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CARE Court or Scare Court? The California CARE Court system allows for involuntary mental health treatment.

It is estimated that more than 170,000 individuals are homeless in California and that one in four of them has a serious mental illness. This is due to a lack of affordable housing and the state’s failure to provide necessary mental health care. Governor Newsom is hoping to change these statistics with his 14-billion-dollar investment in a system that will bring mental health into the courtroom. Judges will be able to order people to get help and counties to provide it under the Community Assistance Recovery and Empowerment (CARE) Court initiative. Newsom believes that the new civil court design will help thousands of people get off the streets and begin to live their lives with the mental health support they need.

Indeed, the CARE Court philosophy seems like a no-brainer. What is there to dispute about finally providing overdue clinical services to this widely ignored and vulnerable population? For starters, the CARE Court program is mandated for those who fall under its purview. Disability rights groups argue the CARE Court system violates the fundamental rights of individuals being forced into involuntary treatment. Further, the efficacy of mandated treatment is questionable.

What Is CARE Court?

Newsom has implemented CARE Court to address people with mental health and substance use disorders. This new court protocol is evidence-based and predicated on the ideology that people can stabilize, begin healing, and exit homelessness in less restrictive, community-based care settings. The CARE Court is designed to aid people who have become homeless, incarcerated, or worse due to mental illness by getting them into treatment, including therapy, medications, and housing. Specifically, Newsom proclaims the CARE Court system steps in and connects a person struggling with mental health and often co-occurring substance abuse with a court-ordered care plan for up to 12 months, which can be renewed for an additional year. Each treatment plan is managed by a care team in the community and is individualized with supportive services that are supposed to be culturally and linguistically competent.

How Does CARE Court Work?

The first step is a petition to the court by a family member, behavioral health provider, first responder, or other approved party to provide care and prevent institutionalization of an individual. Those who are exiting a short-term involuntary hospital hold or an arrest may be particularly good candidates for CARE Court. However, it is not available for every individual experiencing homelessness or mental illness. CARE Court only applies to those people on the schizophrenia spectrum and other psychotic disorders who may also have substance use issues and who lack medical decision-making capacity. Mental illnesses such as anxietydepression, and posttraumatic stress disorder are not included, and the participant must be 18 years or older. The civil court then orders a clinical assessment after a reasonable likelihood of meeting the CARE Court criteria is held. The court appoints a public defender and a CARE supporter to represent the individual to ensure their rights are being protected.

The court reviews the clinical evaluation, and if the person meets the criteria, the development of a CARE plan is ordered, which will include therapy, medications, and housing as part of its objective. As housing is an important component of this system, persons under a CARE Court plan will have access to clinically enhanced interim or bridge housing, licensed adult and senior care settings, and other supportive housing options. The CARE plan is then reviewed and adopted by the court with both the individual and county behavioral health as parties to the court order for up to 24 months. If an individual refuses to participate in their CARE Court-ordered plan, including stabilization medications, they may be subject to an additional court hearing and can be referred by the court for a conservatorship.

Civil Rights Groups Against CARE Court

Not everyone is praising Newsom’s CARE Court system. Helen Tran, senior attorney at the Western Center on Law and Poverty stated: “The CARE Act unnecessarily involves our court systems to force medical care and social services on people.” Additionally, Disability Rights California and The Public Interest Law Project have challenged the constitutionality of the CARE Courts program-mandated treatment agenda. Specifically, they argue that the CARE Court violates constitutional guarantees of due process and equal protection while burdening fundamental rights to privacy, autonomy, and liberty. Moreover, enabling the state to force severely mentally ill individuals into court-ordered treatment and housing programs is unconscionable. Disability activists contend that the CARE Court is a coercive, involuntary system period. Further, there are consequences for not following through with a CARE plan including that the court will refer the person for a conservatorship, which equates to the loss of controlling their own medical care, finances, and housing preferences. Finally, they indicate that there is no proven research that mandated treatment works.

Efficacy of Involuntary Treatment

The CARE Court system is predicated on self-determination for the individual involved. However, at its core, the CARE Act was devised to essentially force people into a court-mandated design of treatment. Taking people off the streets and requiring them to subject themselves to treatment or face conservatorship does not scream self-determination. Moreover, there is evidence that forced treatment doesn’t work. According to Corrado Barbui, the efficacy of mental health treatment when coercive is vastly reduced. Barbui contends that shared decision-making interventions and integrated care to reduce forced treatment in mental health services should be considered in the development of policy and clinical practice. Moreover, Christopher Maylea argues that social workers should reject the compulsion for involuntary treatment as the research does not support this paradigm. Instead, he states that inclusive participatory mental health approaches offer the individual the greatest chance for change.

Conclusion

Advocates of the CARE Court argue that this model of intervention will help thousands of mentally disabled persons. The CARE Court’s inception is brand new, and time will reveal if involuntary treatment offers hope for California’s most vulnerable population. While it was created as a “CARE” Court, its focus on mandated treatment scares many.

References

1. Barbui, C. 2021. Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence. The British Journal of Psychiatry, 218(4) 185–195.

2. Maylea, C. 2017. A rejection of involuntary treatment in mental health social work. Ethics and Social Welfare, 11(4) 336–352.

LA County Care Court aims to help those on streets with mental illness

Thursday, November 30, 2023

LOS ANGELES (KABC) — Los Angeles County has about 75,000 people living on the streets. Officials estimate about 10% suffer schizophrenia or other disorders.

“There are too many people with severe mental illness who are living on the streets,” LA County Supervisor Janice Hahn says. “We’ve all seen them and so far, we’ve been unable to reach them.”

Los Angeles County officials on Thursday announced a new program called Care Court to help people receive treatment and services.

“We are really committed to helping people get the support they need to improve their mental health and well-being. We are here to change the trajectory of people’s lives,” says Dr. Lisa Wong from the Los Angeles County Department of Mental Health.

With this program a family member or someone else can file a petition asking to determine if someone qualifies.

A judge can then order a care plan for the person.

Samantha Jessner, presiding judge for the Superior Court of Los Angeles County, says “This new tool provides an alternative to the way in which most individuals enter our county’s mental health system, which is usually through the criminal justice system.”

“Initially, LA County wasn’t going to have this program until next year. But we are ground zero for this problem. And so, we moved our start date up an entire year,” adds Hahn.

Not everyone likes this program. The Western Center on Law & Poverty sued to stop the Care law, saying it forces treatment on people.

In an article it claimed, “The law paves the way to eventually institutionalize people who are unhoused and have schizophrenia and other psychotic disorders.”

Ricardo García, the Los Angeles County public defender says, “To those who are concerned that Care court will lead to forced treatments or detention, I want to emphasize participation in Care Court is absolutely voluntary.”

The program officially begins Friday and until then authorities say they’re not sure how many people would qualify for Care Court.

Why We Sued to End CARE Court

An unprecedented number of Californians live on the streets and face severe mental illness. It is gut wrenching to see. The CARE Act accurately describes this humanitarian crisis but prescribes a wrong, inhumane solution. Not only is creating this new court system to round up individuals unconstitutional, it is bad policy subject to pervasive societal biases and disproven methods of treating mental illness. That is why on January 26, Disability Rights California, Western Center on Law & Poverty, and the Public Interest Law Project sued Governor Newsom to put an end to CARE Court.

Contrary to some strong opinions that CARE Court is “California’s only real plan for helping our most vulnerable and seriously mentally ill,” Governor Newsom never planned to truly provide behavioral health treatment and housing through this bill. The CARE Act does not mandate counties to provide behavioral health treatment or housing; it creates no new rights or benefits for people with schizophrenia and other psychotic disorders who are summoned to court to join the CARE process. Rather, all CARE Court-ordered services are “subject to available funding and all applicable federal and state statute and regulations, contractual provisions, and policy guidance governing initial and ongoing program eligibility” (Welf. & Inst. Code § 5982(d)). In other words, services will only be provided as they are available.

Here’s a reality check for Sacramento: behavioral health and housing services are not available to all Californians. A person who needs treatment and housing usually cannot receive either in a timely manner because there are not enough mental health providers, facilities, and affordable housing units to access.

A UCSF study projected that if nothing significant changes by 2028, California will have 50% fewer psychiatrists to meet demand for behavioral health services, and 28% fewer psychologists, therapists, and social workers combined to meet the demand. We see this play out daily with stark disparities based on income and race. For example, in Compton, there are only five licensed psychologists compared to Santa Monica, which has 361.

Compounding CARE Court’s false promises is the affordable housing shortage. There is a shortage of 1 million affordable rental homes for extremely low income renters. And the CARE Act does not appropriate one single penny for housing.

The CARE Act pretends this backlog of services and housing does not exist, despite advocates’ cries to increase funding for our behavioral health systems and affordable housing instead of funding new courts. If we invested in behavioral health and housing to their full level of need, and give some time for the workforce to catch up, we would already have a better plan than CARE Court.

So, if not guaranteeing behavioral health or housing services, what does the CARE Act provide? The law paves the way to eventually institutionalize people who are unhoused and have schizophrenia and other psychotic disorders, out of sight from the very people who support CARE Court.

The biggest lie about CARE Court is that it is not involuntary treatment. CARE Court is an involuntary, coercive system. There are consequences for not following through with a CARE plan. When a person does not comply with the exact terms of a CARE plan, the court must refer the person for conservatorship with “a presumption . . . the [person] needs additional intervention beyond the supports and services provided by the CARE plan” (Welf. & Inst. Code § 5979(a)(3)). A person who, for any reason, does not follow through their court order, would more easily be conserved and lose their rights to control their own medical care, finances, and housing preferences. No matter how Governor Newsom and his proponents want to spin CARE Court, the law speaks for itself.

Existing laws already provide for involuntary treatment of persons found dangerous to themselves or others. But the CARE Act takes this a giant step further by permitting a judge to impose restrictions on persons deemed “likely” to become dangerous. Little guidance is offered for judges to make that speculative determination.

The CARE Act was enacted despite any evidence that it would be effective. As Disability Rights California wrote in May 2022 on behalf of our coalition opposing the CARE Act, voluntary treatment works and involuntary treatment does not:

[N]o studies exist to prove that a court order for outpatient treatment in and of itself has any independent effect on client outcomes. Studies show that any positive effects that result from outpatient commitment are due to the provision of intensive services, and whether court orders have any effect at all in the absence of intensive treatment is an unanswered question.

In determining how we provide medical care and housing for Californians, our civil rights and social policies can co-exist. The state should house people first, then let people decide their course of treatment. The Legislature has not explained why it cannot appropriate resources to fund all medically necessary care and permanent affordable housing for individuals and also protect their dignity and privacy interests at the same time. What is clear is that faced at a moral crossroads, Governor Newsom and the Legislature chose a more politically expedient route instead of a benevolent and effective one.

PRESS RELEASE: Disability, Civil Rights Groups Say Fundamental Questions Must Be Answered Regarding ‘CARE Court’ Proposal

FOR IMMEDIATE RELEASE 

After issuing a letter in strong opposition, groups request specific answers for core components of proposal

Sacramento, CA – With Governor Gavin Newsom’s proposal for a so-called “CARE Court” set to be heard by the legislature this week, and after more than 40 advocacy groups including ACLU California Action, Disability Rights California, and Western Center on Law & Poverty submitted resounding opposition to its related bill, SB 1338 (Umberg & Eggman), advocates say fundamental questions remain unaddressed by the administration and bill authors.

The specific questions advocates have about the proposal include:

  1. How would the CARE Court respond to the crisis of insufficient housing and treatment availability for people who need either or both?
  2. How would the CARE Court avoid reinforcing systemic racial biases which result in disproportionate numbers of Black and brown people unhoused and under court supervision?
  3. How would the CARE Court achieve effective outcomes with coerced treatment where evidence has consistently supported adequately resourced voluntary treatment instead?
  4. How would the CARE Court avoid fast-tracking vulnerable people with disabilities to conservatorship and the diminution of their autonomy and legal rights?

The joint opposition letter sent to legislators this month unequivocally states that the framework of the proposal is entirely and irreparably flawed. Specifically, if these fundamental questions go unaddressed, the proposal is simply bill language without substance.

“Instead of creating a new court system to delegate medical care, California should guarantee housing for people who are unhoused and for those with severe mental health disabilities,” says Helen Tran, health attorney for Western Center on Law & Poverty. “Forcing people into court-ordered treatment without guarantee of permanent housing will create a continuous cycle of court intervention when people find themselves back on the street due to California’s severe lack of affordable, permanent supportive housing. State funds should be directed toward the creation of housing and supportive services to help people maintain their housing and health care needs.”

The groups say the proposed CARE Court model will lead to unnecessary institutionalization of people with disabilities and unhoused people and will likely create a chilling effect that prevents people from seeking supportive services for fear of being institutionalized or otherwise having their rights stripped. The proposal also feeds into the false narrative that most unhoused people have a psychiatric disorder.

“CARE Court is a fast track to re-institutionalize Californians living with mental health disabilities,” says Kim Pederson, senior attorney at Disability Rights California. “The state should invest in evidence-based practices for voluntary engagement in community-based, trauma-informed, culturally-responsive mental health services. Instead, CARE Court creates a punitive system under which a person must comply with court orders or risk being conserved and institutionalized. True recovery and empowerment can only come from providing people with meaningful opportunities to make their own choices about the services that will work best for them.”

Additionally, by involving the legal system the proposal will perpetuate institutional racism and exacerbate existing disparities in health care delivery since Black, Indigenous and other people of color are significantly more likely to be diagnosed with psychotic disorders than white people, and because there is clear evidence that adequately resourced, intensive, voluntary outpatient treatment is more effective than court-ordered treatment.

“At a time when there is an unprecedented housing crisis that disproportionately impacts Black people and other people of color, many of whom have already been entangled in failed legal and other systems, this proposal if enacted would have disastrous consequences,” says Brandon Greene, director of the Racial and Economic Justice Program at the ACLU of Northern California. “What we need is investment in holistic community driven systems not punitive ones that further alienate and ostracize.”

Read the full letter of opposition.

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ACLU California Action is the statewide legislative policy arm of the ACLU affiliates in California. The ACLU works to protect civil liberties and civil rights and advance equity, justice, and freedom for all.

Disability Rights California (DRC) is the agency designated under federal law to protect and advocate for the rights of Californians with disabilities. The mission of DRC is to advance the rights, dignity, equal opportunities, and choices for all people with disabilities.Western Center on Law & Poverty fights in courts, cities, counties, and in the Capitol to secure housing, health care, and a strong safety net for Californians with low incomes, through the lens of economic and racial justice.

 

CA’s governor wants mental health courts for homeless people

“The Western Center on Law and Poverty pointed to a 2020 state audit that found many people put under conservatorship wound up with limited treatment and follow-up while the San Francisco Public Defender’s Office called the proposal a “band-aid” approach falling short of the fully funded mental health system California needs.”

Read More 

 

If you think what’s happening to Britney Spears is bad, you should know more about conservatorship in California

Free Britney – the call to end the conservatorship of superstar Britney Spears has expanded across the globe, thanks to a grassroots movement recently bolstered by the New York Times documentary, “Framing Britney Spears.” Since the beginning of her conservatorship critics have demanded its termination; advocates were first dismissed as overzealous fans, but their claims were based on facts uncovered in legal filings, raising legitimate concerns about the probate court system. Spears’ case, while singular in fame and fortune, illustrates the complications of conservatorship, particularly in California.

Britney Spears has been under conservatorship since 2008, though, she continues to fight it in court, and she continues to be highly productive. Paradoxically, Spears has been denied the freedom to make phone calls, operate a motor vehicle, and access her finances, all the while recording four studio albums and performing in four world tours, in addition to a four-year Las Vegas residency.

It is often the case, as it appears to be with Spears, that conservatorship is inappropriate or inadequate for the problem it seeks to solve. Nevertheless, California legislators continue to propose expanding the conservatorship system – 2021 legislative session included.

There are different conservatorships in California. One stems from the 1967 Lanterman-Petris-Short Act (LPS), which established California’s system of conservatorship and involuntary treatment for people who are gravely disabled — meaning they can’t meet basic needs. Those conservatorships are initiated by medical or legal professionals. Another, known as probate conservatorship, has less stringent standards and can be initiated by anyone, including parents. Probate conservatorship, which is what Spears is under, is meant to protect people who are unable to provide for their own needs, or to protect them from undue influence.

Spears’ case illustrates how extreme conservatorship can be – even for someone as wealthy and famous as she; it also represents the tip of a large iceberg. If one of the most successful pop stars of the century can be deemed unfit to control her life, what happens to people who don’t have nearly the amount of fame or money?

Britney Spears can work and make money, even though conservatorship is supposed to be for people who can’t. For those in the system without money, they or their families sometimes receive astronomical bills (in the one-million-dollar range) upon release from California’s State Hospital system, which treats individuals with severe disabilities under LPS conservatorship. The bills say the state can go after the former patient’s spouse, children, parents, and estates for payment. Still, in spite of the potentially devastating financial and psychological effects, California continues efforts to expand conservatorship as a solution for mental illness, instead of addressing root causes for what leads people to be conserved.

Last year, a proposed ballot measure misleadingly titled the “California Compassionate Intervention Act” aimed to make it easier for police to detain people on the street who exhibit signs of mental illness, and to eventually conserve them. While the measure did not make it on the ballot, it received substantial attention.

Other measures also sought to expand forced conservatorship, despite the fact that advocates and mental health practitioners say often and repeatedly that the problem should first be addressed by adequate wrap around services — mental and physical health care, housing, and economic resources at earlier points in a person’s life. Instead of making sure those needs are met, California continued with legislation like SB 1045 and its amendment, SB 40, which allows participating municipalities to force people sent to mental health treatment more than eight times in one year to be automatically conserved.

Though SB 1045 and SB 40 were highly controversial and some counties chose not to participate, their passage shows the appetite for conservatorship as an answer to California’s fundamental social failings. That appetite included other failed proposals, like AB 1971  and AB 2156, which would have expanded to definition of “gravely disabled” to make conservatorships easier to obtain.

Also last year, the state auditor found that under California’s conservatorship system, many people who are conserved end up with limited treatment options – conserved with nowhere to heal. Additionally, the auditor found that once people are released from involuntary holds, most do not get follow up treatment. What’s more, there is also confusion over how public dollars are spent for mental health programs.

The case of Britney Spears exposes how well-intentioned policy can create extreme and undesirable outcomes. While the decision to control a person, their finances, and their movement may seem like a straight-forward solution, what the state auditor’s findings show is what advocates and mental health professionals have said all along – longer term solutions for mental illness, homelessness, and other factors leading to conservatorship involve addressing the root cause.

Does everyone have access to long-term housing, treatment for major trauma, access to drug treatment programs, and access to mental and physical health care throughout their life? Or in Britney’s case, refuge from constant prying eyes and abusive, stalking paparazzi and a bloodthirsty public? The answer is no, California has not invested nearly enough to ensure that those very basic needs are met. In light of inaction on those fronts, expanding conservatorship is not a solution, but rather, a surface fix that will never address the poison at the base of the well.

 

Courtney McKinney is the Director of Communications for Western Center on Law & Poverty. Kevin Wu is a Free Britney activist and runs @freebritneyla. He is featured in “Framing Britney Spears.”