Should S.F. Be Able to Compel Mentally Ill Homeless People Into Treatment?

When it comes to getting homeless people off the streets and into stable housing, San Francisco politicians face hard choices. Some want to expand a controversial legal process called conservatorship that they say would help homeless people with severe substance abuse problems and mental illness. But so far, implementation has been slow and bumpy.

When San Francisco Mayor London Breed went to Sacramento earlier this month to tell state legislators about the plight of the city's most desperate people, she had someone in mind from her former district when she was a supervisor — an older homeless man with a serious substance abuse problem.

“When he gets his check at the beginning of the month, his money gets taken by some other individuals in the neighborhood,” she said. “He was well-known to all the neighbors, all the merchants, all of us. We all did our very best to try and assist him but, sadly, he's still out in the community.”

Breed and other San Francisco politicians had hoped that changes to conservatorship rules would allow city health workers to help homeless people with substance abuse and mental health problems by legally and temporarily stepping in to force a mentally ill person into treatment.

“We believe that there are 50 to 100 people on our streets who are so severely mentally ill and drug addicted — can't make decisions for themselves and who are dying — and who could benefit from a conservatorship,” said state Sen. Scott Wiener, who sponsored Senate Bill 1045, which became law last year.

The new law established a pilot program in San Francisco, Los Angeles and San Diego to allow conservatorships for severely drug-addicted people. To qualify, a homeless person has to be held involuntarily in a hospital for psychiatric reasons eight times in the past year.

But when they began to implement the law, San Francisco officials found that last-minute amendments made it too narrow to apply to many people.

“As drafted, SB 1045 would allow us to help fewer than five individuals,” Breed told the state Senate Judiciary Committee on April 9. She said lawmakers needed to make changes to broaden the law.

So Wiener wrote new legislation, Senate Bill 40, which would tweak the conservatorship law in a few ways. Most importantly, it would remove the requirement that someone with a drug problem or severe mental illness try advanced outpatient treatment first. This qualification means someone has to fail out of such treatment, when specialists agree that the drug users who conservatorship is intended to reach aren’t good candidates for that kind of program. Doctors also say such a requirement gets in the way of providing help.

The bill does little to address the concerns of advocates for the homeless and mentally ill, who say it could violate the civil rights of the homeless. They protested outside a town hall on April 6 at UC Hastings School of Law, then followed Wiener inside and briefly shut down the meeting with booing and singing.

“It’s not progressive to let people die on our streets,” Wiener said.

Raia Small, a community organizer with Senior and Disability Action, said conservatorship could violate civil rights without helping people with what they really need.

“Our greatest fear is that this law is going to be used to take away the civil liberties of people with mental illnesses and drug users, and that it's going to do that without providing the care and treatment that people need to be able to access voluntarily,” Small said.

Small’s group is part of a coalition, Voluntary Services First, that is organizing against conservatorship. Other members include the Mental Health Association of San Francisco and the Coalition on Homelessness.

They say the city should be investing in permanent supportive housing, intensive case management, programs for people with both substance use disorder and serious mental illness, and case managers who can find people when they don’t show up for appointments.

“This expansion of conservatorship doesn't actually create any new services,” Small said. “There's no funding for it. There's no new housing units provided.”

City Supervisor Rafael Mandelman said critics are overstating their case.

“We don't want to recreate the hospitals of the past but we have a kind of institutionalization today, which is jail, and a lot of these folks are finding themselves in jail, in prison or on the streets," he said.

In the face of contemporary addiction, conservatorship needs to adapt.

“It is half a century old. It was not written to address things like meth-induced psychosis or people who suffer from serious meth addiction. We see that as a huge problem in San Francisco every day,” Mandelman added.

Because of critics’ concerns, San Francisco has been slow to implement conservatorship — and it could stop altogether. Before anyone in the city can be forced into conservatorship, the Board of Supervisors has to pass an ordinance that spells out how. The supervisors’ Rules Committee could review the proposed ordinance on May 13.