California officials seek ‘CARE’ without coercion as new mental health courts launch this fall

Reviewed by Megan Craig, M.Sc.Sep 21 2023

The first time Heidi Sweeney began hallucinating, the voices in her head told her Orange County's Huntington Beach was where she would be safe. There, behind the bikini-clad crowds playing volleyball and riding beach cruisers, she slept in homeless encampments, then beside a bush outside a liquor store, drinking vodka to drown out the din only she could hear.

For years, she refused help, insisting to all who offered, "I'm not sick," until police arrested her for petty theft and public drunkenness. A judge gave her an ultimatum: jail or treatment. She chose treatment.

"I'm so thankful that they did that," said Sweeney, now 52. "I needed that. I think there's others out there that need it, too."

If she hadn't been compelled to get care, Sweeney said, she wouldn't be alive today, back at work and reunited with her husband. It's why she supports California's new civil CARE Courts that will launch this fall in eight counties, including San Francisco, Los Angeles, and Orange, followed by the rest of the state in 2024.

Under the new system, family members and first responders can ask county judges to order people with psychotic illness into treatment, even if they are not unhoused or haven't committed a crime. A judge will then determine if a person meets criteria for the program and may oversee a care agreement or compel a treatment plan. That treatment plan could even include involuntary commitment.

The bill creating the program sailed through the state legislature with near-unanimous support last year amid growing frustration from voters over the state's increasing number of homeless people, even as it drew vehement opposition from disability rights groups, who argued CARE Courts' hallmark — compelling people who have done nothing wrong into mental health care — is a violation of civil rights.

That tension — between those who advocate for treatment being voluntary and those who say the status quo allows people to die in the streets "with their rights on" — is playing out all over the state of California. In Orange County, officials are threading a delicate needle: how to convince people to accept care without coercion, particularly when their illness causes them to believe they are not ill.

"We don’t want to punish people," said Maria Hernandez, the presiding judge for Orange County Superior Court. "We want them to maintain their dignity."

Orange County is expecting between 900 and 1,500 residents will be eligible for CARE Court in any given year, according to the county public defender's office. Local lawyers, judges, and health officials have all aligned in designing their program with a distinct patient focus, endeavoring to make the process as benign and nonthreatening as possible.

Hernandez said that means modeling the new civil court after the county's other collaborative courts, where judges often lose the black robe and come down off the bench to work with people, eye to eye.

One prototype, she said, is her Young Adult Court, where, on a day in June, the mood was downright jovial. Defendants and their family members were chatting and laughing, munching on snacks laid out on a table in the back as three young men "graduated" from the diversion program.

"Judge Hernandez is so awesome," said Abraham, 25, a graduate of the program, who asked to be identified only by his first name because he was charged with a felony that has since been expunged from his record. "I don’t even look at her as the judge. She’s just like a mom figure. She’s only trying to push you to be the better you."

A minute later, Hernandez walked through the aisle of the courtroom and gave Abraham a hug.

Even if CARE Court is overseen by a judge like Hernandez, patient advocates object to the idea. Orlando Vera, who lives with bipolar disorder, said helping a vulnerable person heal from mental illness shouldn't involve dragging them into a courtroom.

"It’s not a place you resolve your emotions. It is a very business-oriented environment. So I do feel that this is not the place for it," Vera said, adding, "Can we stop it? I would say we can’t."

After advocates failed to persuade the state Supreme Court to block the program on constitutional grounds, some started referring to gearing up for the rollout of CARE Court as "disaster preparedness," equating it with a devastating earthquake or wildfire.

Peer Voices of Orange County, a group Vera co-founded and runs, plans to install patient advocates at the courthouse to attend all CARE Court hearings.

"Our focus is how do we support those that are going through the system," he said. "We need to be their voice."

Orange County behavioral health director Veronica Kelley is sympathetic to advocates' concerns. She said CARE Court is not the program she would have created to improve the state's mental health system. But she serves at the will of the governor and other elected officials who control her budget.

"So we end up building the Winchester Mystery House," she said, referring to the 100-year-old mansion in San Jose known for its mazelike layout. "It is a structure that was OK, but then it just started adding hallways to nowhere and basements that are on top of the building. That’s what our system looks like."

Kelley is trying to shape the new court process into something its critics can accept. This is why she wanted Orange County to go first: "so we can help craft it into something that’s not another colossal waste of time and funds, and that we don’t destroy the people we’re trying to serve at the same time," she told a roomful of patient advocates during a meeting of the state Patients Rights Committee, held in Santa Ana.

This means social workers from her behavioral health department or the public defender's office might visit people 20, 30, or 40 times to build trust, listen, and set goals.

Under the CARE legislation, county courts are allowed to fine public behavioral health agencies $1,000 a day if they can't find a patient and enroll them in treatment by certain deadlines.

Kelley said her county's judges have agreed to give her staff the time and extensions they need to do their jobs well. She also vowed that no one who declined services in her county would be institutionalized involuntarily, even though the new legislation allows it.

"If someone agrees to do something of their own accord, it is far more probable that there will be long-term success and long-term commitment to the services being provided," she said.

Kelley pointed to the county's success with another civil court process, established by Laura's Law in 2002, in which, for every person involved in court-ordered outpatient care, another 20 accepted treatment willingly.

She said the county has the same goal for CARE Court, with the focus on finding a treatment plan people accept voluntarily, before a judge has to order it.