‘Do You Want Help?’: Inside Orange County’s Bet on Voluntary Mental Health Care

Giovanni Figueroa put 30,000 miles on his car last year.

Driving past cheap motels and abandoned parking lots in Santa Ana, the Orange County social worker scanned the sidewalks for tents and shopping carts, making frequent U-turns to examine men sleeping in doorways wrapped in Mexican blankets — trying to determine whether they were one of his missing clients with schizophrenia.

“I will pull over and I will say the individual’s name, just their first name,” Figueroa said. “And if I see any movement, then I’ll be like, ‘Hey, it’s Giovanni!’ And if I see further movement, then I know that’s my person.”

Figueroa is among the first to work for California’s brand new CARE Courts, the state’s grand experiment wading into one of medicine’s most vexing debates: how to help people whose psychotic illness makes them unable to recognize that they’re ill, whose fixed delusions make them believe doctors are part of an alien conspiracy, or whose voices tell them medication is poison.

While the 2022 law gives judges authority to force people into treatment, Orange County decided early on that its program would be utterly voluntary, leaning on the tenets of relentless outreach to coax, rather than coerce, people into care.

For Figueroa, this means no matter how many times in a year a client tells him to get lost, he visits again the following week. No matter how many times a client spits on him or threatens him, he comes back with an offer of a hot meal, a permanent place to sleep, a doctor’s appointment. And no matter how many times a stabilized client relapses and ends up back in the hospital or jail or on the street, Figueroa returns to start the process all over again.

It could take 20, 30 or 40 visits before a client accepts a bottle of water, let alone a prescription for antipsychotic medication, but Orange County officials say this is the only way to build trust with a population that is paranoid and distrustful by nature, or has had very real traumatic experiences of being forcibly treated or hospitalized in the past.

“Coercion does not work if we want to change things long term,” said Veronica Kelley, director of the Orange County Health Care Agency. “If someone said to you, ‘I need you to stop everything and come with me. I have a different way of life, and you’ll be so much better for it.’ You’re not going to hop in my van! But for some reason, we think that someone who has a mental illness should just do it. That misses the point of how humans connect.”

Figueroa stops to talk to the people lying on the street that most pedestrians step over and walk past. He said social work is his calling. His younger brother developed schizophrenia in his late teens, and when he was hearing voices or feeling paranoid, he sometimes became aggressive, broke furniture or threatened to harm his parents and siblings.

Over and over, Figueroa watched his family call the doctor and the police only to be told the law was very strict and, unless their loved one presented an imminent danger to himself or others, there was nothing they could do to intervene.

“We’re reaching out, we’re asking for help and no one is helping us,” he said. “Until now.”

CARE Court created a new legal pathway to intervene sooner, and the moment Figueroa heard about it, he wanted to be part of it. The goal of the Community Assistance Recovery and Empowerment legislation, championed by Gov. Gavin Newsom, was to get people with schizophrenia into outpatient treatment before their illness reaches a crisis — and before more restrictive interventions were warranted, like involuntary hospitalization or conservatorship, where people lose all decision-making rights to a family member or public guardian.

Family members, doctors or police can file a petition to bring a person into the program, and when Figueroa gets assigned to the case, he gives the family his cell phone number and promises he will do whatever he can, for however long it takes, to persuade their loved one to accept help.

“We tell them, ‘Look, you’ve been carrying this bag of bricks for so long, sometimes decades, give it to us now,’” he said.

When Figueroa finally found one client he was looking for — a young, homeless man with chronic schizophrenia who fell into street drugs to quell his symptoms — he was hostile. He told Figueroa, “Get away from me. Leave me alone.”

Figueroa respected his wishes and left. Then he came back the next week and then the next, chatting for 10 to 15 minutes each time. Then he heard from the client’s mother that he had been hospitalized in San Bernardino.

Figueroa drove an hour and a half to get there, and because they had met and talked a few times already, the client agreed to see him.

“The first thing he says is ‘Giovanni!’ and he starts throwing his hands in the air, he’s excited to see me,” he said. “One minute later, he’s spitting on the ground, telling me to get the F out of there.”

Figueroa let him vent, and when he came back the next week, his client was crying. The following week, as the medications started to take hold, he was more stable. The week after that, Figueroa broached the subject of ongoing treatment and the client agreed. When he was discharged, Figueroa arranged to meet him at a clinic in Orange County, where he saw a doctor, got medication and was placed in housing.

“Relentless pursuit and engagement,” Figueroa said. “When they see you, one time, two times, three times, then they see you in San Bernardino County one week, two weeks, three weeks, four weeks, and then they see you at the provider upon discharge, that’s when they realize, ‘Oh wow, they really are here to help me. They actually do care. And I’m not invisible.’”

Orange County Superior Court Judge Ebrahim Baytieh hears CARE Court cases on Tuesday mornings. The cases that actually get to him, that is. Of the eligible petitions filed in Orange County, about 10% — or 12 people — are actively engaged in treatment. The county is still looking for — or relentlessly reaching out to — the other 60, with Baytieh’s full support.

“It takes time. You have to be patient,” he said.

Even though the law gives Baytieh the power to fine the county $1,000 for each day it doesn’t produce a client, he doesn’t do it. The law also gives him the power to order people into treatment, but he doesn’t do that either.

“We’ve had cases where somebody says, ‘I don’t wanna take medication.’ They need it, we all agree that they need it,” he said, referring to lawyers and clinicians from the county and the public defender’s office. “The court can order it, but the court cannot enforce that order. If they refuse to do it, there’s nothing the court can do, so to me it’s counterproductive to do that.”

CARE Court is a civil process, and people cannot be held in contempt or sent to jail for refusing care. However, the law does create a pathway to conservatorship for people who don’t comply with a judge’s treatment orders. State Sen. Tom Umberg, who authored the law, intended the threat of conservatorship to be a “negative incentive,” but officials in his own Orange County district, and several other counties, have refused to use this lever.

“Conservatorship is a dramatic move. Basically, you’ve lost your free will,” Umberg said. “But for many folks who are gravely mentally ill and a danger to themselves or others, it’s better than just letting them live under a bridge.”

Orange County’s purely voluntary approach exasperates some families. They want more results, more quickly. They beg workers at CARE Court clinics to use a heavier hand or to help conserve their loved one. Some are bypassing CARE Court altogether and pursuing conservatorships on their own.

“They’re frustrated, they’re tired. They don’t know what else to try,” said Lei Portugal Calloway, a CARE Court peer counselor and supervisor. “Maybe they’re getting along in age, and they’re asking, ‘What will my son do? Who’s going to take care of him when I’m gone?’”

Some people are simply too sick, too overwhelmed by voices in their heads or too divorced from reality to ever make a rational decision to accept or reject care. More than 50% of people with schizophrenia have no awareness that they’re ill. This is not denial or obstinacy, but a symptom of the disease. No amount of persuasion will ever convince them.

“If you build a system that is entirely dependent on the idea that eventually people will seek care, that very ill segment of the population is just trapped outside of it,” said Lisa Dailey, executive director of the nonprofit Treatment Advocacy Center.

Relentless outreach that drags on for more than a year is more like never-ending outreach, she said. Involuntary tools or “light coercion,” like inducements or leaning on the threat of conservatorship, may be necessary to get some people well, Dailey argued. To simply dismiss cases where people won’t or can’t agree to treatment is unethical.

“You’re really just prolonging a miserable state for people,” she said.

Research on mandatory treatment programs in other states shows mixed results, but with solid funding and court oversight, approaches similar to Orange County’s that meet people where they are and surround them with services and support tend to be the most effective at reducing hospitalization and incarceration.

While there is little research examining whether relentless outreach alone is effective at getting people to accept comprehensive treatment, other studies show that people who have a consistent and trusted ally — such as a clinician, a peer or a social worker like Figueroa — are more likely to participate in their own care.

One of the biggest victories of the CARE Court legislation, even to some skeptics of the law, was the new reimbursement structure it created to pay counties to do relentless outreach. The state typically doesn’t reimburse for street searches, casual visits or taking calls from family members, but CARE does. It incentivizes sticking with hard-to-reach clients rather than moving on to the next person.

“Relentless outreach, to me, means you don’t abandon the person,” said Keris Myrick, a mental health advocate who has schizophrenia. “The beauty of the CARE Act was lifting this thing up and putting a magnifying glass on it.”

But even ardent supporters of relentless outreach, like Myrick, are still critical of using it in a legal context, saying any involvement of judges in black robes is inherently coercive.

“The idea of court and voluntary is an oxymoron to me,” Myrick said. “It’s everything imposed on the person, even if it’s voluntary. As I get better, I might be grateful, but I also might look back and go, ‘Wait, what the f—? That wasn’t voluntary. Why was I in court? Why was I talking to a judge?’”

Even in counties like Orange, where judges are aligned with the long and slow approach to winning consent, she argued the court’s involvement is still manipulative, and funneling money into it is misdirected.

“I don’t get why we’re paying a judge to be a social worker,” Myrick said. “The social worker should be the social worker.”

Figueroa said he is sympathetic to people on both sides of the debate. He relates to the frustration of families after witnessing his brother get tossed around the health care system like a hot potato. But he said violating people’s civil liberties is not the answer. He believes the court can split the difference.

“Accountability,” he said. “This is more about accountability for the county and the provider.”

The specter of a judge staring down from the bench helps him do his job better, he said. Not by instilling fear in his client, but in his client’s doctors and therapists instead. After six months of relentless outreach, Figueroa finally convinced one client to return to therapy — but the clinic refused to take him back.

“Once they know that the CARE Act is involved, once they know that the judge is overseeing them and there’s the possibility of sanctions or fines, they play ball,” he said.