Proposition 1, Care Courts and Conservatorship –“Controversy” Eclipses the Opportunity

By Bart Magee, Ph.D.
​
After a close election, Proposition 1, the bond measure sponsored by Governor Newsom to provide billions for mental health and substance abuse-related housing and treatment, passed. This comes on the heels of the recent establishment “Care Courts”, and changes in conservatorship laws, which will allow, for the first time in decades, compelled treatment for individuals with schizophrenia and other forms of  severe mental illness. There is no question that these hotly debated proposals now being implemented add up to a paradigm shift in the approach to the treatment of severe mental illness. The question is: Will they work as intended?

Some are hopeful that using “sticks” along with “carrots” will help get folks off the streets and into care. Others are opposed, citing ethical concerns and fear a return to warehousing rather than providing effective treatment. Much of the media coverage focuses on this controversy and fails to highlight the way that both sides are largely correct. Compelled treatment may be the only option when an individual cannot think and care for themselves, AND taking someone’s rights away should only be done judiciously, after meaningful efforts at encouragement and support have failed.
 
What so many are not appreciating is how the endless debate diverts our attention from addressing the deep problems in the mental health system that continue to be obstacles to good patient care.

In my 30 years as a clinical psychologist in San Francisco, I’ve witnessed how our system fails to serve those with severe mental illness. This makes no sense, since our understanding of the complexities of mental illness and treatments for it have advanced dramatically. We see the positive results every day at Access Institute: judicious use of medicine and the provision comprehensive assessments followed by intensive, long-term, patient-centered therapy works and allows for stability and improved quality of life. Treatment saves lives. At the same time the number of people suffering and dying, untreated in our community only seems to grow.

How is it that we can have effective treatments yet leave so many people untreated? A large part of the answer is that our mental healthcare system that serves low-income people is fractured and byzantine impeding access to care. Information is not shared and resources are inefficiently allocated. This is true locally and in other cities.

The passage of Prop. 1 and the implementation of Care Courts is a clear recognition that the system is broken. My concern is that adding new programs to a dysfunctional system may be a set-up for failure. Now is the opportune time to implement a few logical and affordable changes that would benefit everyone who interacts with the mental healthcare system.  

In one way, the diversity of the system makes it robust. Public clinics, residential treatment centers, inpatient units, intensive programs, non-profit and for-profit outpatient clinics and independent practitioners, all these elements possess differing and overlapping specialties (assessment, therapy, psychiatry, substance abuse, social service) and have varying capacities to treat patients at all levels of functioning.

That strength is also weakness. It creates inefficiencies and makes it a nightmare to navigate. If you are a family member or a case manager seeking treatment for someone with complex mental health, substance use and social needs, brace yourself. Is there one place that can provide all the care? If not, how do you coordinate all the providers? Where are the openings and what are eligibility requirements? What about insurance and payment? Can I get a call back?

Similar problems occur on the other end of the system. At Access Institute and at other community clinics there are periods with ample availability and other times significant wait lists, but there is no process for smoothing the bumps. When we need to find additional services for a patient, or to coordinate care with another provider, we are required to spend time making individual calls and waiting for information. Each provider has to keep and make updates to its own referral database.
 
The obvious solution, one that would be cheered by patients and providers alike, is creating or assigning one organization to serve as a hub for information, referral and coordination with the county or region. It would keep real time information on all providers, their specialties, capacities, and current openings. It could also track progress and measure outcomes. Technology, including artificial intelligence, would play key role. The hub would connect with all mental health providers and would be a place where anyone could seek information and referral. It would improve efficiency and support coordination of care. In addition, it could identify where additional capacity is needed and funding could be directed appropriately. The modest cost of this would be more than made up by enhanced efficiency and improved patient care.

Making this kind of change means coming together to advocate for it. Now is the time to move beyond the debates and get it started.