Should Courts Be Able to Mandate Psychiatric Care?

Opponents of New York Mayor Eric Adam’s plan to involuntarily send mentally ill homeless people…

Should Courts Be Able to Mandate Psychiatric Care?

In the cities of the American West, the number of homeless people is at near-historic highs. California is the epicenter of this crisis; fully half of the nation’s unsheltered homeless live here. Once restricted to well-known skid rows, tent encampments are now everywhere: in parks, along thoroughfares, on residential side streets, in parking lots, along freeways and riverbanks, behind restaurants, and near schools and businesses.

There are roughly 170,000 homeless people in California. Upward of 115,000 of them, according to the latest counts, are unsheltered.

The state has thrown billions of dollars at the problem, yet the number keeps spiraling upward. What California is experiencing is partly the legacy of the 2008 housing market collapse. But there are other reasons: thousands of homes lost to fires and floods; a rethinking of the criminal justice system, which has resulted in tens of thousands of people being released from prison only to find the housing market largely closed to them; the opioid crisis; unaffordable rents; the economic and psychic dislocation of the pandemic; and, at least as important as any of these, a decades-long mental health crisis that has been met by a shambolic public health and legal response.

Last year, California Governor Gavin Newsom persuaded the state Legislature to fund a CARE Courts system, which requires counties to provide mental health services for poor unhoused residents and forces residents to participate in that treatment.

The policy divided the mental health and civil rights communities. The ACLU, Human Rights Watch, and Disability Rights California opposed the legislation, arguing that the element of compulsion was discriminatory and ineffective, while the state affiliates of the National Alliance on Mental Illness supported it.

I generally agree with the ACLU, but on this issue it is off base. If you live in a California city—or, for that matter, in any major city in the West—you are exposed to shantytowns that are effectively outdoor public bedlams. You see and hear floridly psychotic people screaming and shouting, hitting people and objects, and having conversations with themselves that bear no relation to reality. Many are clearly too sick to make rational choices. Lacking options, they bounce between encampments and local jails or state prisons.

CARE Courts are a way to help vulnerable sick people function better and reach a place of greater safety and dignity. They are a way to limit the chaos and costs of thousands of extremely ill individuals with no place to live.

Since the 1960s, when California and then the country at large turned against the idea of holding the severely mentally ill in psychiatric facilities, the story of mental health care provision for the poor has been one of repeated failure. The original promise was to replace inpatient treatment with outpatient resources. But the money never materialized, and the infrastructure for comprehensive, timely assistance for those whose families weren’t affluent was never developed. In place of psychiatric facilities, prisons and jails became de facto mental health care providers.