Up First from NPR - The Sunday Story: Mental Health Care Goes to Court

Episode Date: January 14, 2024

California's governor has made the rounds on local and national news pitching a new court as a solution to homelessness. But there's a gap between how these courts are being sold and the reality. Today on The Sunday Story, Ayesha Rascoe and Anna Scott explore what this policy experiment in California can help us understand about the causes of and solutions to homelessness.Learn more about sponsor message choices: podcastchoices.com/adchoicesNPR Privacy Policy

As you can hear, I'm starting this episode outside in Washington, D.C., the nation's capital. 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 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. The public has had it. They're fed up. I'm fed up. We're all fed up. And people are dying. They're suffering on the streets and sidewalks. Late last year, California launched what's known as CareCourt, 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. When people get their meds, when people get support, we know we can turn people's lives around.

This is eminently solvable. Joining us to talk about care court is Anna Scott, a reporter who's covered homelessness issues for years at member station KCRW in Santa Monica, California. Thank you for having me. So nationally, it's estimated that about 650,000 people live outside or in shelters. That's the highest number ever recorded. And Anna, the crisis is that it's worse where you are. LA has one of the largest homeless populations in the country. So what does that look like? Oh boy, picture people camped out pretty much anywhere you could pitch a tent, 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 it, 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 LA, 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. And is this a new problem or a new reality? Like, I would think that in a big city like L.A. that this issue has been around for a long time. Yes, you are correct about that. 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 this 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. So your governor, Gavin Newsom, has been making what seem like fairly innovative moves to address the 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 care court. Yeah, Governor Newsom has been talking up this new system he came up with 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. You think CARE Court 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 and bold. So CARE Court 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 care court 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 what does a middle ground look like? It's part of the civil court system, not the criminal court system. So that is an important distinction. And you don't get into care court by committing a crime or anything like that. Instead, someone in your life can petition to enroll you in care court. So that could be a family member, it could be a health care worker, or any number of people. If a care court 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, care court 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. Okay, so I have a lot of questions about this, especially like the civil rights aspect. 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? Well, this is where this gets tricky. Care Court is being sold as a fix for homelessness,

but there is a gap between that messaging and the reality. The connections between homelessness and mental illness are probably not what you think. I'm curious to hear more about that. Our conversation continues when we come back. Stay with us. Now Our Change will honor 100 years of the Royal Canadian Air Force and their dedicated service to communities at home and abroad. From the skies to Our Change, this $2 commemorative circulation coin marks their storied past and promising future.

Find the limited edition Royal Canadian Air Force $2 coin today. 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? Well, I want to answer that partly by sharing the insights of someone experiencing homelessness in L.A. right now. 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. No, that is not true. A lot of homeless people get mental health problems because they're out here. A lot of them go off the deep end because of being able to just survive out here. It's so hard. She's saying that mental illness is a result of homelessness as often as it's a cause of homelessness. 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 will 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% really have that very serious mental health psychotic disorder issue. But 10%, that's got to be higher than what you'd find in the general population, right?

Yeah, it's true. These illnesses are significantly more common in the unhoused population than in the general population. 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. So really, that's just getting down to the heart of this. If there aren't enough affordable places to live, people are going to end up on the street. Yeah. At the same time, while these diseases are definitely overrepresented among the unhoused, 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. Following up on what you're saying about serious mental health 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? This is a really open question that a lot of people are wondering.

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 Nani 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. It blew up our family. It just changes everything. going through a 20-year odyssey 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. So he has been living on the streets in Anaheim, on and off, in shelters, would not accept any help whatsoever. She gets why her younger son doesn't want to take medication. The medications have such bad effects that it makes almost zombie-like if it's not right. 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.

She thought CareCourt would be a lifesaver for him, 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 the problem, as you've laid out, is that CareCourt is not something where you can force someone into it, right? No. Now, for Ibarra, she hoped that it would force him 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. Okay, so now we're talking civil rights. Yes. And so the ACLU, for example, got involved and was very opposed to care court right off the bat. 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. So are the advocates who were concerned about coercion now on board with the care courts since they're voluntary now? Well, no. Simply having this be part of the court system at all remains controversial.

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 CareCourt is really just another road to nowhere. So what does Governor Newsom say to criticisms of CareCourt, the idea that more people will end up

in conservatorships, that it won't actually help people experiencing homelessness? Well, he essentially says that his critics are defending the status quo, which is not working. 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. As Governor Newsom said,

enough is enough. 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 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 are a danger to themselves or they do something that causes them to get arrested. Because that's what's happening now. What about the mother who you were telling me about earlier? Did she end up using the care court for her son? That mom, Nana Barra, she doesn't think that care court is the right option for her son anymore. There's one big reason for that.

Because it's voluntary. That's the big word. 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. So she decided to push for conservatorship instead. And these are really hard decisions. She knows conservatorship is an extreme measure, and she struggles with that. Like my son will not be able to drive. 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. That's so hard. It's a really rough dilemma when it's someone that you love. 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? Well, we won't really know the full impacts of care court at least until the end of next year 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.

I mean, that's what can make this feel so overwhelming and so huge 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? Yeah. And I don't want to leave you in a totally hopeless place. 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 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. Well, thank you so much for your reporting on this issue and for all that you do. Well, thank you so much for having me. I really appreciate it. This episode of The Sunday Story was produced by Raina Cohen and edited by Jenny Schmidt. 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.