Politics & Policy

San Francisco’s Humane Policy of Hospitalizing the Homeless and Mentally Ill

They’re a vast improvement over California’s incoherent commitment policy.

The rapid decline of San Francisco is emblematic of the corrosion now typical in California’s once-glorious cities.

Needles, human waste, and litter are ubiquitous on the city’s streets. San Francisco’s homeless population has exploded; some estimate that as many as 10,000 people live on the street, a census larger than the entire population of almost 85 percent of American townships. City residents have been disturbed by the size and behavior of the homeless population, some of whom, according to the Associated Press, have made a habit of “dashing into traffic or screaming at strangers.”

A not-altogether-inappropriate simulacrum of the California state legislature.

Some municipal leaders are trying to change the culture of disregard that has long characterized California’s urban governance. On Tuesday, San Francisco officials took the bold (and rather brave) step of defying vocal advocacy groups and expanding the city’s involuntary-commitment policies for the state’s most severely mentally ill.

The policy allows a court to appoint a “conservator” (an acting legal guardian for a mentally incapacitated adult) for an individual who has been involuntarily hospitalized eight or more times in the past calendar year. Because of state law, those prior commitments were almost certainly of the 72-hour variety, putting many chronically and acutely ill individuals right back on the street after a nominal evaluation to ensure they didn’t meet the (tragically high) suicidal-or-homicidal threshold. The conservatorship allows for a longer period of commitment, which will grant the profoundly ill access to care that, one hopes, will allow them to avoid long-term homelessness.

California’s incoherent commitment policies for persons with severe mental illness deserve much of the blame for the state’s homelessness crisis, though it has become increasingly unfashionable to say so. Data from California’s Department of State Hospitals reveals that in fiscal year 2017–18, there were more than 5,700 patients forensically committed to state mental institutions. This number, by way of comparison, was more than 45 times larger than the number of civil commitments (125) that occurred in the same time period; it was likewise the official policy of each of the state’s six public mental hospitals to refuse admissions to any voluntary patients.

It was, in essence, the practice of the state of California to look on helplessly as the gravely ill deteriorated to the point of criminality.

There is nary a state in the country more familiar with parens patriae governance than California — for instance, Governor Gavin Newsom recently implored his state to “insist on nurturing, nourishing and encouraging all of California’s children, from cradle to career.” Every non-vulnerable citizen in the state of California is subject to the bureaucratic creep of Governor Newsom’s Brave New World, but the seriously mentally ill sit around in their own filth because the state has discovered Millian objections to involuntarily treating the schizophrenic with delusions of grandeur. It is utterly lunatic.

Disability Rights California, the Californian iteration of the nationwide organization that opposes what it deems “institutional” settings for individuals with both psychiatric and developmental disabilities, was predictably disappointed by San Francisco’s decision. The group’s legislative director told the Associated Press that his organization is “concerned about ensuring that persons receive mental health treatment and services in their communities, in supportive housing, in supportive environments — and not in facilities.”

Heaven forfend that urine-drenched souls talking to themselves on the streets of San Francisco be treated in therapeutic “facilities”!

One would think that, after seeing the outcome — an explosion in homelessness and incarceration among the most seriously mentally ill — of our 50-year experiment of doggedly pursuing and funding “community” solutions, opponents of institutionalization would add at least a little nuance to their moral certainty.

There will always be a tension between a bona fide concern for civil liberties and treating the gravely ill anosognosiac patient. But author and industry critic D. J. Jaffe puts it well when he states that it is folly to “believe that being psychotic, delusional, and hallucinating is a ‘right’ to be protected rather than an illness to be treated.” To force a delusional person who is disconnected from reality to reach a point of no return (“a grave danger to themselves or others”) before granting them the treatment they cannot know they need is to use the vocabulary of civil rights to justify abject cruelty.

In their genre-defining Clinical Handbook of Psychiatry and the Law, Thomas G. Gutheil and Paul S. Appelbaum suggest that there is a “cyclical alteration between periods of beneficent enthusiasm and times of apathetic neglect” in American psychiatry. Perhaps, in a small way, San Francisco’s future restoration lies in its present rediscovery of a “beneficent enthusiasm” for treating its most vulnerable citizens.


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