San Diego's CARE Court Isn't Forcing Treatment

By Lisa Halverstadt, the Voice of San Diego

March 3, 2025

When Gov. Gavin Newsom first proposed CARE Court in 2022, he presented it as a game-changing solution to force people with serious untreated psychotic conditions into care.

That’s not happening here.

San Diego County was one of the first to implement the new court system, but San Diego’s CARE Court program isn’t forcing anyone into treatment. Instead, county officials made the program voluntary.

If a person, whom a judge has decided is eligible for CARE Court, refuses help, outreach workers simply keep visiting them in hopes they’ll change their mind.

Families of people struggling with serious mental illnesses, San Diego police and other stakeholders expected something different. Many hoped the program would ensure treatment for a population that often declines it.

The law itself didn’t quite match Newsom’s rhetoric, and neither has San Diego’s interpretation of it.

Here’s how it was supposed to work. Family members, police and others petition for court-ordered care for a person with an untreated psychotic disorder who might otherwise cycle between jail, hospitals and the street. If the court and the county deemed the person eligible for the program and they didn’t agree to a voluntary treatment plan, the court could set one for them – and if that didn’t pan out, their failure in CARE Court could help set the stage for a more draconian conservatorship. The goal was to avoid that outcome and hold counties accountable to connect Californians, who might otherwise languish, with treatment.

Unlike in the past, where families and others were often left hoping a person would eventually access needed treatment, CARE Court allowed individuals to directly petition for specific individuals to get help, and for the county to follow up on those petitions and treatment requests.

That has meant the county and outreach teams repeatedly engage people who are the subject of valid CARE Court petitions, hoping to get them to agree to participate and to opt into a voluntary treatment plan. They offer access to housing, treatment options and support that may have been elusive in the past with the promise that the court will ensure the county delivers. If the person refuses, they aren’t enrolled in CARE Court though the county says it directs other outreach teams to keep visiting them in hopes they’ll change their mind.

San Diego’s CARE Court program dismissed 47 – or 18 percent – of the 258 petitions it received through mid-January due to respondents’ lack of willingness to participate. The more than 90 treatment agreements the CARE team reached were with people who chose to participate.

Still, the county’s initial track record – particularly with initial petition and agreement numbers that outpaced other communities – drew positive attention throughout the state from both state officials and media outlets. The county’s program and its first graduation are highlighted on the state’s CARE Act website. 

The county and state’s visible behavioral health and homelessness crises, challenges that CARE Court aimed to help address, have raged on since the county rolled out its program. More Californians are clamoring for forced treatment for people struggling with mental health and addiction challenges on the street and clashing with advocates who argue that’s ineffective and violates civil liberties.  

San Diego County began its CARE Court program under that backdrop. More than a year in, county officials maintain that the law itself didn’t provide teeth to clamp down on people who refuse treatment offerings or don’t follow court-mandated plans. They emphasize that the law dictates the voluntary approach, and that forced treatment isn’t the goal.

The county’s approach has left some stakeholders dissatisfied with the still-new state law they thought represented a paradigm shift. 

While the program has connected dozens with treatment, it’s been treatment that CARE Court enrollees agreed to – and not the forced care that many envisioned would come with it.

…

Newsom announced his CARE Act proposal in May 2022 to much fanfare. 

The San Francisco Chronicle columnist who broke the news described it like this: “For the first time, the state would require counties to provide comprehensive treatment to those suffering from debilitating psychosis — and risk sanctions if they don’t. The people in the program, in turn, would be obligated to accept the care.” 

Families who had for years watched their loved ones languish cheered. The bill would empower family members and other stakeholders to make the case for court-ordered care for people with psychotic disorders. That care could include treatment, medication, housing and other services. Counties that failed to deliver could face court fines. If a person struggled in the program, it could lead to court-ordered clinical evaluations and the prospect of conservatorship.

A coalition of housing and disability rights organizations assailed the proposal and the concept of forcing people into treatment.  

State lawmakers and lobbyists pushed state Sen. Tom Umberg of Santa Ana, author of the bill, to make amendments. The CARE Act ultimately received almost unanimous support in the legislature.  

The bill that became law wasn’t exactly what Newsom first implied in May 2022.  

It allowed counties to pursue voluntary treatment agreements with participants before moving to a court-ordered CARE plan. San Diego County embraced the voluntary approach.

Despite the rhetoric surrounding it, the law made it impossible to force people into treatment, local officials said. Amber Irvine, San Diego’s CARE program manager, said she and other officials recognized soon after they implemented the CARE Act in October 2023 that court-ordered plans weren’t worth the harsh reactions they’d generate from potential enrollees since there were no consequences for participants who failed to follow them. (Counties, however, could still face sanctions for not delivering.) 

“There’s no enforcement mechanism so wagging our finger or the black robe effect or trying to forcefully get people into treatment, they’re going to shut the door,” Irvine said. “They’re going to walk away. They’re not going to talk to us.”  

San Diego Superior Court Judge Paula Rosenstein, who hears CARE cases, and Public Defender Paul Rodriguez, whose office represents CARE enrollees, both lauded the focus on voluntary agreements. 

“We are proud of the fact that our court has not needed to order a Care Plan because the parties have all reached agreements,” Rosenstein wrote in a statement. 

Irvine and other San Diego County officials said they’ve had significant success with the voluntary strategy.  

Irvine said the county has seen a 64 percent reduction in 911 calls, emergency room visits and the use of other crisis services among CARE enrollees who tapped those services in the six months before they entered the program. She said 72 percent of those who made CARE agreements agreed to take psychotropic medications. 

The county also reports that four out of five CARE enrollees who were homeless when a CARE petition was submitted have since moved off the street. 

Yet the county acknowledges the recovery process hasn’t been easy for all CARE enrollees. 

Participant Pharoh Degree has twice been jailed for weeks-long stints since his mother Anita Fisher submitted a CARE petition in late 2023. At one point, he went missing for three weeks after walking away from a treatment program. More than a year later, 46-year-old Degree remains in the CARE program and is now staying at an independent living facility after two months in county jail. 

“This is not what they said the CARE Court was,” said Fisher, who advocated for the law hoping she wouldn’t feel the need to enroll her son who has long struggled with schizophrenia and addiction. 

When she decided she had no other option and the process began, Fisher expected the CARE program to provide a path to a conservatorship if Degree needed more support. That hasn’t happened. 

But Degree said he has appreciated the program’s willingness to continue working with him through struggles.  

“They meet me where I’m at and I don’t feel afraid or threatened or anything,” Degree said. 

Irvine said the recovery process is complicated. 

“Ideally in a perfect world, recovery would be completely linear, and every day would be a step forward and a step forward and step towards stability, but that’s just not the reality with this population and with any population really,” Irvine said. 

But how is the county responding when participants like Degree stop participating?

County spokesperson Tim McClain said once a person enters into a CARE agreement, the county and its contractors try to work with them for a year – even when they step away from treatment.

If the participant asks to be dismissed, McClain said, the county will offer connections to other treatment options.

The CARE Act noted that counties and courts could seek a court-ordered clinical evaluation if a person seemed to be deteriorating or failed to follow their treatment plan.

The Superior Court said there’s been only one of those but declined to provide more details. The county separately said one CARE enrollee was placed on a permanent conservatorship. A deputy public defender said last fall that it “was not due to her participation in CARE.”

Spokespeople for Newsom and the state Department of Health Care Services said counties can and should use other tools such as evaluations and conservatorships if they are concerned that CARE enrollees’ conditions are worsening in the voluntary program.

Umberg, author of the CARE Act, said he also expected counties and courts to pursue conservatorships.

“Ultimately if someone is non-cooperative, they can’t stay in CARE Court,” Umberg said.

McClain and Irvine acknowledged the county’s CARE team and contracted providers have called the county’s Psychiatric Emergency Response Teams and Mobile Crisis Response Teams “many times” to assess if people enrolled in CARE agreements or the subject of petitions could be considered eligible for 72-hour involuntary holds. It’s unclear how often those calls resulted in holds or hospitalizations that CARE aims to minimize. 

But the city of San Diego and its police department are concerned that first responders don’t have background on patients that the CARE team does to detail why forced care might be necessary – and that the county’s voluntary CARE program is leaving vulnerable San Diegans behind.  

In a statement, the police department raised concerns about petitions dismissed because a person refused to participate. The police department, which has submitted CARE petitions, argued the county should do more for these San Diegans.

“For those patients who are so severely mentally ill that they cannot voluntarily engage, a dismissal without a treatment plan means they will return to cycling between the jails, hospitals and the street,” police wrote. “In addition to first responder petitioners, this truth is also felt painfully by family members who file with CARE Court in a desperate attempt to get help for their loved ones, only to be dismissed without knowing another option.” 

The city also flagged this issue in an October memo to Newsom’s office urging updates to state law, arguing that “CARE respondents whose cases are dismissed are left to languish without support.” 

Following a new state law, counties must share more data on CARE Court dismissals and the state has committed to share statewide numbers this summer.

Irvine said the county doesn’t give up on people who decline CARE Act services. She said the CARE team has spent as long as 134 days engaging with someone before enrolling them in a care agreement. If a person continues to show disinterest, Irvine said, the county directs another outreach team to keep visiting them and can issue an internal CARE petition if they ultimately agree to participate. 

“I think there’s some unrealistic expectations around the timeframes of being able to effectively engage someone,” Irvine said. 

Some advocates remain convinced CARE isn’t voluntary enough.

Disability Rights California was among the loudest opponents of the CARE Act. The organization remains concerned about court involvement in treatment and the possibility of conservatorship that hangs over it.

“One of the purposes of CARE Court is to utilize the so-called black robe effect,” Disability Rights senior policy attorney Samuel Jain said. “Because a judge is the one that’s ordering services it makes you fearful and more likely to comply.” 

Jessica Kramer, a disability rights advocate who has served as a court-appointed supporter to an enrollee in San Diego’s CARE Court and advised other stakeholders, said a county-contracted CARE team urged a participant she helped to accept medication that previously caused a speech impairment and housing options that didn’t meet her needs, creating unnecessary stress. She said the woman was subjected to multiple involuntary holds and felt stuck in the CARE process – even after moving off the street and into housing. 

Kramer said that enrollee, who recently passed away following an unrelated health issue, tried to access voluntary treatment outside the CARE program for years without success after providers repeatedly rejected her attempts for reasons including her speech impairment and limited space.  

Kramer said the woman would have preferred to get that help outside of what she felt was a coercive court process. 

“Why bother with a court process when the services are not there?” Kramer said. 

Umberg said the legislation envisioned Superior Court judges ensuring counties delivered services to people with psychotic illnesses often abandoned by county health care systems and that patients stuck with much-needed treatment. 

“They have to work together but the court has to be ultimately the entity that holds the others accountable, including the participant,” Umberg said.

The San Diego Superior Court said it hasn’t issued any fines against the county, which says it has embraced the additional accountability. 

But the county and other stakeholders have decided they don’t have the same authority over CARE Court participants. 

Umberg said he will pursue amendments to the CARE Act after gathering feedback on successes and challenges. Umberg said he plans to work with stakeholders including San Diego Mayor Todd Gloria, San Diego County supervisors and judges – and in a statement, focused on how the law might link enrollees who are spiraling with a higher level of care. 

“While conservatorship is not the preferred avenue for those suffering from severe mental illnesses, it is an important last resort for this vulnerable population that must be considered in order to avoid jail or grievous harm,” Umberg wrote. “Senate Bill 27 will be a vehicle for tackling some of these issues in the months ahead.”

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