Novel Mental Illness Court Offering Aid Struggles to Find Takers

California opened a new mental health court system last fall in an unprecedented effort to address the state’s homelessness and mental health crises, and Anita Fisher was hopeful that her 46-year-old son would finally get help.

The day of her son’s first hearing at the Community Assistance, Recovery and Empowerment Court felt different from the almost 40 criminal proceedings she has attended since her son was diagnosed with schizophrenia two decades ago. She was used to researching the penal code before hearings, bracing herself for multiyear sentences, and knowing that for however long her son would spend incarcerated, he’d also likely be unable to access proper mental health care.

This time, Fisher had petitioned her son into California’s civil CARE Court system, which was founded on a promise that a judge could order her son, and others with conditions like schizophrenia, into treatment, without the looming threat of criminal charges.

“For once, I wasn’t going to court for him to see him punished for his mental illness. It was for help,” said Fisher, a 67-year-old resident of San Diego County. “Or I thought it was for help.”

The CARE Court was born out of a massive push from Gov. Gavin Newsom (D) to address severe mental illness and homelessness, the latter of which the US Supreme Court has taken up for the first time in four decades.

More than a quarter of the homeless population in the US is in California, according to a US Department of Housing and Urban Development report. At least 4,500 of LA’s homeless residents are diagnosed with a mental illness that could qualify them for this court, a California Policy Lab study found. Homelessness isn’t an eligibility requirement, but treatment plans set up under the court can include housing options.

The CARE Court system, which has received about $200 million in state funding since 2022, is only about half a year old in its first eight counties, so it’s too early to determine whether it’s helping Californians find housing in the long term. But early figures show that this ambitious experiment to assist one of California’s most underserved populations has seen only a tiny fraction of the people it expected. Those that do opt to enter the system find that the agencies that work with the courts struggle to secure them housing.

Some counties braced for a deluge of petitions that didn’t come. Los Angeles County public defender Ricardo García, for example, projected at a November press conference that 4,500 Angelenos could be petitioned into CARE Court in its first year. At the end of March, about four months after the county’s CARE Court launch, only 109 petitions were filed. However, the California Health & Human Services Agency said in a report released in April that the numbers are “in line with expectations and allow the courts and counties to effectively manage the resources needed to serve the population.”

The aid that is offered has been disappointing to Fisher, who said her son languishes without treatment. Despite signing to start the process this year, her son, whom Bloomberg Law is not naming to protect his privacy, cycled between county-backed motels and homelessness for more than a month. (Fisher’s son could not be reached for an interview.)

While Fisher wishes the court would quickly compel her son into treatment, critics say the court could threaten the civil liberties of those with severe mental illnesses. They cite conservatorship abuses and a legacy of mistrust in courts and mental health care institutions, and say the system doesn’t address the root causes of mental health disparities, like poverty, a shortage of affordable housing, and racism.

Meanwhile, in March, after being kicked out of another motel, Fisher’s son was arrested again. In April, he spent his birthday in jail, where Fisher said he remains in touch with his CARE team. His May CARE Court and criminal hearings are scheduled a week apart.

Repeated Outreach

After the Community Assistance, Recovery and Empowerment Act was signed into law in 2022, eight local judiciaries, which together make up about half of California’s population, had about a year to build their courts—a fast pivot for a slow-moving system. Public health departments scrambled to shore up scarce resources that they’d be ordered by judges to provide, such as options for housing, counseling, and medication.

Part of what differentiates this court from other mental health courts is the wide range of people who can initiate proceedings, compared with other kinds of proceedings that may require involvement in the criminal justice system or have a narrower list of possible petitioners. Family members, health care providers, roommates, and police officers are among those who can file CARE Court petitions, and they can sometimes stay involved in the case after proceedings start.

Court officials from several counties told Bloomberg Law that continued participation is supposed to be voluntary. Still, the law carries a consequence for dropping out of CARE Court: a judge can order an evaluation that may lead to separate conservatorship proceedings.

Each of the eight counties involved in the initial rollout of the CARE Courts—including Los Angeles County, which has the largest homeless population in the state and started two months later than the others—has built a different system around the same set of guidelines. Although each local CARE Court is slightly different, court officials, public health workers, community members, and others meet quarterly to share what’s working, and what lessons they’ve learned.

CARE Courts for the state’s remaining 50 counties are set to come online by the end of the year.

“This is a bold, untested initiative. And I know CARE Court has its skeptics, but the status quo hasn’t worked,” said Los Angeles County Supervisor Janice Hahn during a November news conference.

Part of the challenge has been figuring out how to reach a population with disproportionately low access to technology and transportation. CARE Court participants in Los Angeles can video call into their hearings at self-help centers across the county. The centers often also act as a one-stop shop for families who need help filing petitions or want to connect with the behavioral health department in other ways.

Many counties have also sent outreach teams to locations such as homeless encampments to find people who have been petitioned into CARE Court and pitch the process to them. It can take between 20 to 40 face-to-face visits from a behavioral health provider to convince people to enter treatment, said Veronica Kelley, Orange County’s health care agency and behavioral health services director.

It took Fisher’s son about eight visits to agree to be part of CARE Court, Fisher said. He was eventually won over by the promise of a motel where he could stay until the court worked out a more permanent treatment plan for him.

A dearth of long-term housing is one of the biggest challenges facing CARE Court, said Maria Hernandez, Orange County Superior Court’s presiding judge, in an interview.

“That is a problem for all of us” in the CARE Court system, Hernandez said. “If we had our wish list, it would be to have more housing for individuals, that we could get them into very rapidly.”

Courts will work with “anyone who’s willing to coming to the table” to secure more shelter for CARE Court participants, Hernandez said. Orange County’s behavioral health department in fall 2023 received more than $30 million to create new bridge housing beds, and CARE Court participants will be prioritized for access, according to Kelley.

In response to concerns about a lack of resources, Newsom in a March press conference pointed to a law voters approved that month, which directs $6.3 billion toward the creation of about 11,000 mental health treatment beds and housing units, as well as tens of thousands of treatment slots. Yet the National Low Income Housing Coalition estimates that the state is more than 900,000 rental units short.

Barriers to Trust

Emily Wu Truong, a community mental health advocate who lives near Pasadena, Calif., said she’s watching the court’s rollout with suspicion. She’s had little faith in law enforcement and health care since she was held in a hospital against her will last summer, she said. That process, called a 5150 hold, is something the bulk of CARE Court respondents will have also experienced before they’re petitioned into court.

“How can we trust a system that legally kidnaps us?” said Truong, who has not been petitioned into CARE Court but fears it could happen to her in the future.

A trusting relationship with the mental health system paired with appropriate housing options —instead of crowded or temporary shelters, which can destabilize people with serious mental illness—is more likely to prompt CARE Court participants to agree to treatment than a court order, said Eve Garrow, a homelessness policy analyst and advocate with the ACLU.

“CARE Court is based on the idea that people are either resistant to services or they’re too ill to know that they need help. And so they need this gentle push, they need to be pushed or coerced into treatment,” Garrow said. “But when the treatment isn’t there in the first place, when the supports aren’t there in the first place, it’s really a moot point.”

Fears that CARE Court will expand conservatorship pipelines are top-of-mind for Garrow, the ACLU, and disability rights groups.

Samantha Jessner, Los Angeles Superior Court’s presiding judge, said in an interview in late November that “CARE Court is absolutely not a side door to conservatorships.” And Hernandez of Orange County Superior Court stressed that proceedings, and outcomes, will vary by individual.

But the ACLU and disability rights groups in California point to the CARE Act’s text, which states that if a person is offered treatment and support through their CARE plan but doesn’t accept it, this could be used against them in a separate conservatorship proceeding—assuming it’s within six months of the CARE plan’s termination.

The fact that the respondent failed to complete the plan and the reasons why “shall create a presumption” at the hearing “that the respondent needs additional intervention,” according to the law.

If a court finds by “clear and convincing evidence” that the respondent isn’t participating in the CARE process after they receive notice, the law also hands the court the ability to order a psychological evaluation to determine if that person is “gravely disabled.” These evaluations can lead to referrals for treatment or recommendations for conservatorship.

A conservatorship gives a court-appointed guardian near-total control over a person’s life, from shopping to health care and even marriage. It’s the system pop star Britney Spears escaped from in 2021. A 2023 Bloomberg Law investigation found that the national conservatorship system is poorly regulated and easily exploited.

Because CARE Court proceedings are closed to the public, Garrow said the ACLU is trying to obtain redacted and de-identified proceeding transcripts.

Disability Rights California and other advocates wrote in a 2023 petition to the California Supreme Court that the law targets Black Californians, who are both overrepresented in California’s homeless population and disproportionately misdiagnosed with schizophrenia. The court declined to take up the case.

“We need to know who’s being targeted, what happens if somebody is unable to comply with the CARE plan, what happens if somebody doesn’t want to be part of the CARE Court process,” Garrow said.

On the other hand, Fisher had been hoping CARE Court would give her a conservator-like level of control over her son’s health care and is disappointed at her son’s ability to refuse treatment while in the program.

“I really thought that, that black robe would have been able to mandate my son into care, instead of sending him to jail or prison,” she said. “Because it has no teeth, it doesn’t even need to be in a courtroom. I don’t think we need a judge.”

Measures of Success

The CARE Act requires health departments and partners to create an annual report that describes, among other metrics, how CARE reduces rates of homelessness and involvement with conservatorships for participants.

California courts largely aren’t naming a decrease in these numbers as how they measure the new system’s success. That’s in part because of the obligation for courts “to maintain neutrality and impartiality over every proceeding,” a spokesperson for Riverside said. The Riverside court measures success by how closely it hews to the CARE Act; educates judges and staff; creates CARE proceedings; provides self-help services, and works with other stakeholders.

Some jurisdictions, like Orange County, Los Angeles, and San Diego, measure success broadly in terms of how CARE Court expands access to the justice system. Hernandez said Orange County is tracking the number of people who engage with behavioral health resources through the program, even if they don’t end up joining the CARE petition process.

For Jessner, of Los Angeles, “if CARE Court can assist one individual with finding a path to stability and support through a voluntary plan, CARE Court can be considered a success,” she said.

With so many people watching CARE Court’s rollout closely, those working on the new system urge patience.

“I look at it similar to a newborn,” Claude Winship, a behavioral health program manager with San Diego County’s Health and Human Services agency, said during a February meeting. “We’re getting out of that infancy stage. You’ve got to learn to crawl before you can walk.”

But Fisher knows what success looks like to her: “I don’t want to see the money wasted paying a bunch of high-ranking people like lawyers and judges,” Fisher said. “I would prefer it sent directly to supportive housing.”

She’d like to see her son enrolled in a place where peer support specialists live on-site and her son is free to take classes and receive job training:

A “community of live, work, and play.”