Conservatorship: Inside California’s System of Coercion and Care for Mental Illness, by Alex V. Barnard (Columbia University Press, 416 pp., $35)
In New York City and California, politicians have been pushing to expand involuntary psychiatric care to deal with their communities’ abysmal street conditions. No one believes that allowing those with untreated psychosis to suffer in public is anything other than disgraceful. But definitive solutions have proved elusive because, many assume, policymakers can’t agree on when it is acceptable to force people to accept treatment.
In his new book on mental-health care in California, Conservatorship, Alex V. Barnard suggests a different explanation. “Abdicated authority,” he says, better explains the street chaos than poorly designed civil commitment laws. California persistently fails to make progress on serious mental illness because no one’s in charge.
Barnard is a sociologist, based at New York University, but his book may best be understood as a study of public administration. Conservatorship takes readers, step by step, through the process by which Californians with schizophrenia and other serious mental illnesses “fall through the cracks” of their state’s generously funded but fragmented “nonsystem of care.”
Readers meet several mentally ill Californians who are homeless, floridly psychotic; who have taken a pass on all treatment offers; who are socially isolated, decompensating, and nearly certain to be incarcerated or victimized if not stabilized soon. Barnard then goes through every mental-health system stakeholder’s incentives not to intervene. Police are often reluctant to make an arrest or apply a “5150 hold,” to evaluate someone for psychiatric hospitalization, because the mentally ill person will likely wind up back on the street in no time; drug-treatment programs, shelters, and private housing providers will say that those with serious mental illness require a “higher level of care” than their program can provide; state and county government see no point in civilly committing someone to a hospital bed that doesn’t exist. Thus, Barnard’s “abdicated authority”: everyone is profuse with reasons about why their responsibilities don’t extend to someone with untreated serious mental illness. “[N]egative discretion, exercised in inconsistent ways, is king.”
The book’s title refers to a legal mechanism by which government may assume control over mentally ill Californians’ care. A conservatorship was what, during the 2021 #FreeBritney public controversy, pop singer Britney Spears successfully sought to be freed from. Her legal status was not, strictly speaking, the same as the form of conservatorship used for the mentally ill, which confers stronger powers. Barnard explains that those powers should be plenty strong enough to stabilize even the hardest cases. Why they can’t be effectively brought to bear owes mainly to decentralization.
Scholars have always understood that decentralized government, though a cherished American principle, sometimes has trouble managing crises. Compared with, say, Hurricane Katrina, mental-health crises are more complicated in two respects. First, in addition to confusion among federal, state, and local authorities, roles must be assigned to a wide array of private-sector players, such as insurers, hospitals, and landlords. Second, for someone with a chronic and serious mental illness, life is a permanent crisis, a daily Katrina for him and his family.
California began deinstitutionalizing the mentally ill in earnest with the 1967 Lanterman-Petris-Short Act. That law passed the state legislature overwhelmingly and was signed into law by Governor Ronald Reagan. Barnard compares “LPS” to the Magna Carta for its liberating thrust and landmark status. It promised more accountability for public mental health. Pre-LPS, California’s mental-health agency, responsible for running the old asylum programs, was the second-largest agency in the state. Audits found it wasteful and incompetent. Republicans and Democrats alike reasoned that a less centralized system, one more reliant on private entities, would deliver better care and show more sensitivity to civil rights. The real result was extreme unaccountability: “an absence of government leadership, coordination, and regulation creates the readily apparent failings of California’s mental health system.”
Conservatorship makes for an interesting read during our populist moment. Barnard interviewed more than 250 people involved in some way in California’s mental-health crisis. Among his more sympathetic subjects are parents of mentally ill adults. However they vote, parents code as “conservative” in the mental-health context, but they are not localists. They want a more assertive central government, one empowered to force local governments and private entities to serve the seriously mentally ill, even when disinclined to do so, and to force the mentally ill adults to accept that care. Parental deference in mental health thus points in the opposite direction as in the public education debate, in which school reformers are pushing for extreme decentralization.
Barnard refutes several myths that stymie clear thinking about mental-health policy, such as that Reagan is to blame for everything that’s gone wrong over the past half century, or that deinstitutionalization phased out the use of involuntary treatment. Involuntary treatment may not now be standard psychiatric practice as it was in the 1950s, but it’s used more commonly than the conventional wisdom assumes and certainly feels like a common experience for the most seriously mentally ill Californians. The threat of it looms constantly as a way to compel medication adherence. Barnard is sympathetic to pushes to expand the use of conservatorship. But he urges more attention to the quality of involuntary care over the sheer quantity of how many people are sent into it.
Conservatorship delivers the kind of critical analysis that, given its force and sweep, must almost of necessity turn anticlimactic when the author turns to prescription. Barnard concludes with a call for more “engaged authority” on the part of state government. That would entail a certain restoration of the status quo ante deinstitutionalization, when the state called all the shots on mental health in California. It would require California politicians, more comfortable with increasing budgets than investigating outcomes, to expose themselves to more blame. More engaged authority seems a bit wishful, in light of everything Barnard shows about the current order’s tolerance for dysfunction and tragedy.
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