The Sunday Story: Mental Health Care Goes to Court

I'm in front of Union Station, which is this very majestic train station in D.C.

Beautiful architecture, really just an incredible sight in the middle of this city.

You can see the capital in the distance.

But then, standing in front of the train station where I am right now, you see another reality,

and that's people's belongings outside, tarps.

It's a very cold day, and it's clear that people are going to be staying on the streets tonight.

This is a problem that's happening here, but it's also happening all over the country.

And today, we're going to talk about what's going on in California,

the state that's dealing with homelessness on a level that's not seen anywhere else in the country.

I'm Aisha Roscoe, and this is the Sunday Story.

Okay, I'm back in the studio now.

And as I was saying, California is facing the worst homeless crisis in the nation.

There are more people living outside in California than anywhere else in the U.S.

It's become a huge political issue there and a major policy focus of Governor Gavin Newsom.

And people are dying. They're suffering on the streets and sidewalks.

which is designed to get people with serious mental health issues off the streets and into care.

Newsom has been all over the press, saying CareCourt will go a long way toward addressing the state's homelessness crisis.

This is eminently solvable.

for years at member station KCRW in Santa Monica, California.

That's the highest number ever recorded.

And Anna, the crisis is at its worst where you are.

L.A. has one of the largest homeless populations in the country.

So what does that look like?

in parks, under freeway overpasses, sometimes just on the sidewalks,

even in front of City Hall in downtown Los Angeles.

Yesterday, while I was walking around, I was thinking about this conversation that we would be having

and thinking about how to paint a picture for you.

And I was standing on a corner in one of the trendy, more expensive neighborhoods in L.A.,

right by a very popular Starbucks.

And there was a median in the middle of the road with an encampment on it,

with tarps, luggage, some shopping carts piled up with belongings.

Somebody's made it their home.

And that's a very typical scene all over L.A.

Like, I would think that in a big city like L.A., that this issue has been around for a long time.

It's not new, but for decades, homelessness in Los Angeles was mostly confined to one 50-block area

near downtown L.A. called Skid Row.

Generally, L.A. is a really segregated city.

And nowadays, homelessness is a sort of equalizing crisis where it's visible in just about every neighborhood,

even wealthy, fancy neighborhoods.

And we don't have a huge shelter system here like in New York City, for example,

so a lot of people live outside.

So you just can't go around L.A. and not see the crisis here,

which is partly why it's become such a huge political issue.

I know last year a lot of money was put into building tiny homes for the homeless,

but one of his biggest moves was CareCourt.

of mental health courtrooms around the state that are in the process now of being rolled out.

And he's saying that this is a solution to homelessness.

Here he is talking to a reporter about his proposal on CBS 60 Minutes.

Do you think CareCourt could be the solution that could save someone's life?

I don't think that I know it.

It's very familiar what we're doing, even though it's novel and new in bold.

So CareCourt is an acronym that stands for Community Assistance, Recovery, and Empowerment.

And the general concept is to create a kind of missing middle option when it comes to mental health care,

including for people living on the streets.

The way things are now, if you're mentally ill and you're not able to take care of yourself,

there isn't much that anyone else can do for you either,

unless you end up breaking the law and going to jail and then getting into the criminal justice system,

which could result in things like being forced to take medication.

Or a family member or someone close to you could go to the courts for a conservatorship,

which maybe you've heard about if you've been following the Britney Spears case.

This is a legal tool, and it's when a family member or friend or just somebody close to the person

takes over all of their personal and financial decisions.

And it's very extreme. People lose their freedom indefinitely.

So CareCourt is supposed to be this moderate solution that offers a way to help people with serious mental illnesses

without resorting to that extreme or waiting until they end up in a place like jail.

So that is an important distinction.

And you don't get into CareCourt by committing a crime or anything like that.

Instead, someone in your life can petition to enroll you in CareCourt.

So that could be a family member. It could be a health care worker or any number of people.

If a CareCourt judge accepts the petition, then the person who's the subject of it is assigned a public defender

and goes through a series of hearings.

The goal is to develop a care plan, which might include therapy, medication assistance,

doctor's visits, and even a housing plan if the person is in need of housing.

But let me be clear.

CareCourt is not for every single person experiencing homelessness on the streets, not even close.

It's only designed for people with untreated schizophrenia or other psychotic spectrum disorders,

which is a very specific sliver of the population.

But to start with, I'm not a doctor, but it does seem like looking at the population of people

who are dealing with homelessness, that there is a lot of mental illness.

So could this court have a big impact on the homelessness crisis?

CareCourt is being sold as a fix for homelessness, but there's a gap between that messaging and the reality.

The connections between homelessness and mental illness are probably not what you think.

Our conversation continues when we come back.

Stay with us.

On the TED Radio Hour, MIT psychologist Sherry Turkle.

Her latest research into the intimate relationships people are having with chatbots.

Technologies that say, I care about you, I love you, I'm here for you, take care of me.

The pros and cons of artificial intimacy.

That's on the TED Radio Hour from NPR.

I'm here with Anna Scott from KCRW, who's been covering the homelessness crisis in her state of California,

the state with the largest number of homeless people living outside.

Anna, you said the connection between homelessness and mental illness is more complicated than it looks.

How so?

Her name is Cece Smith.

I've known her for a while.

She camps in an area called Highland Park on a little patch of grass by the 110 freeway there.

And I visited her in June to talk about this exact topic and asked her what she thinks about the perception

that is pretty widespread that a lot of people are falling into homelessness because of mental illness.

A lot of homeless people get mental health problems because they're out here.

A lot of them go off the deep end because being able to just survive out here is so hard.

And she's not the only person who told me that.

I also heard this exact same thing from the director of the L.A. County Department of Mental Health, Lisa Wong.

When we look at the research on people experiencing homelessness in California,

about 25 to 40 percent may have some kind of mental health issue, which is understandable.

You know, if you're homeless, even if you didn't come in with a serious mental health issue,

you will have depression, you'll have anxiety and other things.

So she's saying exactly what Smith said, that the experience of being homeless exacerbates

or even creates mental health problems in a lot of cases.

But when it comes to serious illnesses, the kinds of illnesses that would qualify a person for care court,

like schizophrenia or other psychotic spectrum disorders, those numbers are a lot lower.

Only 10 percent really have that very serious mental health psychotic disorder issue.

But it's also important to think about why that number is higher for people living on the streets.

So one researcher that I spoke to helped explain this.

She's at UC San Francisco, and she used a really helpful metaphor on the connection between houselessness and mental illness.

She said to imagine a game of musical chairs and the chairs are housing.

Well, here in California, we have a housing shortage that's been very well documented over many years

and has made housing prices incredibly expensive.

And that is really at the root of our homelessness crisis.

So if you think about this metaphor, imagine a game of musical chairs.

There are not enough chairs for everybody playing, right?

So when the music stops, somebody is going to land on the floor.

Well, the parallel is if you have a very serious mental health disorder or any number of issues going on,

you might be more likely to be that odd one out.

So you will see higher incidences of issues like these among the unhoused population.

But that doesn't mean that the root problem behind homelessness is mental illness or other issues like that.

The root problem is that we don't have enough chairs for everyone,

meaning there just simply isn't enough housing to meet demand here in California.

If there aren't enough affordable places to live, people are going to end up on the street.

it's also easy to overestimate how much of the homeless population has a serious mental health disorder

because as doctors who practice street medicine have told me,

the typical person really can't tell the difference between somebody experiencing psychosis

or somebody under the influence of drugs or alcohol or somebody just having any number of behavioral issues.

not being the driver of a huge percentage of homelessness,

I guess then when you look at these care courts,

it seems like they wouldn't be able to solve the homelessness crisis if that's the case.

So who do you think the care court will help?

and I think that we're going to see answered over the next year as this rolls out across the state.

So far, it's opened up in eight counties here in California,

just starting in October, so it's pretty new.

And so far, the number of petitions moving forward in these care courts is small.

I talked to one mother who at first thought her son would be the perfect candidate for care court

based on how Newsom pitched this idea.

Her name is Nanny Barra. She's a mother of four.

She has two boys and two girls, and her two sons, who are both in their 30s now,

both of them have schizoaffective disorder, which causes delusions and dramatic mood swings.

of dealing with police, having a restraining order at one point,

navigating social services for her sons, and what she just generally describes

as a really patchwork system of resources and running around trying to stitch them all together.

Both of her sons have been hospitalized numerous times,

but they've had very different trajectories in recent years,

and their experiences really show the limits of the current system in California.

So her older son ended up in a program through the criminal courts,

very different from care court, which is part of the civil court system.

He ended up receiving substance abuse treatment and other services

as an alternative to penalties, essentially.

And Ibarra says he's doing really well now. It worked for him.

I talked to Ibarra about this when she was passing through town,

and we met in a coffee shop, so be warned, there's some noise in the background.

After she told me about her older son, she then described what has been going on with her younger son.

would not accept any help whatsoever.

It requires a cocktail of medications in order to stabilize an individual,

and then as their body changes as they get older, that has to be adjusted.

So in reality, it requires, talk about a village.

You need a village of people to sustain one person.

a way to force her younger son to get help but with a time limit

and with opportunities along the way to change the plan if they needed to.

but as care court evolved from a concept to an actual law,

it stirred up a lot of really long-standing conflicts that you've been alluding to over any kind of involuntary treatment.

For good reason. Research shows that voluntary care is generally more effective than any kind of coerced mental health treatment.

Plus, the ACLU and many others have pointed out there are big racial disparities when it comes to who's likely to become homeless in California,

on top of which Black, Brown, and Indigenous people are often misdiagnosed with serious mental health disabilities.

So eventually lawmakers came up with sort of a compromise.

They made care court voluntary, meaning that there are not any civil or criminal penalties for not complying with a care plan or attending hearings.

One person I talked to who's very critical of it is Claire Courtright.

She's the policy director for Cal Voices, a Sacramento advocacy organization that is run by and for people with serious mental illnesses.

Essentially, Courtright says that once people become subjects of care court, they're on the radar, so to speak.

And if they choose to walk away, she believes it's more likely that they'll be referred to conservatorships, not less likely.

And a lot of advocates want care away from courtrooms and say the real problem here isn't that we don't have enough law and order or compelled care around mental health,

but rather that we lack housing and treatment options and resources for people who need help.

Critics say care court is really just another road to nowhere.

And some people that I've talked to for this story agree they're really hopeful about care court.

One of them is Susan Partovi. She's a doctor in Los Angeles who's been practicing street medicine for decades, treating unhoused patients.

And she says that at least in L.A., there are plans for intensive outreach to bring people into care court voluntarily, not through law enforcement or anything like that.

And she thinks it'll be a really helpful tool.

Like, we're not taking care of these people. And it's tragic. It's embarrassing. It's shameful.

And if you don't agree, then give us give us another solution.

But don't just say, no, we don't want care court.

It really is trying to work with people before they get so disabled that they they are a danger to themselves or they do something that causes them to get arrested, because that's what's happening now.

There's one big reason for that.

And those of us who deal with somebody with severe mental illness, we know that it's a slippery slope.

If they choose to go off their meds, it takes a little while.

You can still reason with them and then you can't.

And these are really hard decisions.

She knows conservatorship is an extreme measure and she struggles with that.

I will make decisions on where he will go, which look really harsh, counterintuitive to mothering.

So that's another stigma. It's like, how could you do this?

It's a terrible thing for mothers to have this in their lives.

So this is a mother who isn't going to use care court for her son who's homeless.

After digging into this policy, how likely do you think it is that care court will help people who are homeless?

when all of the counties in California have to have these courtrooms up and running.

So far in the counties that have opened these courtrooms, as I said earlier,

a very small number of petitions have moved forward, less than 100 altogether,

according to some numbers that were put together by the Los Angeles Times.

And it looks like it's a narrow program so far.

Certainly it may impact some people's lives positively, housed and unhoused.

As a part of the mental health care system, you've just heard a variety of predictions and critiques and hopes,

and exactly what it looks like remains to be seen.

But the framing of it as a fix for homelessness is the part that seems disingenuous.

Just think back to that musical chairs analogy from the researcher that I mentioned before.

As long as there isn't enough affordable housing in California,

people are still going to fall into homelessness and will be dealing with this crisis.

because if you don't have money for a place to live or don't have some sort of support,

you're going to end up on the streets, right?

Like, that's just a fact. Until that is dealt with, this isn't going to change, right?

I will say that as overwhelming as it can feel, there are things that we know work to combat homelessness,

and that's a whole other conversation that I'm happy to have any time.

And there are people working hard on those solutions.

And I think that's just the point of this conversation, that when these programs roll out,

I think it's really helpful to get clear on exactly what problem they're trying to address.

And so this one may not be the wholesale solution for homelessness,

but we've done our best to unpack what it really will do.

The mix engineer for this episode was Gilly Moon.

Our team includes Liana Simstrom, Justine Yan, Andrew Mambo, and our executive producer is Irene Noguchi.

We always love hearing from you, so feel free to reach out to us at thesundaystoryatnpr.org.

I'm Aisha Roscoe. Up First is back in your feed tomorrow with all the news you need to start your week.

Until then, enjoy the rest of your weekend.