Last February, I visited the Garfield Neurobehavioral Center, a psychiatric facility in Oakland that provides long-term supportive housing for people with severe mental illnesses. The scene was tranquil: men sat in wheelchairs, one wearing a helmet, while another shot hoops on a small basketball court. Inside, people either sat in their rooms or shared common spaces, chatting with staff and one another. Despite a sense of sadness, the kind familiar to even the most high-end nursing homes, the patients seemed content and well cared for—a stark contrast to the fate of many mentally ill individuals in California, whose problems have become the public’s problem due to a dysfunctional mental-health-care system.
Admission to Garfield requires a conservatorship, where a third party, usually a family member or government agent, assumes legal responsibility for the patient. The bar for obtaining one is high: a person must be a threat to himself or others, or be “gravely disabled,” meaning that he cannot perform tasks basic to survival. But “unable” means quite literally no ability—if someone can get food from trash, shelter by sleeping in a tent, and clothes by stealing, courts may not deem him disabled enough for conservatorship.
The high bar is understandable, as conservatorship strips a person of civil rights indefinitely. But this also means that very few people make it to places like Garfield, which, as a private facility, can choose its patients and typically avoids those prone to violence or repeated institutional failures—the very people who pose the greatest challenges for society. If you live in any urban area on the West Coast, you know the type: homeless, clearly disturbed, and often seeming to be a small provocation away from violence.
These individuals are on the streets because we have nowhere else to put them, having downsized or closed our asylums decades ago. If someone is experiencing a dangerous psychiatric break, police caninstitutionalize him, but the process that follows usually means that he is discharged without any medium- or long-term treatment plan in place.
If a mentally ill homeless person has a psychotic break and someone calls 911, first responders typically can’t do much more than stabilize him at the scene. If the psychotic person presents a threat to himself or others, however, an officer or a paramedic can initiate what’s known in California as a “5150 hold.” Once it’s initiated, an ambulance transports the person to the hospital for psychiatric assessment.If the psychiatrist signs off on the 5150, the patient will be placed in the locked psychiatric ward of the hospital for up to 72 hours.
During that time, medical staff try to stabilize the patient. This could mean offering antipsychotic medications (which a judge can compel), detoxing the patient with medical assistance, or merely keeping him confined until he calms down. If the psychotic episode is drug-induced, the patient will typically stabilize within 72 hours. Calm and lucid, he will usually opt to leave the hospital, especially if he is in withdrawal.
If the psychotic episode is a manifestation of underlying schizophrenia, then 72 hours may not be enough, and the psychiatrist may elect to initiate a “5250 hold.” A 5250 extends the 72-hour hold to up to 14 days. Unlike a 5150, a 5250 requires a court order. If after two weeks the patient remains psychotic and dangerous, the hospital can initiate a conservatorship.
At any point along this continuum, providers can—and do—simply release patients back onto the streets. Indeed, this is where momentum leads them. Doing so is in the hospital’s interest, as they’re on the hook for any costs that Medicaid doesn’t cover. And California’s laws tilt toward protecting individual civil liberties.
Further, California still lacks sufficient facilities to treat these people. The state’s remaining public psychiatric hospitals are a shell of their former selves, and today they house mostly forensic patients. Vanishingly few long-term-care institutions remain. The state now throws people with serious mental illness in jails or dumps them on the streets. And given California’s embrace of decarceration, it’s increasingly the streets.
Photo by David McNew/Getty Images
