On a cold day in March, Shahada Hull admitted herself to the hospital.
She had been sleeping outside in San Francisco’s Tenderloin neighborhood for months, ever since she was evicted in December from the affordable studio apartment she'd rented near the Presidio. Her feet felt numb, her back sore from the concrete sidewalk.
“After a while, I was like, look, I’m going to 5150 myself,” Hull said, referring to the civic code to place someone on an emergency, 72-hour psychiatric hold. Hull has been diagnosed with obsessive-compulsive disorder, anxiety, PTSD and depression.
But on that particular day, it wasn’t the intrusive thoughts that sometimes cloud her mind that brought her to Sutter Health’s Street Care Center. She was just looking to get off the street.
“I was praying, like, please just let them help me today,” Hull said. “Please let there be resources open today, just anything.”
After she spent a week in the psychiatric ward, the on-site social worker produced a sheet of paper. On it was a list of shelters.
“They were going to take me back out into the streets because they felt that I didn't need any further help,” Hull said. She was upset. “Like, really? You can clearly see that I’m not really in the right state of mind right now.”
Throughout her life, Hull, 30, has had around 160 mental health episodes, documented in a thick case file. At 13 months old, the San Francisco resident was placed in foster care. And she’s been in “the system” ever since — cycling in and out of affordable housing placements, the courts and county behavioral health services.
In many ways, she’s the archetypal candidate for CARE Court, part of a sweeping new proposal to address mental health care in California. The state Senate voted Wednesday to approve the legislation, SB 1338. It now heads to the Assembly for a vote.
When Gov. Gavin Newsom unveiled CARE Court in March, he said it’s designed to help people like Hull, who move between emergency psychiatric treatment and homelessness.
“This approach with the courts allows … a pathway to actually develop a strategy and a plan with oversight and accountability, with housing supports, that are a component of this, to achieve some more permanency and success as opposed to episodic experiences through the 5150,” Newsom said.
Under the governor’s Community Assistance, Recovery, and Empowerment Court, Hull would be able to enter into a civil process with a judge to oversee her mental health treatment.
She’d have a public defender and a supporter to help her make decisions about what sorts of treatment programs she would like, with a care plan lasting up to two years. In turn, the county behavioral health department would be compelled to provide her with treatment or face fines if they do not.
Ideally, the program would enable Hull to reach her goals, all the things she had wanted to achieve by the time she turned 30: her GED, a job, stable housing, a car.
But Hull is skeptical the program really would help. She sat at a café in San Francisco’s Civic Center on a recent afternoon and looked toward City Hall.
“Wanting to force people that are homeless and on drugs into treatment and to housing, that’s just forcing,” she said. “That’s still not giving them a chance to talk.”
Newsom and officials in his administration say the treatment is voluntary. But the legislation also comes with a threat: Continued refusal to participate in CARE Court could be used as justification for conservatorship, where people could be forced into care against their will.
That has provoked harsh criticism from civil rights advocates who say compelling people into care is not only less effective, it undermines the kind of trust-building needed to actually bring people into treatment successfully.
“It seems to just undercut a lot of the principles of disability rights, the right to self-determination, the need for services to accommodate people with disabilities,” said Lili Graham, a lawyer with Disability Rights California. “And there is this coercive component to it because it's under the court's mandate.”
But Hull is also optimistic. If there’s a chance that CARE Court could help, she’d welcome the change.
“Sometimes there's a lot of things that you don't like and you have to do it,” Hull said. “So, yeah, if it’s a chance for somebody to be housed and get their word out, I'm all for it.”
Newsom’s administration poured $12 billion into homelessness and mental health programs last year — with another $2 billion proposed this year. But the state still faces serious shortages in behavioral health care workers, treatment programs and housing. And Hull’s most recent experience seeking help illustrates the hurdles CARE Court will have to clear to ensure that Hull, and others with a similar experience, can break the cycle of homelessness and succeed in treatment.
When Hull realized the hospital staff were going to discharge her to the streets, she called her godfather in a panic. He called the Coalition on Homelessness in San Francisco.
That’s how Hull first met Christin Evans, who owns the Booksmith, an independent bookstore in San Francisco, and also volunteers with the coalition. Evans stepped in as an advocate to help Hull find someplace to stay.
Hull has a paid social worker, appointed by the city. But with a heavy caseload, Evans said, the city social worker isn’t always able to give Hull as much time as she needs.
Across California, the behavioral health care industry faces a worker shortage, and it's expected to grow. A 2018 University of California San Francisco study found that by 2028, California will have 50% fewer psychiatrists and 28% fewer psychologists, licensed therapists and social workers than needed, due to retirement and attrition.
The pandemic only exacerbated that shortage, said Dr. Le Ondra Clark Harvey, CEO of the California Council of Community Behavioral Health Agencies. And Newsom’s administration estimates that 7,000 to 12,000 people will qualify for CARE Court each year, adding to that caseload. All of these people will be, by definition, high-needs cases.
“As the system currently stands, we're already struggling,” Harvey said. “We need to be able to have dependable, well-trained workers within this CARE Court system to make it successful.”
Without Evans volunteering support, Hull said she would have been lost.
“I would be downtown, going to see case manager after case manager, praying that there's an opening somewhere, praying that I'll be safe, sleeping in doorways,” Hull said.
Evans was able to spring into action. She started by convincing the hospital to keep Hull for a few more days — days that Evans spent trying to find housing.
She couldn’t place Hull at an emergency shelter in the Tenderloin, where Hull knew the heroin dealers. Sober for a week, Hull didn’t want to be tempted to use again.
“The options for her for emergency shelter were really limited,” Evans said.
She found a substance use treatment program that agreed to do an intake assessment, but not right away.
In the meantime, the hospital did discharge Hull, who was able to stay with her godparents over the weekend. That wasn’t a long-term option, though, because they only let Hull stay with them when she’s sober and getting into treatment.
When it came time for the program to do the intake assessment, however, the staff determined Hull needed more care than they could provide. She wouldn’t be getting a bed there. So, Evans started over, searching for a place that could provide both substance use and mental health treatment for Hull’s dual diagnoses.
“We started cold-calling, basically,” Evans said. “We were informed that there really weren't dual-diagnosis beds readily available that she could go into that night.”
To get into dual-diagnosis programs, Hull needed to fill out a five-page application, get a TB test and get a referral from a primary care physician, all of which took several days. Hull spent those nights with her godparents and at an overnight urgent care facility.
Finally, she got into The Avenues Transitional Care Center. But it was only temporary.
She had to wait another couple weeks until a bed opened at Baker Places Inc., which operates a 90-day treatment program in San Francisco. The whole process took about a month.
“I really do believe that in her case, she's not service-resistant,” Evans said. “The system is resistant to serving her.”
California faces a shortfall of nearly 5,000 psychiatric beds for short- and medium-term care, according to the RAND Institute, as well as nearly 3,000 long-term care beds.
Last year, the state budget included $2.2 billion to create or acquire residential treatment facilities, including board and care homes for people with mental health issues. This year’s proposed budget includes another $1.5 billion for short-term housing for people exiting homelessness and entering behavioral health treatment programs.
But Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California, said all those facilities will need ongoing funding.
“Those are buildings. They're not the people to work in the buildings,” Cabrera said. “We still have not expanded funding at the state level to support the expanded services that would be needed to go along with those buildings.”
The governor’s proposed budget includes $65 million to implement CARE Court, including $39 million to facilitate proceedings in county courts, $10 million to finance a supporter program through the state’s Department of Aging and $15 million to provide county governments with training and technical assistance.
It doesn’t specify any additional funds to increase services for new CARE Court enrollees. But it does include a projected $11.6 billion for county behavioral health departments, which are charged with providing services to people on Medi-Cal. That would be a nearly 50% increase from the prior year’s budget, if actual revenues match the projections.
Health and Human Services Secretary Dr. Mark Ghaly said in an interview it’s about prioritization.
“Our focus [is] on prioritizing this population,” Ghaly said, “not just making sure that they are no longer out of the line, but that they are towards the front of the line and getting these services in a prioritized way.”
Hull isn’t sure where she will go when her treatment program ends in early July. Evans is worried that all the work done to get Hull sober and stabilized will be undone if she goes back to homelessness.
The shortage of affordable housing remains a huge problem in California, particularly for people who often need on-site services to help them remain stably housed. Nearly 14,000 people experiencing homelessness voluntarily sought mental health services last year, but only half were placed into housing, according to a survey conducted earlier this year by the County Behavioral Health Directors Association of California.
For the other half, there simply weren’t enough affordable options that could accommodate people with complex behavioral health needs.
“We've sort of been casualties of the hot housing market in California,” Cabrera said, noting the state has lost many residential treatment facilities in recent years. “We have very limited resources ourselves to support our clients’ housing needs.”
An early draft of the CARE Court legislation didn't guarantee housing as part of the plan. But recent amendments to the bill now require county staff to identify an available housing placement for CARE Court enrollees. And courts could order other government agencies to provide that housing.
Hull tries not to think about what will happen to her in July, “because I don't want to get into a depression,” she said.
She’ll be 31 in September, and she’s still a long way from her goals. Sitting at the café in San Francisco's Civic Center, she said she knows that, ultimately, getting there is up to her.
“At the end of the day, the government has this and they have that,” she said. “It’s really up to you to fight for that.”
She turned her face toward the gilded dome on top of City Hall.
"But the fight shouldn’t be this hard,” she said.
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