Every Saturday morning, Phil Cenedella sets up at the corner of Newport Avenue and Abbott Street, just steps from the sand in Ocean Beach, with a small group of volunteers to serve food and connect people living on the streets to services.
Cenedella, who chairs the OB Task Force on Homelessness, tries to bring in providers so people struggling with mental illness or addiction can get help right there, instead of having to navigate the system on their own. But there are a handful of people who seem unreachable.
He and other residents know them by name — or at least the names they use: Butterfly, Sharae, Kristen. Cenedella is who gets the phone calls when they act up.
Recently, Kristen chased a terrified family with young children up a nearby stairway. Butterfly, Cenedella says, is often yelling at people on the street, defecating on the sidewalk.
It’s Sharae he’s most concerned about. She’s been the repeated subject of police calls and recently threatened to kill an elderly woman who called Cenedella, sobbing.
In October, Cenedella reached out to Dr. Aaron Meyer, a UC San Diego psychiatrist and the city of San Diego’s Behavioral Health Officer. Meyer, speaking independently and not for the university, suggested he call the county and ask about 5200, a provision in California’s Welfare and Institutions Code that allows “any individual” to request a comprehensive mental health evaluation of a person who is believed to be a danger to themselves or others, or is gravely disabled.
Cenedella was told that wasn’t an option.
“I call the number and 37 minutes later, I was told five times, no, no, no. I asked nicely, and it’s, like, no,” he said.
He said he’d asked the county’s Mobile Crisis Response Team to come to Ocean Beach “to get a firsthand read on the untenable situation we have here.”
He was told that this was not an option, either, and the teams “are only sent out after a screening process.”
“We’re not vigilantes,” Cenedella said. “But the status quo isn’t acceptable.”
For Cenedella, the lack of options has reached a breaking point — one state lawmakers have been trying to address without violating California’s strong protections for people with mental illness, which make involuntary intervention difficult.
A new bill, Senate Bill 1016, introduced last week by state Sen. Catherine Blakespear, proposes modifying existing law, including 5200, to make it easier for members of the public to request a court-ordered mental health evaluation if they believe someone is a threat to themselves or others or is gravely disabled.
It’s an attempt, Blakespear, an Encinitas Democrat, said in an interview this week, to address the growing public frustration around cases where people with obvious mental illness seem to go untreated, often while unhoused.
Traveling back and forth weekly between San Diego and Sacramento for the past four years, Blakespear said she’s constantly reminded of the problem.
“I see people that are severely, severely mentally ill; people talking to themselves, people completely inappropriately dressed, people with extremely bad hygiene,” she said. “You know that they are suffering and that they are literally dying in front of us, and you ask yourself, ‘What are we doing about this person?’”
Recently, this frustration coalesced around Welfare and Institutions code 5200.
A report by Sacramento advocacy group Quarter Turn Strategies, published in January, found that counties, including San Diego, do not accept evaluation requests under this law, instead directing inquiries to first responders, whether law enforcement officers or mental health response teams.
Despite being law since 1967, 5200 is “largely unavailable in practice,” the report says, and most counties lack “written policies, procedures, or publicly accessible processes” for handling petitions.
This gap has real consequences, the authors argue. The mental health system is largely crisis-driven, with interventions happening in response to an emergency need.
There is disagreement around how well this emergency system works.
In a statement this week, a spokesperson for the county’s behavioral health department said that existing resources are adequate to get those with serious mental health needs into treatment.
“In modern practice, the county’s mobile crisis clinicians already conduct these on-scene assessments,” the statement said. “These teams receive extensive training to determine whether someone should be brought to an LPS-designated facility for further evaluation and treatment.”
LPS is short for the Lanterman Petris Short Act, legislation passed in 1967 that governs involuntary treatment statewide.
But a growing number of people, like Cenedella, say those who seem to need the most help often don’t get the comprehensive mental health evaluations that could lead to appropriate care.
Instead of requiring county behavioral health departments to get involved directly, the bill proposes that such requests be added to the existing CARE Court process.
CARE Court allows a wide range of people in the community, from family members to first responders, to file a petition if they believe someone diagnosed with schizophrenia or some types of bipolar disorder need more comprehensive treatment.
The courts consider the CARE Act process voluntary, and some people refuse to participate. Generally, this would disqualify them, but Blankspear’s bill would allow a petitioner to ask the court for an evaluation if they believe the person’s unwillingness stems from “the severity of their mental disorder or lack of insight into their mental disorder.”
The courts would require anyone making such a request to provide “any supporting records, reports, or other evidence available to the petitioner, setting forth facts sufficient to establish probable cause.”
When the law that governs CARE Court was being written, many advocacy groups insisted that coercion is ineffective and that modern mental health care favors treating people in the least restrictive settings possible.
Blakespear said she believes that it’s possible to protect a person’s rights while also taking action when grave disability erodes someone’s capacity for rational decision-making.
“We have to acknowledge that there is a very small subset who will need to be involuntarily committed in the same way that people with advanced Alzheimer’s (disease) are put behind a door that’s locked for their own safety,” she said. “Involuntary commitment conservatorships, the removal of people’s rights to make every decision for themselves, is in the best interest of them and society, and I don’t personally shy away from that.”
“We don’t have to go back to ‘One Flew Over the Cuckoo’s Nest’,” she added, referencing the 1975 film that depicted the horrors of forced mental health treatment. “We have had enormous advancements in both medical care and understanding of civil rights and behavioral health needs, and we are able to be much more protective of people’s human rights while also treating their mental illness.”
The county said it is reviewing the bill, but predicted it would likely have a narrow effect. Most residents with severe mental illness, an emailed statement says, already have access to evaluation and treatment.
“In rare, exceptional situations, a court-ordered evaluation could be useful, but generally only for a person who is both unknown to the local mental health system and physically isolated,” the county’s statement said.
The county said it is “aware of recent public discussions around a historical process referred to as a 5200 petition,” but that this process “has largely been rendered obsolete by the expansion of modern mental health services and access points.”
The statement, which does not address specific individuals due to privacy concerns, pushes back against the notion that allowing 5200 petitions will help get more people with severe mental illness into treatment.
“Contrary to recent claims, these code sections do not create a new treatment pathway or authorize long-term detention,” the county said. “When read in full, they allow a court — under narrow circumstances — to order only an evaluation that may result in a standard 72-hour evaluation and treatment hold.”
Meyer, who co-authored the Quarter Turn Strategies report, and other advocates say the normal avenues of detention and treatment are not being properly applied to those with severe mental illness.
In a follow-up email Friday, the county said it is committed to “ensuring that individuals who meet criteria are appropriately connected to evaluation and care.” San Diego County’s financial commitment to mental health care has grown dramatically. Behavioral health spending hit $1.2 billion this year, a nearly 300% increase over the $440 million spent in the 2015-2016 budget year.
San Diego Mayor Todd Gloria said Blakespear’s bill is part of a broader effort to fix gaps in county behavioral health systems.
But even as lawmakers propose new tools, Gloria said, the larger issue is whether existing tools are being used effectively.
At a gathering of California’s big-city mayors this week, Gloria argued that counties are failing to pull their weight in responding to homelessness, mental illness and addiction.
“There are dollars that are flowing to our local government counterparts at counties, and they have to get in the game,” he said, adding that cities are left with “a sanitation department” and “a police department.”
“Neither of those are appropriate tools for responding to somebody that’s dealing with addiction and mental illness,” he said.
“I can point to every shelter bed that we’ve created, but that’s not a mental health institution,” he said in an interview with The San Diego Union-Tribune. “People fail out and return to the street and cycle through shelter, cycle through jail. At some point, they need to be put in a clinical setting that can help them address their underlying concerns.”
While he pointed to reforms such as the CARE Act as steps forward, he said their impact has been somewhat limited in practice. In many cases, he said, “you end up with programs that started out as compulsory and become voluntary.”
The result, he said, is a system that continues to miss people who most need, but refuse, treatment.
“Often, I’m in conversations where people think that existing processes are fine when they clearly aren’t,” he said. “Anyone walking around a major city, really, anywhere in the country, not just in California, knows that we have untreated mental illness.”