The Washington PostDemocracy Dies in Darkness

Forcing homeless people into treatment can backfire. What about a firm nudge?

California Gov. Gavin Newsom’s proposed Care Courts have set off a debate about civil rights and human needs

A homeless encampment in Oakland, Calif., in 2018. California officials are searching for solutions to the homelessness problem, which has reached crisis levels. (Michael Macor/San Francisco Chronicle/AP)

California’s intertwined mental health and homelessness crises have become impossible to ignore: The state has an astonishing 160,000 unhoused people. In Los Angeles, an estimated 20 percent of them have a formal diagnosis of serious mental illness, and the county jail claims the dubious distinction of being the country’s largest de facto psychiatric facility. In San Francisco, homeless deaths last year more than doubled — mostly because of overdoses. In response to the crisis and voters’ restlessness on the issue, California Gov. Gavin Newsom (D) proposed in March tackling the problem with a sweeping new plan involving something called Care Courts that could push people with psychosis into treatment.

Newsom’s program would allow providers, family members, first responders and some local officials to petition for a court order of 12 months of supervised treatment and housing, with the possibility of an extension. A public defender and a designated “supporter” would advocate for this person before a county court. Officially voluntary, participation in treatment would be encouraged by an implicit threat: Continued refusal might lead to a legal guardianship that could force people to take medication and live in locked facilities. The courts would also track county governments to ensure they provide the services outlined by the state and would sanction those that fail to comply.

When the proposal was unveiled — it could involve 7,000 to 12,000 people at first, the governor said — California was immediately plunged back into a polarized debate that has haunted mental health politics since the 1960s, when the United States moved away from large-scale psychiatric asylums. One side sees the homelessness problem largely as a result of civil rights protections that make it too difficult to force treatment on people who desperately need it; the other asserts that there simply aren’t enough care and housing resources available and that the argument about “excessive” civil rights is at best a distraction.

Indeed, civil liberty groups have lined up to condemn the Care Courts proposal. The “draconian” plan, one policy analyst at the ACLU of Southern California said, “would take us back to the bad old days of confinement, coercive treatment and other deprivations of rights targeting people with disabilities.” And it’s true that Newsom sounded like a critic of the civil liberties approach when he announced the new policy: “There’s no compassion with people with their clothes off defecating and urinating in the middle of the streets, screaming and talking to themselves,” he said.

Both of us are sociologists who have studied California’s public mental health system and worked to understand the opposing perspectives. In Newsom’s proposal — which has already cleared the state Senate’s Judiciary Committee — we see an opportunity to rethink the terms of the debate. The Care Courts, if implemented with sensitivity and robust resources, could actually be a step forward. But for that to happen, each side will have to acknowledge some hard truths — namely, that their opponents make some reasonable points.

California gave people the ‘right’ to be homeless — but little help finding homes

The hard truth that advocates of forced treatment ought to concede is that coercion often backfires. Each year in California, tens of thousands of people are already transported involuntarily to ERs and admitted to hospitals against their will. These involuntary hospitalizations may save a person’s life in the moment, which is no small thing, but research shows that many who undergo this process are traumatized and humiliated, leading to increased suicide risk and long-term distrust of treatment providers. When delivered in a heavy-handed way, court-ordered treatment is not only ineffective but can also drive people decisively away from essential services.

Anti-coercion advocates, on the other hand, are right that most homeless people are clamoring for voluntary resources and housing. (Newsom’s last two budgets included $14 billion in new funds to combat homelessness, through housing and services, to be distributed over several years; it is unclear what the tab for Care Courts would be, though they may draw on those funds.) But the reality is that some people who might have accepted assistance earlier in their lives, had it been available, have deteriorated psychologically or become so skeptical of providers that they won’t accept help they need. One county official we interviewed (granted anonymity by university protocols) described an elderly homeless person with psychosis who had refused more than 100 offers of supported housing. We’ve observed such refusals ourselves, and we’ve watched people drink themselves to death or die from untreated medical conditions when left with purely voluntary supports in independent apartments. Our society should not sacrifice these vulnerable people on the altar of a one-size-fits-all ideal of voluntary care.

Three goals should be kept in mind as Care Courts (or similar approaches, like a new court-mandated treatment program in Washington state) are designed, to ensure that public policy transcends polarized ideas and delivers effective services. First, people who have been through the existing coercive system — including those alienated by it — should have a primary voice in designing the new one. “Peer supporters” with disabilities are often better at connecting with patients than clinicians are, and they have an untapped insider’s perspective on what makes involuntary care go wrong. We envision the state working with these peers to develop best practices for emergency responders and more welcoming intake procedures for clinics. European hospitals have begun to redesign psychiatric wards with just this kind of patient input. Relatedly, Care Courts could emphasize alternative emergency options such as “peer respites,” short-term housing for people in crisis staffed by others with similar experiences, instead of using hospitalization as a default.

Care Courts would certainly depend in part on the implicit threat of guardianship. To be effective, however, the focus must not be on the threats but on relationship-building to figure out what people want — even if they say “no” to treatment at first. Too often, treatment refusal is taken at face value. Newsom’s Care Courts would move us in the right direction by obligating providers to engage people over the course of a year, making it less likely that providers would drop complex cases.

But even persistent outreach won’t lead to real therapeutic relationships unless clinicians listen. This starts with acknowledging people’s legitimate gripes with the system, like having been overmedicated during past hospital stints, discharged with nowhere to go or placed in dilapidated housing that felt more dangerous than the streets. Unless providers deliver something better, they will never get buy-in. We’ve seen “treatment resistant” people become open to therapy or medication, but only after clinicians offered them help with their own priorities, such as replacing lost identification cards, clearing citations and fines, or rides to appointments. Care Court treatment plans and reimbursement rules need to empower clinicians with the resources and housing stock to address the whole range of clients’ social, not just medical, needs.

Solving homelessness requires getting the problem right

Finally, even in those rare cases that do move to legal guardianships, guidance from people who have been through such processes remains crucial. Research shows that people often place less weight on their degree of legal independence than on whether they are treated with dignity and respect. We’ve witnessed hearings where patients described their transportation to an ER as an “arrest,” hospitalization as “incarceration” and a doctor’s petition as “charges”; it all felt punitive. But we’ve also seen judges and lawyers listen attentively to patients’ unusual beliefs, or order the mental health system to provide unlimited drawing supplies for a person living in a locked facility. This may seem trivial, but a fair process, even for people who ultimately will lose their case, is both a decent thing to pursue and a critical ingredient for making sure coercion doesn’t lead to cynicism and disengagement. Care Courts legislation should prioritize peers with lived experience for the role of designated “supporter,” and give them real power to intervene in the court process to ensure procedural justice and respect.

This user-informed system will only be window dressing, though, if the care and court procedures are underfunded, and the ACLU is correct that increased coercive powers have the potential for abuse. Yet even civil liberties activists should want something like Care Courts — shaped and improved with their input — to succeed in some form. Many voters want streets cleared of homeless people with mental health problems or addiction, and advocates’ hesitancy to come to the table will only increase support for harsher proposals that will fast-track people into locked facilities where they can be pinned down and forcibly injected with medication. The visible failure to address the challenges of a small subset of the homeless population will undermine support for the independent housing and voluntary services appropriate for the vast majority.

Effective implementation will not be cheap or easy: It requires building up the infrastructures for housing, voluntary care and court-ordered treatment simultaneously. It will also require that proponents of a more strong-armed approach, who think the ends justify even harsh means, recognize that poorly executed coercion will backfire. If Newsom’s Care Courts are the breakthrough he promises, it won’t be because they forced more people into care against their will — it will be because they forced the system to provide the care people want.

Loading...