about the assailant, who she said appeared to be homeless and clearly needs help.

“I’m born and raised in San Francisco, and I’ve seen the drastic changes that have occurred firsthand,” she said. “So many people don’t have money when there’s so much wealth and opulence in the Bay Area. Something better has to be done — real services and real support.”

Last year, the state approved spending $12 billion to address homelessness and mental health. Newsom’s proposed budget for this year includes another $2 billion. Of the $14 billion total, $4.5 billion is tagged specifically for mental health treatment.

The state’s Mental Health Services Act, a 1% income tax on the wealthy that passed in 2004, will provide another $3.8 billion this year to counties for treatment, a pot that’s grown significantly from last year as incomes of the wealthiest Californians have soared.

Whether the money will be enough to provide the huge amount of care Newsom envisions is a big question, but the governor’s team says the program would save money elsewhere in pricey jails and hospitals.

Darrell Steinberg, the Sacramento mayor who authored the Mental Health Services Act when he was in the state Legislature, said he supports the Care Court concept because it would finally compel counties to provide services on the state’s dime.

“Everything that cities and counties are called upon to do in providing help and treatment is voluntary and optional,” Steinberg said. “We don’t say to our local communities, ‘You know, provide a free public education to kids or don’t, whatever you choose.’ We require it.”

Clearly, the up-to-you approach for counties when it comes to mental health isn’t adequate. Under Laura’s Law, the program designed to compel outpatient treatment for seriously mentally ill people, just 218 people in the entire state were subject to enter court-ordered treatment in 2018-19, according to the governor’s office.

The foundation for mental health treatment remains the Lanterman-Petris-Short Act, signed by Gov. Ronald Reagan in 1967 in a bid to empower people experiencing mental illness. It allows for short, involuntary psychiatric holds if a person is deemed potentially dangerous, and allows a judge to appoint a longer-term conservator to make decisions for people who are “gravely disabled.”

But in 2019-20, though there were more than 55,000 short-term holds around the state, just 5,584 long-term conservatorships were put in place. Some of those could have been renewals in cases that are years or even decades old.

Last year, judges found 4,531 people incompetent to stand trial on felony charges, meaning they couldn’t understand the nature of their case or assist in their defense. Two-thirds of them were homeless, and nearly half had received no mental health treatment in the previous six months.

In June 2019, San Francisco opted into a controversial state law to expand eligibility for conservatorship to include those suffering from severe drug addictions and mental illness. But nearly three years later, just two people have been conserved.

Newsom called all of these initiatives “small ball” compared to Care Court, asserting that many of them involved years of fights for few results.

“This is a moral exercise,” he said. “The risk here is not taking one.”