Susan Shelley: Bureaucracies Crush Good Intentions

The Challenges of Bureaucratic Implementation

Bureaucracies often have a tendency to stifle well-intentioned initiatives. This is evident in the CARE Court program in Los Angeles County, which was designed to help families assist loved ones dealing with severe mental illness or substance use disorders. The initiative was introduced through Senate Bill 1338 in 2022, known as the Community Assistance, Recovery, and Empowerment (CARE) Court Program.

The program was implemented in Los Angeles County on December 1, 2023. However, just a few months later, on February 11 of this year, the Board of Supervisors approved a motion directing the Department of Mental Health to collaborate with the Behavioral Health Commission to collect “stakeholder feedback” and provide a report.

The reports that followed highlighted widespread frustration. Many stakeholders expressed concerns that the program does not allow for the court or providers to compel treatment. Additionally, there was frustration over the lack of a process to transition individuals requiring more intensive care out of the CARE Court into more suitable treatment programs, including conservatorship when appropriate, based on clear documentation of diagnosis.

Ongoing Delays and Calls for Action

What comes next? It’s likely another motion ordering another report. On July 8, the Board of Supervisors approved a motion directing the Department of Mental Health to provide a written report within 120 days, detailing progress on various collaborations, discussions, processes, mechanisms, plans, and protocols. The board also ordered another “stakeholder forum” in six months and a meeting in October for the Department of Mental Health and the Behavioral Health Commission to discuss improvements to the program.

Meanwhile, individuals suffering from conditions like schizophrenia spectrum and psychotic disorders, who lack medical decision-making capacity, may continue to face dire circumstances. They could end up dying in tents on the sidewalk, despite the existence of the CARE Act and the efforts of their families. Good intentions alone do not guarantee positive outcomes.

A New Approach: Federal Executive Order

Can government bureaucracy be prompted to act with urgency matching the scale of the problem? One approach involves cutting off funding that supports ineffective programs. President Donald Trump has taken such an approach by signing an executive order titled "Ending Crime and Disorder on America’s Streets." This order aims to address homelessness by redirecting federal funds and reversing judicial precedents that hinder civil commitment.

The executive order encourages states and cities to enforce prohibitions on open illicit drug use, urban camping, loitering, and urban squatting. The language used is strong, resonating with many Californians who have long complained about encampments, broken-down RVs, and public disturbances. These citizens often feel ignored when they voice their concerns to elected officials, only to be told they must support higher taxes to build expensive housing for the homeless.

Potential Impact and Resistance

Will these changes make a difference? The old joke about how many psychologists it takes to change a light bulb might apply here—only one, but the bulb needs to be willing to change. Threatening to cut federal funding from failed programs in Los Angeles and other areas could push for urgent reconsideration.

Trump's executive order calls for using civil commitment or other available means, to the maximum extent permitted by law, to address individuals who are a danger to themselves or others due to serious mental illness or substance use disorder, or those living on the streets without the ability to care for themselves.

This aligns with the original goal of the CARE Court program, though it hasn’t fully achieved its intended purpose yet. The president also seeks to fund evidence-based recovery treatments while avoiding harm reduction or safe consumption programs that distribute free needles. He wants to defund “housing first” programs that don't require treatment participation or accountability as a condition for receiving taxpayer-funded housing.

Legal and Political Implications

“Housing first” is embedded in California law, making it illegal to condition government-funded housing on treatment or job training. Only taxpayers are required to participate. California officials have resisted the Trump administration’s use of federal funding to influence state policies, but they still rely on the money.

It remains to be seen whether this strategy will work. The effectiveness of such measures will depend on how states respond to the pressure to change their approaches. The challenge lies in balancing compassion with practicality, ensuring that policies not only intend to help but also deliver meaningful results.