How S.F.’s court system fails to treat combined addiction and mental illness

Newsom wants to create an alternative court for substance abuse. San Francisco already tried it.

San Francisco’s efforts to get people who suffer from both mental illness and addiction off the street and out of jail has failed many of the people it aims to protect.

In The City it often takes weeks or months for individuals who are in jail to be placed into the mental health treatment they need. And most often, they are referred to a lower level of care because not enough beds are available for people struggling with both severe mental illness and substance use disorder, together known as a dual diagnosis.

State and local officials are starting to focus on the issue.

On Thursday, Gov. Gavin Newsom unveiled a new approach to mental health care in California centered around an alternative CARE Court, in part inspired by conditions on the streets in San Francisco. The idea is to connect the thousands of Californians with untreated mental illness and substance use disorders to a court-ordered care plan for up to 24 months, and prevent homelessness and incarceration among those who are suffering.

The announcement comes after a judge in San Francisco’s own alternative court system — created with a similar goal in mind — said The City’s program is failing.

No one who came through San Francisco’s Adult Drug Court in recent years struggling with combined mental illness and substance use disorder was placed at Baker Places or the Progress Foundation, the only two facilities in San Francisco that are specifically for persons with dual diagnosis conditions, court officials said in a public hearing Wednesday.

As a result, some of the most vulnerable San Franciscans have been sitting in jail for weeks and months, often with worsening mental health conditions, as The City works to add more care beds.

“Drug court treatment staff have basically abandoned hope of getting anyone into a dual diagnosis treatment program,” San Francisco Judge Michael Begert, who presides over San Francisco’s Adult Drug Court, said at a hearing to probe The City’s efforts to increase the availability of mental health care beds. The alternative court was created in 1995 as part of an effort to reduce recidivism and respond to drug-related crimes with treatment rather than jail time.

Out of 15 people currently in two San Francisco jails who could qualify for treatment, wait times spanned from three to 37 weeks to receive placement in a facility, the judge said. Individuals in jail are eventually placed into treatment, but the judge said it’s often less acute care than what people struggling with dual diagnoses need.

The City is working to add 30 more dual diagnosis beds. And mental health care facilities across San Francisco offer a range of mental health treatments, including substance use disorder treatment and a combination of the two, said Dr. David Pating, who working with the Department of Public Health on the effort.

But bed availability does not meet the current demand.

“These are people who are not well and they are not getting better by staying in the county jail,” said Begert. “Not only do you have the impact of paying for them to be in jail and not accessing treatment, but there is a negative impact of being in jail on their mental health.”

A new approach

Newsom has his own plans for relying more on the criminal justice system to help people struggling with homelessness, substance use and mental illness. CARE Court, which stands for community assistance, recovery and empowerment, would create a mental health-focused arm of the civil courts in all 58 counties across the state.

The proposal, which needs legislative approval, focuses on individuals experiencing severe mental illness, such as schizophrenia or psychosis, as well as substance use disorder.

Unlike San Francisco’s Adult Drug Court, participants in CARE Court may not always be criminal defendants. Under the governor’s plan, people could be referred to the system by a doctor, family member or first-responder. They could also be put into the system when their involuntary psychiatric hold ends, or if they are involved in a criminal case that gets diverted to the CARE Court program.

California counties could face sanctions if they do not provide adequate treatment, and individuals who refuse to participate could be required to appear before a court or be referred for a conservatorship.

Participation would also be limited to one year, with the possibility of an extension, unlike an indefinite conservatorship.

To fund the idea, Newsom is proposing to add $2 billion to the state’s $12 billion allocations to address homelessness and mental health in its most recent budget cycle. About a third of that $14 billion would be earmarked for mental health treatment.

An additional $3.8 billion from California’s Mental Health Services Act will be allocated across counties to implement treatment options.

The governor’s proposal won applause from mayors across the state including in Los Angeles, San Diego and Sacramento, all cities dealing with similar mental health challenges as San Francisco. Supporters say it could be a valuable tool outside of the state’s existing mental health infrastructure to help individuals with some of the most severe cases of psychosis or substance dependence who might not otherwise receive help.

It was also met with skepticism from some professionals who have seen other alternative court approaches fail to meet their mission.

“Governor Newsom wants to have a fast solution to a very entrenched problem through his recently announced CARE Court proposal. But the reality is that we already have a number of alternative courts. We don’t need another court that criminalizes mental health and poverty,” San Francisco Public Defender Manohar Raju said in a statement. “As it stands, because of the drastic underfunding of our mental health care system, our clients are waiting for nine weeks to six months in jail for treatment.”

Persons involved in CARE Court would be represented by a public defender.

Others said the issue of mentally ill individuals waiting in jail comes back to lack of beds and dollars for treatment, and are waiting for more details on how Newsom’s idea will be funded.

“I think it should make anyone think twice if they are thinking the criminal legal system is a way to get people treatment or that an arrest will help people get treatment,” said Laura Thomas of the S.F. Aids Foundation. “By virtue of being in that (alternative drug court) system we have already said jail is not the appropriate place for them, and yet they end up sitting longer in jail.”

Hunt for beds

The backlog in San Francisco’s jails is top of mind for those examining the puzzle of approaches in tackling mental health, substance use disorder and homelessness in the Tenderloin, where the majority of overdose deaths in San Francisco occurred in the last two years.

The City poured attention and resources at the new Tenderloin Linkage Center, which aims to serve as a low-barrier access point for individuals experiencing homelessness or struggling with substance use to find social and medical services and housing opportunities. The center offers a variety of crucial health services, including showers, meals and assistance signing up for health care.

But city documents show very few people have successfully been linked to substance use treatment, one of many stated goals of the operation.

Begert’s remarks also leave a big question mark for Mayor London Breed’s recent signal that police will ramp up efforts in the Tenderloin to push drug users on the street into treatment or face jail time, given that treatment beds to refer anyone to are still scarce.

In July 2021, Breed and the Department of Public Health announced they would be adding 400 new mental health and substance use disorder treatment beds, a 20% expansion at the time. The goal was based on a 2020 report assessing the scope and scale of what beds are needed. (An updated version of that survey is expected for December.)

Since then, 89 beds have been added and more are expected later this year. For example, SoMa RISE, a 20-bed center where people who are intoxicated can sober up and be connected to longer-term treatment, is slated to open this spring.

But those working closely with drug users and homeless populations say treatment options must be available before law enforcement comes down hard on individuals.

“The more important issue is the underlying lack of capacity in our treatment system. We have judges saying this isn’t working, we can’t get people into treatment and they are going to a lower level of care than what they need,” said Thomas of the AIDS Foundation. “Dual diagnosis is so important for people with concurrent mental health and substance use because they are often intertwined.”

Stumbling on solutions

The comments from Begert appeared to come as a shock to several San Francisco supervisors, the majority of whom were present for the hearing Wednesday.

“When I look at this dashboard I get depressed,” said Supervisor Rafael Mandelman, referring to a webpage where the Department of Public Health tracks available mental health beds. “It does not feel like we are anywhere close to achieving the things we need to.”

Supervisor Hillary Ronen, who called for the hearing, decried the lack of progress in adding beds, which was a key component of Mental Health SF, San Francisco’s landmark legislation that overhauled how The City is addressing health and homelessness.

“I have been quiet during the pandemic because it was absolutely impossible to address both crises at the same time. I will no longer be quiet. This is not moving fast enough,” said Ronen, who co-authored the Mental Health SF legislation. “Our behavioral health court is rendered useless.”

Officials at the Department of Public Health responded by noting the frustratingly slow progress of adding beds. They also said many existing mental health care facilities that work with The City have some capacity to treat both mental illness and substance use.

“I want to acknowledge and share a sense of urgency and need to go faster,” Dr. Hillary Kunins, director of behavioral health for the San Francisco Department of Public Health, said at the hearing Wednesday. “We are not ahead of where we were 10 years ago in some areas. We need to identify these resources to be able to move quickly.”

Stakeholders on all sides bemoan how slow the process has been. Health department officials said it’s been a labored process of securing sites, navigating bureaucracy and finding trained professionals to staff or contract with.

“Our next step is to talk with the judges and jail staff to try to understand the cases,” said Pating of the Department of Public Health. “Each case is different and there isn’t a one-size-fits-all.”

In the meantime, mental health care beds across the board in San Francisco remain limited.

“We should be dramatically and vastly expanding our treatment capacity on the ground so people can access it when they need it,” said Thomas. “We need to make it easy before we punish people.”

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