Human Rights Watch’s Opposition to CARE Court (CA SB 1338)
Honorable Chris Holden Chair, Assembly Appropriations Committee Capitol Office, 1021 O Street, Suite 5650 Sacramento, CA 95814 Re: Human Rights Watch’s Opposition to CARE Court (SB 1338) as amended June 16, 2022 Dear Assemblymember Holden: Human Rights Watch has carefully reviewed SB 1338 , the amendments to SB 1338, and the proposed framework for the Community Assistance, Recovery and Empowerment (CARE) Court created by CalHHS, and must respectfully voice our strong opposition. CARE Court promotes a system of involuntary, coerced treatment, enforced by an expanded judicial infrastructure, that will, in practice, simply remove unhoused people with perceived mental health conditions from the public eye without effectively addressing those mental health conditions and without meeting the urgent need for housing. We urge you to reject this bill and instead to take a more holistic, rights-respecting approach to address the lack of resources for autonomy-affirming treatment options and affordable housing. CARE Court proponents claim it will increase up-stream diversion from the criminal legal and conservatorship systems by allowing a wide range of actors to refer people with schizophrenia and other psychotic disorders to the jurisdiction of the courts without an arrest or hospitalization. In fact, the bill creates a new pathway for government officials and family members to place people under state control and take away their autonomy and liberty. It applies generally to those the bill describes as having a “schizophrenia spectrum or other psychotic disorder” and specifically targets unhoused people. It seems aimed at facilitating removing unhoused people from public view without actually providing housing and services that will help to resolve homelessness. Given the racial demographics of California’s homeless population, and the historic over-diagnosing of Black and Latino people with schizophrenia, this plan is likely to place many, disproportionately Black and brown, people under state control. CARE Court is Coerced Treatment Proponents of the plan describe CARE Court in misleading ways as “preserving self-determination” and “self-sufficiency,” and “empower[ing].” But CARE Court creates a state-imposed system of coerced, involuntary treatment.
The proposed legislation authorizes judges to order a person to submit to treatment under a CARE plan. That treatment may include an order to take a given medication, including anti-psychotic medications, housing, and other enumerated services. Housing must be provided through a designated list of existing program that includes interim housing or shelter options that may be unacceptable to an individual and unsuited to their unique needs. The CARE Court proposal does not provide additional housing and does not envision enforcement of long-term prioritization of housing for its graduates. A person who fails to obey the court ordered treatment plan may be referred to conservatorship, which would potentially strip that person of their legal capacity and personal autonomy, subjecting them to forcible medical treatment and medication, loss of personal liberty, and removal of power to make decisions over the conduct of their own lives. Indeed, the court may use failure to comply with their court-ordered treatment as “a presumption at that hearing that the respondent needs additional intervention beyond the supports and services provided by the CARE plan” paving the way for detention and conservatorship. In practical effect, the mandatory care plans are simply pathways to the even stricter system of control through conservatorship. This approach not only robs individuals of dignity and autonomy but is also coercive and likely ineffective. Studies of coercive mental health treatment have generally not shown positive outcomes. Evidence does not support the conclusion that involuntary outpatient treatment is more effective than intensive voluntary outpatient treatment and, indeed, shows that involuntary, coercive treatment is harmful. Coerced Treatment Violates Human Rights Under international human rights law, all people have the right to “the highest attainable standard of physical and mental health.” Free and informed consent, including the right to refuse treatment, is a core element of that right to health. Having a “substitute” decision-maker, including a judge, or even a “supporter,” make orders for health care can deny a person with disabilities their right to legal capacity and infringe on their personal autonomy. The Convention on the Rights of Persons with Disabilities establishes the obligation to “holistically examine all areas of law to ensure that the right of persons with disabilities to legal capacity is not restricted on an unequal basis with others. Historically, persons with disabilities have been denied their right to legal capacity in many areas in a discriminatory manner under substitute decision-making regimes such as guardianship, conservatorship and mental health laws that permit forced treatment.” The US has signed but not yet ratified this treaty, which means it is obligated to refrain from establishing policies and legislation that will undermine the object and purpose of the treaty, like creating provisions that mandate long-term substitute decision-making schemes like conservatorship or court-ordered treatment plans.
The World Health Organization has developed a new model that harmonizes mental health services and practices with international human rights law and has criticized practices promoting involuntary mental health treatments as leading to violence and abuse, rather than recovery, which should be the core basis of mental health services. Recovery means different things for different people but one of its key elements is having control over one ́s own mental health treatment, including the possibility of refusing treatment. To comport with human rights, treatment should be based on the will and preferences of the person concerned. Housing or disability status does not rob a person of their right to legal capacity or their personal autonomy. Expansive measures for imposing mental health treatment like the process envisioned by the CARE Court plan infringe on it and discriminate on the basis of disability. As discussed below they also run the risk of being abused by self-interested actors. This coerced process leading to “treatment” undermines any healing aim of the proposal. CARE Court Denies Due Process The CARE Court proposal authorizes family members, first responders, including police officers or outreach workers, the public guardian, service providers, conservators, and the director of the county behavioral health agency, to initiate the process of imposing involuntary treatment by filing a petition with the court. These expansive categories of people with the power to embroil another person in court processes and potential loss of autonomy, many of whom lack any expertise in recognition and treatment of mental health conditions, reveals the extreme danger of abuse inherent in this proposal. For example, interpersonal conflicts between family members could result in abusive parents, children, spouses, and siblings using the referral process to expose their relatives to court hearings and potential coerced treatment, housing, and medication. Law enforcement and outreach workers would have a new tool to threaten unhoused people with referral to the court to pressure them to move from a given area.
These state actors could funnel those who disobeyed their commands into the CARE Court process and potentially under the control of courts. Given the long history of law enforcement using its authority to drive unhoused people from public spaces, a practice that re-traumatizes those people and does nothing to solve homelessness, it is dangerous to provide them with additional powers to do so. The legislation does not set meaningful standards to guide judicial discretion and does not delineate procedures for those decisions. It establishes a contradictory and unworkable procedure that allows certain people diagnosed with schizophrenia or other psychotic disorders to be ordered into treatment if, among other criteria, a judge believes that they are unlikely to survive safely in the community without supervision, or that they are at risk of relapse or deterioration into grave disability or serious harm.  These criteria are extremely subjective and speculative and subject to bias.
The court commences the process of engagement if a petition merely asserts facts supporting eligibility and attaches documentation of either contact or attempted contact with a behavioral health professional or of prior intensive treatment. If the court finds the person meets or “likely meets the criteria,” then the court orders a hearing, which may be conducted in the person’s absence. At the hearing, if the court examines the “prima facie” evidence presented by the petitioner and finds “reason to believe the facts stated in the petition appear to be true,” the person is then required to enter into negotiations with the county behavioral health agency to come up with a purportedly voluntary treatment plan. The role of the behavioral health agency poses a great potential for conflicts of interest, as they will presumably be funded to carry out the Care Plans that result from their negotiations and their evaluations. However, failure to agree to that supposedly voluntary plan results in a court-ordered evaluation by that same behavioral health agency, which can be used to impose a mandatory, court-ordered course of treatment if the court finds the person meets the criteria following a hearing. Once ordered, if a person does not complete the CARE program, they may be “involuntarily reappointed” to the program for an additional year. This process is entirely coercive, despite procedures that claim to be voluntary. Welfare and Institutions Code section 5801(b)(5), as amended by SB 1338, makes this coercion clear: "The client should be fully informed and volunteer for all treatment provided, unless... the client is under a court order for CARE pursuant to Part 8 (commencing with Section 5970) and, prior to the court-ordered CARE plan, the client has been offered an opportunity to enter into a CARE agreement on a voluntary basis and has declined to do so." The CARE Court plan threatens to create a separate legal track for people perceived to have mental health conditions, without adequate process, negatively implicating basic rights. Even with stronger judicial procedures, this program would remain objectionable because it expands the ability of the state to coerce people into involuntary treatment. CARE Court will harm Black, brown, and Unhoused people The CARE Court directly targets unhoused people to be placed under court-ordered treatment, thus denying their rights and self-determination. Governor Newsom, in pitching this plan, called it a response to seeing homeless encampments throughout the state of California. CARE Court will empower police and homeless outreach workers to refer people to the courts and allow judges to order them into treatment against their will, including medication plans. CARE Court does not increase access to permanent supportive housing or mental health care and instead relies on existing programs and service providers that already struggle to meet the needs of the unhoused. Due to a long history of racial discrimination in housing, employment, access to health care, policing and the criminal legal system, Black and brown people have much higher rates of homelessness than their overall share of the population. The CARE Court plan in no way addresses the conditions that have led to these high rates of homelessness in Black and brown communities. Instead, it proposes a system of state control over individuals that will compound the harms of homelessness. Further, much research shows that mental health professionals diagnose Black and Latino populations at much higher rates than they do white people. One meta-analysis of over 50 separate studies found that Black people are diagnosed with schizophrenia at a rate nearly 2.5 times greater than white people. A 2014 review of empirical literature on the subject found that Black people were diagnosed with psychotic disorders three to four times more frequently than white people. This review found large disparities for Latino people as well. CARE Court may place a disproportionate number of Black and Latino people under involuntary court control. CARE Court Does Not Increase Access to Mental Health Care The CARE plan would establish a new judicial infrastructure focused on identifying people with mental health conditions and placing them under state control for up to 24 months. While touted as an unprecedented investment in support and treatment for people with mental health conditions, in reality, the program provides no new funding for behavioral health care, instead re-directing money already in the budget for treatment to programs required by CARE Court. According to the DHHS presentation on the proposal, the only new money allocated for the program will go to the courts themselves to administer this system of control. The court-ordered plans include housing, but not necessarily permanent supportive housing. The proposal seems to anticipate allowing shelter and interim housing to suffice if available, without recognizing the vast shortage of affordable housing, especially supportive housing, throughout most of California. To the extent the proposal relies on state investment in housing already in existence, it will prioritize availability of that housing for people under this program, meaning others in need would have reduced access to that housing. California Should Invest in Voluntary Treatment and Supportive Services CARE Court shifts the blame for homelessness onto individuals and their vulnerabilities, rather than recognizing and addressing the root causes of homelessness such as poverty, affordable housing shortages, barriers to access to voluntary mental health care, and racial discrimination. CARE Courts are designed to force unhoused people with mental health conditions into coerced treatment that will not comprehensively and compassionately address their needs. Californians lack adequate access to supportive mental health care and treatment. However, this program does not increase that access. Instead, it depends on money already earmarked for behavioral health initiatives and layers harmful and expensive court involvement onto an already inadequate system. Similarly, the “Care plans” mandated by the CARE Courts do not address the shortage of housing. Investing in involuntary treatment ties up resources that could otherwise be invested in voluntary treatment and the services necessary to make that treatment effective. California should provide well-resourced holistic community-based voluntary options and remove barriers to evidence-based treatment to support people with mental health conditions who might be facing other forms of social exclusion. Such options should be coupled with investment in other social supports and especially housing, not tied to court-supervision. Rather than co-opting the language used by movements supporting housing and disability rights and cynically parading the trauma of family members let down by the state mental health system, as proponents of CARE Courts have done, we instead ask that you reject the CARE Court proposal entirely and direct resources towards making voluntary treatment and other necessary services accessible to all who need it. Sincerely, Olivia Ensign John Raphling Senior Advocate, US Program Senior Researcher, US Program Human Rights Watch Human Rights Watch  California SB 1338, “Community Assistance, Recovery, and Empowerment (CARE) Court Program (Umberg, Eggman),” 2022, https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202120220SB1338 (accessed April 12, 2022).  California Health & Human Services Agency, “CARE Court: A New Framework for Community Assistance, Recovery & Empowerment,” March 2022, https://www.chhs.ca.gov/wp-content/uploads/2022/03/CARE-Court-Framework_web.pdf (accessed April 12, 2022).  California SB 1338, “Community Assistance, Recovery, and Empowerment (CARE) Court Program (Umberg, Eggman),” 2022, https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202120220SB1338.  Marisa Lagos, “Gov. Newsom on His Plan to Tackle Mental Health, Homelessness with ‘CARE Courts’,”KQED, March 16, 2022, https://www.kqed.org/forum/2010101888316/gov-newsom-on-his-new-plan-to-tackle-mental-health-homelessness-with-care-courts (accessed April 12, 2022).  Los Angeles Homeless Services Authority, “Report and Recommendations of the Ad Hoc Committee on Black People Experiencing Homelessness,” December 2018, https://www.lahsa.org/documents?id=2823-report-and-recommendations-of-the-ad-hoc-committee-on-black-people-experiencing-homelessness (accessed April 12, 2022).  Charles M. Olbert, Arundati Nagendra, and Benjamin Buck, “Meta-analysis of Black vs. White racial disparity in schizophrenia diagnosis in the United States: Do structured assessments attenuate racial disparities?,” Journal of Abnormal Psychology 127(1) (2018): 104-115, accessed April 12, 2022, doi: 10.1037/abn0000309; Robert C. Schwartz and David M. Blankenship, “Racial disparities in psychotic disorder diagnosis: A review of empirical literature,” World Journal of Psychiatry 4 (2014): 133-140, accessed April 12, 20220, doi: 10.5498/wjp.v4.i4.133.  “CARE (Community Assistance, Recovery and Empowerment) Court,” California Health & Human Services Agency, March 14, 2022, Slides 5, 10 and 20, https://www.chhs.ca.gov/wp-content/uploads/2022/03/CARE-Court-Stakeholder-Slides-20220314.pdf (accessed April 12, 2022); Marisa Lagos, “Gov. Newsom on His Plan to Tackle Mental Health, Homelessness with ‘CARE Courts’,” KQED, March 16, 2022, https://www.kqed.org/forum/2010101888316/gov-newsom-on-his-new-plan-to-tackle-mental-health-homelessness-with-care-courts (accessed April 12, 2022).  SB 1338, Section 5982 (a)-(b).  SB 1338, Section, 5982; 5971  SB 1338, Section 5982(c); “CARE (Community Assistance, Recovery and Empowerment) Court.” The DHHS presentation discusses a range of housing possibilities including “interim or bridge housing,” which in common usage means temporary shelter.  SB 1338, Section 5979(a); California Welfare and Institutions Code Section 5350—5372, https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=WIC§ionNum=5357 (accessed April 12, 2022).  SB 1338, Section 5979(a).  Sashidharan, S. P., Mezzina, R., & Puras, D., “Reducing coercion in mental healthcare,” Epidemiology and psychiatric sciences, 28(6) (2019): 605–612, accessed April 12, 2022, https://doi.org/10.1017/S2045796019000350 (“Available research does not suggest that coercive intervention in mental health care “are clinically effective, improve patient safety or result in better clinical or social outcomes.”).  Sashidharan, S. P., Mezzina, R., & Puras, D., “Reducing coercion in mental healthcare,” Epidemiology and Psychiatric Sciences, 28(6) (2019): 605–612, accessed May 5, 2022, https://doi.org/10.1017/S2045796019000350; Richard M. Ryan, Martin F. Lynch, Maarten Vansteenkiste, and Edward L. Deci, “Motivation and Autonomy in Counseling, Psychotherapy, and Behavior Change: A Look at Theory and Practice,” Invited Integrative Review 39(2) (2011): 193–260, accessed May 5, 2022, doi: 10.1177/0011000009359313; McLaughlin, P., Giacco, D., and Priebe, S., “Use of Coercive Measures during Involuntary Psychiatric Admission and Treatment Outcomes: Data from a Prospective Study across 10 European Countries,” Plods one 11(12) (2016), accessed May 5, 2022, doi: https://doi.org/10.1371/journal.pone.0168720 (“All coercive measures are associated with patients staying longer in hospital, and seclusion significantly so, and this association is not fully explained by coerced patients being more unwell at admission.”).  Joseph P. Morrissey, et al., “Outpatient Commitment and Its Alternatives: Questions Yet to Be Answered,” Psychiatric Services (2014): 812-814; S.P. Sashidharan, et al., “Reducing Coercion in Mental Healthcare,” Epidemiology and Psychiatric Sciences 28 (2019): 605-612.  International Covenant on Economic, Social and Cultural Rights, (“ICESCR”), adopted December 16, 1966, entered into force January 3, 1976, Art. 12(1), https://www.ohchr.org/en/professionalinterest/pages/cescr.aspx (accessed May 5, 2022).  Human Rights Council; United Nations, General Assembly, “Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health,” March 28, 2017, https://undocs.org/en/A/HRC/35/21, para. 63. See also Convention on the Rights of Persons with Disabilities, art. 12 read in conjunction with art. 25; Committee on the Rights of Persons with Disabilities: General comment No. 1 (2014), May 19, 2014, https://documents-dds-ny.un.org/doc/UNDOC/GEN/G14/031/20/PDF/G1403120.pdf?OpenElement (accessed May 5, 2022), para. 31, 41.  Convention on the Rights of Persons with Disabilities, art. 12; Committee on the Rights of Persons with Disabilities: General comment No. 1 (2014), May 19, 2014, para. 7.  Committee on the Rights of Persons with Disabilities: General comment No. 1 (2014), May 19, 2014, para. 7.  See Vienna Convention on the Law of Treaties (1969), art. 18, https://legal.un.org/ilc/texts/instruments/english/conventions/1_1_1969.pdf. The Vienna Convention is recognized as customary international law.  World Health Organization and QualityRights, “Freedom from coercion, violence, and abuse,” 2019, https://apps.who.int/iris/bitstream/handle/10665/329582/9789241516730-eng.pdf?sequence=5&isAllowed=y (accessed May 5, 2022), p. 2, 8, 22.  SB 1338, Section 5974; 5978.  Chris Herring, “Complaint-Oriented Policing: Regulating Homelessness in Public Space,” American Sociological Review 1-32, (2019), accessed May 5, 2022, doi: 10.1177/0003122419872671.  SB 1338, Section, 5972-5978.  SB 1338, Section 5972.  SB 1338, Section 5977(a)(3).  Id.: SB 1338, Section 5977(c)(2).  SB 1338, Section 5977(d).  SB 1338, Section 5977.1. SB 1338, Section 5977.3(c).  SB 1338, Section 5801(b)(5).  Committee on the Rights of Persons with Disabilities, “Guidelines on article 14 of the Convention on the Rights of Person with Disabilities: The right to liberty and security of persons with disabilities,” (September 2015), https://www.google.com/search?q=Guidelines+on+CRPD+article+14%2C+paragraph+21&rlz=1C1PRFI_enUS936US936&oq=Guidelines+on+CRPD+article+14%2C+paragraph+21&aqs=chrome.69i57j33i160.3045j0j7&sourceid=chrome&ie=UTF-8 (accessed May 5, 2022), para. 14.  Marisa Lagos, “Gov. Newsom on His Plan to Tackle Mental Health, Homelessness with ‘CARE Courts’.”  SB 1338, Section 5982(c).  Kate Cimini, “Black people disproportionately homeless in California,” CalMatters, February 27, 2021, https://calmatters.org/california-divide/2019/10/black-people-disproportionately-homeless-in-california/ (accessed May 5, 2022) (”about 6.5% of Californians identify as black or African American, but they account for nearly 40% of the state’s homeless population”); Esmeralda Bermudez and Ruben Vives, “Surge in Latino homeless population ‘a whole new phenomenon; for Los Angeles,” LA Times, June 18, 2017, https://www.latimes.com/local/california/la-me-latino-homeless-20170618-story.html (accessed May 5, 2022); Los Angeles Homeless Services Authority, “Report and Recommendations of the Ad Hoc Committee on Black People Experiencing Homelessness,” December 2018, https://www.lahsa.org/documents?id=2823-report-and-recommendations-of-the-ad-hoc-committee-on-black-people-experiencing-homelessness (accessed May 5, 2022).  Charles M Olbert, Arundati Nagendra, and Benjamin Buck, “Meta-analysis of Black vs. White racial disparity in schizophrenia diagnosis in the United States: Do structured assessments attenuate racial disparities?,” Journal of Abnormal Psychology 127 (2018): 104-115, accessed May 5, 2022, doi: 10.1037/abn0000309; Robert C. Schwartz and David M. Blankenship, “Racial disparities in psychotic disorder diagnosis: A review of empirical literature,” World Journal of Psychiatry 4 (2014): 133-140, accessed May 5, 2022, doi: 10.5498/wjp.v4.i4.133.  Ibid.  Schwartz and Blankenship, “Racial disparities in psychotic disorder diagnosis.”  “CARE (Community Assistance, Recovery and Empowerment) Court,” California Health & Human Services Agency.  Ibid.  SB 1338, Section 5971; 5982.  Ibid.; National Low Income Housing Coalition, “The Gap: A Shortage of Affordable Homes,” March 2020, https://reports.nlihc.org/sites/default/files/gap/Gap-Report_2021.pdf (accessed May 5, 2022), p. 2, 9; California Housing Partnership, “California Affordable Housing Needs Report,” March 2020, https://1p08d91kd0c03rlxhmhtydpr-wpengine.netdna-ssl.com/wp-content/uploads/2020/03/CHPC_HousingNeedsReportCA_2020_Final-.pdf (accessed May 5, 2022).  Liz Hamel, Lunna Lopes, Bryan Wu, Mollyann Brodie, Lisa Aliferis, Kristof Stremikis and Eric Antebi, “Low-Income Californians and Health Care,” Kaiser Family Foundation, June 7, 2019, https://www.kff.org/report-section/low-income-californians-and-health-care-findings/#:~:text=About%20half%20of%20Californians%20with%20low%20incomes%20%2852,not%20able%20to%20get%20needed%20services%20%28Figure%208%29 (accessed May 5, 2022). ( “A majority of low-income Californians (56 percent) say their community does not have enough mental health care providers to serve the needs of local residents.”)  Physicians for Human Rights, “Neither Justice nor Treatment: Drug Courts in the United States,” June 2017, phr_drugcourts_report_singlepages.pdf (accessed May 5, 2022), p. 3.
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