During the last presidential elections cries of “lock her up” energized the crowds. Have our city supervisors taken a page from that book by yelling “lock the homeless up?’
The California legislature passed a law that would allow San Francisco, to institute a new type of conservatorship. Supervisor Mandelman with the encouragement of Mayor Breed has proposed legislation to implement this.
When someone is conserved they lose all civil rights and a court appointee has authority to make all decisions for them. The new law states that an individual who is seriously mentally ill, has a substance use disorder and has been brought to a hospital for competency evaluation (5150) eight times in one year can be taken to court by the Sheriff, the head of a hospital, or the head of the Department of Health for a conservatorship hearing to determine if they can care for themselves.
The law requires that housing, mental health and substance abuse treatment as well as other services be made available to them. In general, these are homeless people who are considered nuisances by the police and residents of the neighborhoods where they stay. It has been estimated that currently 55 individuals meet, and about 48 more may soon meet, the requirements for a hearing. This has the appeal of allowing the City to say it is doing something about bothersome homeless people.
This is a bad idea for many reasons. The people in question have already been found to be able to care for themselves on eight evaluations, thus it ignores the opinion of medical professionals and puts the decision in the hand of lay bureaucrats. Further, when these people get housing, treatment, and other services, they will go to the head of long waiting lists for these services, thus pushing out the elderly, disabled and pregnant as well as other high priority unhoused who are waiting for these services.
Past experience suggests the forced treatment approach is not likely to be successful in rehabilitating the conserved individuals. Many of these seriously mentally ill people have had drug treatment in the past and have failed. In fact, 30 percent of the seriously mentally ill are drug resistant and will never respond. Putting these people in the hospital and trying to medicate them will probably lead to expensive hospitalizations.
Forced treatment for substance use has been tried for many years but evidence that it leads to long term success is lacking. It tends to lead to reduced substance use while a person is in the program with relapse when they are discharged. The best one group studying this could say is that it is probably better than nothing. This is a contrast to those who enter treatment voluntarily, where there is reasonable rate of long-term success. Eventually many of these people may end up being conserved and housed out of the city at a cost of about $160,000 per year, or in even more expensive chronic psychiatric hospital beds.
Is there an alternative? A coalition of groups and individuals with expertise and experience in this area have suggested “voluntary services first.”
This would require intensive case management to encourage the people to enter supportive housing and encourage voluntarily entrance to treatment. This will require trained case managers who will see their patients on an almost daily basis to establish a relationship and coax them into supportive housing where they can manage them over the long term. Let’s try it before we end up depriving these unfortunate people of their civil rights. Call your supervisor and tell them don’t “lock them up.”
Allen Cooper, M.D. is a professor of medicine emeritus at Stanford University who worked for Healthright360 at the Treasure Island Job Corps and the Height Ashbury Free clinic after retirement. He has treated numerous patients with alcohol and drug use problems, as well as mental illness and homelessness.