By Teresa Wiltz, Stateline

Often, when she got high on meth, “Melanie,” who suffers from schizophrenia, would strip naked and run screaming straight into San Francisco traffic. Invariably, police would bring her to the hospital, where she’d undergo treatment. There, her psychotic symptoms would quickly subside. 

But by law, Melanie, who is homeless, couldn’t be held for longer than 72 hours without her consent, so back on the street she would go. Until she relapsed, and her drug use triggered yet another psychotic episode, and she ended up in the emergency room all over again. And each time, she got a little worse. 

“Legally, she couldn’t be helped,” said Angelica Almeida, director of the forensic and justice involved behavioral health services at the San Francisco Department of Public Health. 

“Those are the cases we bring home with us, when we really feel limited in our ability to help people recover.”

Melanie may soon be able to get the long-term help she needs. Under a new pilot program, court-appointed guardians in San Francisco will be able to order treatment for up to six months for people with mental illness and addiction who are deemed by doctors to be “gravely disabled.” The program will focus primarily on the city’s homeless population.

Most of the treatment will be paid for through the state’s Medicaid program, Medi-Cal. 

San Francisco’s program is allowed under a new California law that permits counties to include addiction along with mental illness in the criteria for involuntary treatment.

Facing increasing homelessness — up for the second year in a row, according to federal statistics — the opioid crisis and many people with severe mental illness living on the street, cities and states are taking a fresh look at involuntary commitment, said Lisa Dailey, legislative and policy counsel for the Treatment Advocacy Center, a nonprofit based in Arlington, Virginia, that advocates for those with severe mental illness. 

But advocates for the homeless and for civil rights are pushing back against those laws, arguing that confining people against their will violates their civil rights. They also worry that facilities won’t have enough room for the additional patients, and that the laws will disproportionately affect minorities. 

The new California law assigns people who are incapacitated to conservators, who are guardians appointed by a court to make decisions on their behalf. To qualify under the new conservatorship law, people must have refused treatment, been detained frequently by the police, and, at least eight times in one year, been held for treatment and observation at a mental hospital under a “psychiatric hold,” typically for 72 hours. 

This year, California removed a provision that required a person to receive outpatient treatment before being involuntarily committed. San Francisco will be the first county to use the law.

“It’s heartbreaking,” said California Democratic state Sen. Scott Wiener, who sponsored the measure. “You see people who are literally dying on our streets. It’s not compassionate or progressive to let them unravel and die.” 

The law doesn’t specifically address homelessness, but it came in direct response to the state’s homeless crisis, Wiener said. 

About 4,000 people in San Francisco are homeless, have a mental illness and an addiction, according to city officials. Wiener said the county expects to enroll about a hundred people in the program.

But at a May hearing, San Francisco Supervisor Shamann Walton, who was the lone vote against the program, said he was worried that most of the people forced into treatment would be minorities. 

“As a person of color, there is always a major concern any time we put any system in place of incarceration,” he said at the hearing. (Walton declined a Statelinerequest for an interview.)

Another concern is whether there are enough beds to house homeless people with mental illness, said Jennifer Friedenbach, executive director of the Coalition on Homelessness, a San Francisco-based nonprofit. 

“And, of course there aren’t,” Friedenbach said. “Look around the city. If there were beds, you wouldn’t see what you see.” Politicians wanted to respond to the crisis, she added, but the law “doesn’t really do anything but sounds good to the public.”

Since 2012, San Francisco has lost more than a third of licensed residential facilities for people under 60 with mental illness, and more than a quarter of those for the elderly with mental illness, because the cost of operating them is too great, according to the San Francisco Chronicle. City officials expect to lose another 71 beds by 2020, according to Mayor London Breed’s office.

On Monday, Breed, a Democrat, announced plans to expand mental health residential facilities. The city plans to increase funding for “board and care homes”— privately owned and operated residential facilities — and purchase homes at risk of closing.

A Growing Trend

A similar effort is underway in Hawaii, where a new state law allows courts to order treatment for homeless people deemed to be a danger to themselves. In the past year, Alabama, Pennsylvania, Texas, Utah and Washington also have eased their involuntary outpatient commitment rules for getting people with mental illness into treatment. 

In Pennsylvania, for example, a person no longer has to become violent to qualify for help, and Texas now allows jail inmates to be diverted to mental health treatment.

Pennsylvania state Rep. Thomas Murt, a Republican, said he introduced the bill because he hoped to keep people at home while they got mental health treatment. He said he wanted to make the commitment criteria more flexible, so patients could be treated sooner, on an outpatient basis, rather than being committed to a hospital. 

The idea is to stabilize people, get them into treatment early, so they can stay at home and avoid brushes with the criminal justice system, Murt said. 

“Families who care for a loved one who struggles with mental illness don’t want the police to show up and put handcuffs on the person and take them to jail,” Murt said. “If you struggle with a mental illness, prison or jail is not the place you want to be.” 

To be sure, mandating treatment for people with severe mental illness isn’t new. But most states’ involuntary commitment laws are rarely used, Dailey said, because they are vaguely worded or have restrictions that create barriers to timely treatment. 

According to data compiled by the Treatment Advocacy Center, 24 states have ambiguous laws on the books relating to court-ordered outpatient programs. That can make it harder to get patients treated if officials aren’t clear about how the program is supposed to work or who the right candidates are, she said. 

“You really need to address mental health issues if you’re going to make any headway getting people off the street,” Dailey said. 

Roughly a third of the U.S. homeless population has an untreated, serious mental illness — such as schizophrenia, schizoaffective disorder, bipolar disorder or major depression — according to a 2016 report by the Treatment Advocacy Center. Among homeless people with severe mental illness, who are often victims of predators, the mortality rate is as much as nine times higher than the general population, the report found. 

A 2015 survey by the National League of Cities found that mental illness was the third-highest cause of homelessness among single adults. (Poverty and a lack of affordable housing were the top causes.)

Because there aren’t enough hospital beds, “jail becomes the default” for those with severe mental illness, said Bill Johnson, executive director of the National Association of Police Organizations, a coalition of police unions and organizations based in Alexandria, Virginia. 

Hawaii Effort

Under Hawaii’s new law, courts may assign a public guardian for up to a year and order psychiatric treatment for patients deemed to be a danger to themselves.

Honolulu will deploy a “street medicine team” to identify homeless people in need and try to get them into treatment. If they refuse, the team will try to identify a potential guardian among their family members and friends. If none can be found, the team can enlist the help of a judge. 

Court-ordered treatment improves the odds of continued treatment after discharge, helping keep people from becoming homeless, said Dailey of the Treatment Advocacy Center. And if a person is already homeless, having the ability to refer that person for an evaluation “provides a much-needed avenue to care,” she said. 

Kimo Carvalho — director of community relations and development for the Institute for Human Services, the Honolulu nonprofit that will be administering the program — praised the approach as “much more proactive,” as opposed to “hospitalizing them because they’ve got wounds with maggots coming out.”

In a statement to state lawmakers, Mandy Fernandes of the ACLU of Hawaii said the measure may infringe on people’s civil liberties. She said people shouldn’t be compelled to get treatment until they’ve been offered housing, case management by a social worker and other aid. (The ACLU of Hawaii declined an interview request from Stateline.)

But mental health advocates argue that the Hawaii program and others like it restore civil rights to those with mental illness by getting them on a path back to health. 

Carvalho pointed out that many homeless people with mental illness live in undignified, unsanitary conditions. 

“Because of that, their skin has rotted, they have flesh-eating diseases, they have chronic medical illnesses parallel to their homelessness,” Carvalho said. “There’s a new generation of psychiatric meds that have the potential to dramatically change their lives.”

Stateline is an initiative of The Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy. Since its founding in 1998, Stateline has maintained a commitment to the highest standards of non-partisanship, objectivity, and integrity. Its team of veteran journalists combines original reporting with a roundup of the latest news from sources around the country. Stateline focuses on four topics that are key to state policy: fiscal and economic issues, health care, demographics, and the business of government.