This story is part of our May 2026 issue. To read the print version, click here.
A man is yelling for help. He looks to be about 65, is
unkempt and in a wheelchair that he can only roll backward with
unsteady feet. I’ve seen him before on my street. Sometimes he
says hello; other times he’s engaged with unseen entities. Today,
he says that God has abandoned him, and he wants to die. He howls
in pain and asks someone to call 911. I look around and realize
that I am that someone, and I oblige, even as he ignores my pleas
to stay put. There’s a fecal odor coming from the trash bag he
carries, and flies circle relentlessly. I wonder, not for the
first time, how a human being could reach such a state in an
abundant society.
A firetruck arrives, and I watch from a distance as EMTs approach
the man. He shakes his head, refusing their efforts. The EMTs get
back into their engine, and the man disappears into the streets.
About a week later, I see him again — this time, cleaned up in a
hospital gown. He’s clear-eyed as he explains that his caseworker
got him to the hospital, where he was given a proper meal and
scheduled for surgery. “You have a caseworker?” I ask, but his
lucidity is fleeting.
I see him a few more times, in varying states of filth and
clarity, then never again.
For those who live in Sacramento or most any urban center in
America, this story may ring familiar. For those who don’t, the
apparent ease with which city dwellers walk past someone
exhibiting psychosis may seem like apathy. But many will tell you
it’s a learned helplessness instilled by decades of
live-and-let-live policies concerning mental health and substance
use.
In recent years, however, leaders have changed their tune,
responding to a growing sentiment that intervention may sometimes
supersede autonomy when it comes to humane outcomes for people
with mental illness and their communities.
Recent legislation signals that the priority is getting people
into treatment, but whether that translates to large-scale impact
is less clear.
How we got here
In the mid-20th century, public opinion was turning against
psychiatric hospitalization as the standard of care. Concerns
about horrendous conditions inside state-run hospitals had
entered the national zeitgeist, fueled by reports of patients
with very few legal rights living in abject filth and suffering
inhumane treatments. Outrage coincided with the advent of
antipsychotic drugs, leading to deinstitutionalization in favor
of community treatment centers.
At least, that was the vision. Pres. John F. Kennedy promised a
robust system of community treatment centers, but following his
death in 1963, only about half were built, and funding was
insufficient.
Yet deinstitutionalization continued. In 1967, Gov. Ronald Reagan
signed the Lanterman-Petris-Short Act, which placed strict limits
on involuntary commitment and effectively emptied the state’s
mental hospitals. Among its provisions is the 5150 hold, which
permits involuntary placement in a psychiatric facility for up to
72 hours while the detainee is assessed for further treatment. To
be detained, an individual must be deemed a danger to themself or
others or “gravely disabled,” a designation that carries a heavy
burden of proof.
Then-California Gov. Ronald Reagan with his family in 1967, the
year he signed the Lanterman-Petris-Short Act, which placed
strict limits on involuntary commitment and effectively emptied
the state’s mental hospitals. (Public domain photo)
The result is the world we inhabit now, one where streets and
prisons serve as de facto psych wards. This reality became even
more visible in 2011, when Gov. Jerry Brown signed legislation to
reduce the state’s crowded prison population.
“Creatures of the law”
California’s current governor has one eye on the 2028
presidential election, and a triad of the state’s most visible
crises — mental health, drug use and homelessness — is a pressure
point.
As the nation’s most populous state, California has more unhoused
people than any other: A 2024 point-in-time count found 187,084
individuals. Within that population, 27 percent said they’d been
hospitalized due to a mental health condition, and 65 percent
reported a history of using amphetamines, cocaine or
non-prescribed opioids regularly, according to a 2023 survey
conducted by UC San Francisco.
An encampment in Oakland. (Shutterstock photo)
In the first year of his second term, Gov. Gavin Newsom signed
Senate Bill 43, which broadens the criteria for “gravely
disabled,” adding severe substance use disorder as a qualifying
condition alongside mental illness and chronic alcoholism.
While it’s a meaningful change, it hasn’t significantly altered
the landscape in Sacramento.
Initially, there was trepidation that SB 43 would overwhelm
emergency rooms, but that hasn’t been the case, according to
Sacramento County Behavioral Health Director Ryan Quist. That’s
because law enforcement officers often can’t tell the difference
between a mental health crisis and substance-induced psychosis,
taking drug cases to the ER before jail. “We were already seeing
the full volume of folks at the emergency departments prior to
the law changing,” he says.
Nor has there been an influx of individuals deemed gravely
disabled, because substance use disorders and mental illness are
often co-occurring.
Related: The
Capital Region Is in the Vanguard of Autism Research and
Treatment
But there’s another new law that’s wielding more weight. In 2022,
Newsom signed the CARE Act — a significant step toward the
community-based treatment system that deinstitutionalization
promised but never delivered.
An acronym for Community Assistance, Recovery and Empowerment,
the CARE Act establishes a civil court process, known as CARE
Court, through which people diagnosed with a qualifying psychotic
disorder can access wraparound treatment and support services.
What makes CARE Court distinctive is that referrals can come from
virtually anyone — a family member, first responder or roommate —
not just a doctor.
The law has been criticized by some, including Disability Rights
California, for potential discrimination and civil rights
concerns. Judges can impose a court-ordered “CARE plan” if an
individual refuses treatment, but that outcome is rare, according
to a 2025 report from CalMatters, and some counties have forgone
CARE plans altogether. In Sacramento County, the program is
“strictly voluntary.”
CARE Court treads more softly than originally proposed. The
initial legislative draft included substance use as a qualifying
disorder. Additional amendments further narrowed eligibility,
increased the burden on petitioners, prioritized voluntary
treatment over court-ordered plans and gave counties the freedom
not to provide certain services.
Related: Perspective:
The Ever-Growing Sacramento Homeless Crisis
Statewide, enrollment numbers are lower than projected. All
counties were required to implement CARE Court starting in
December 2024, and rollout has been slow. As of July 2025, just
2,421 petitions had been filed statewide, and only 528 had
resulted in treatment agreements or plans, according to a
CalMatters survey.
Whether the law oversteps or doesn’t do enough is a matter of
perspective, says Sacramento County Superior Court Judge Lawrence
Brown, who presided over CARE Court in its first year. “We’re
just creatures of the law. We will use the tools that have been
provided. If the tools are expanded, we’ll use those tools as
well.”
Sacramento County Superior Court Judge Jennifer K. Rockwell
presides over the county’s first CARE Court graduation ceremony
March 17, with graduate Lorenzo Leon and supporters in
attendance. (Photo courtesy of Sacramento County)
According to Quist, 144 CARE Court petitions had been filed in
Sacramento County as of March 1. No data was provided on how many
have resulted in treatment. The biggest challenges have been the
paperwork for petitioners and securing more permanent housing for
those who complete the program. “The central issue is that we
don’t have affordable housing for those that need it,” Quist
says.
Even so, Sacramento County outperforms those of a similar size on
homelessness and behavioral health metrics. The unsheltered
population is down by over 40 percent since 2023, according to a
state dashboard, while more than 2,500 people are in full-service
partnerships that provide 24/7 support for those with severe
mental illness. The county has also been adding beds to its
psychiatric care facilities, according to Quist.
“No way to live”
Alicia Leon used to go long stretches without seeing her adult
son. One of the challenges of having a loved one with a psychotic
disorder is that they may be unaware of their condition and
distrustful of those who try to help. Alicia’s son, Lorenzo, was
living on the streets when her petition for CARE Court was
granted last year.
Lorenzo Leon enjoys a slice of cake at his graduation ceremony
and holds graduation presents with his mother, Alicia. (Photo
courtesy of Sacramento County)
“There was some level of skepticism by
the mother as to if this was going to work,” says Judge Brown.
“And I suspect it was born of, probably, prior frustrations and
trying to get assistance for her son.”
According to Brown, CARE Court has changed the system by allowing
anyone to petition a judge directly. “This is, to me,
unprecedented to have a family member come directly and say, ‘We
need help,’” he says.
For Lorenzo, help was given. During his year in CARE Court, he
received psychiatric treatment and social services through a
dedicated team, checking in with the court each month. CARE Court
recipients are also provided with housing options, if needed. But
first, they must be located and accept care.
Edward Pochay, a behavioral health peer specialist for Sacramento
County, spends a lot of time playing detective — tracking down
CARE Court recipients and introducing them to the program. He
reads up on their history and tries to understand their
perspective before making contact. In Lorenzo’s case, it was a
matter of identifying the places he frequented and knowing his
preferred nickname. “I would see him standing there and greet him
by that name, which brought a secret smile to his face. So I knew
we were on the right track,” Pochay says.
Lorenzo ultimately agreed to participate. When he left home, his
care team would find him and persuade him to come back. Pochay
says the lived experience of peer specialists like him makes them
uniquely able to establish rapport with people struggling with
mental illness, homelessness or substance use.
“A seed was planted. That person now knows there are people out
there willing to go to great lengths to offer services without
any negative encounter, that she can say no without
consequences.”
— Edward Pochay, behavioral health peer specialist,
Sacramento County
But they aren’t always successful. He describes a case where a
woman living in an encampment littered with used syringes refused
all help. “I can be disappointed. I can be let down. But
frustration doesn’t factor in, because I cannot imagine what they
are experiencing,” Pochay explains. “A seed was planted. That
person now knows there are people out there willing to go to
great lengths to offer services without any negative encounter,
that she can say no without consequences.”
Pochay believes voluntary participation is integral to recovery,
even if it takes many attempts before someone accepts help. He
recalls a recipient referred by law enforcement who was “primed
against the system” but ultimately won over through persistent
contact. At a recent CARE Court appearance, he brought Judge
Brown a gift and asked him for a hug. “You could feel the silence
in the room for a moment. And then Judge Brown got up from his
bench, came around to the podium … and gave him a hug,” Pochay
says. “That’s what it’s about.”
On March 17, Lorenzo Leon became Sacramento County’s first-ever
CARE Court graduate. His mother and care team were present at the
courthouse to celebrate and share his cake. “Being on the street
is no way to live,” Lorenzo said in a county press release. “So,
you know, I did what I have to do, straightened up so now I have
a place to live.”
For Pochay, true progress is measured in these moments. Another
milestone, he says, was when Lorenzo’s mother started swimming in
the mornings. “That just fills my heart. She was consistently
seeing improvement in him to the point where she felt it was her
time to do something for herself.”
If you or someone you know is experiencing a mental health
crisis,
call the 988 Suicide & Crisis Lifeline.
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