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Imagine standing on a street corner and trying to decide whether someone has a severe, moderate or mild substance use disorder, whether their medical condition is serious and likely to deteriorate, or whether their personal safety is so compromised that they are likely to die if they are not detained.
Such weighty decisions are usually the domain of trained medical professionals, but starting Jan. 1, rank-and-file law enforcement officers and other designated first responders must begin making these calls throughout San Diego County due to a new law that expands the definition of grave disability.
Standing before a group of mental health care professionals at the Psychiatric Hospital of San Diego County on a recent afternoon, attorney Mike Phillips explained the highly nuanced criteria of Senate Bill 43, the law signed by Gov. Gavin Newsom that many have said attempts to increase the number of unhoused residents placed under government conservatorship.
Phillips, co-chair of the region’s SB 43 readiness committee, acknowledged the pressure the law puts on front-line workers asked to make snap judgments on involuntary detention, which often means a handcuffed ride in the back of a patrol car to the nearest assessment center where trained clinicians can make a more complete assessment of whether an individual meets the criteria to be held and treated involuntarily.
There will, he warned, be some trial and error as those involved in the process try to apply what the Legislature enacted.
“We’re all gonna figure this out together, I think, is the answer,” Phillips said.
Today, it takes quite antisocial behavior, acting out that makes another person worry about harm to oneself or others, to be involuntarily detained under section 5150 of the state’s Welfare and Institutions Code. But, ever since the California Legislature passed a new set of rules for handling community mental health care in 1967, there has always been an exception for those considered to be “gravely disabled.”
The original text of the law defines grave disability as “a condition in which a person has such pronounced disturbance in judgment, thinking and conduct as a result of mental disorder or impairment by chronic alcoholism that he is unable to provide for his basic personal needs for food, clothing, or shelter.”
Additional language crept in over the intervening five decades, addressing those found to be mentally incompetent to stand trial for alleged criminal offenses and clarifying that the term does not apply to those with “intellectual disabilities.”
But a big change arrived in the fall of 2023 when the governor signed SB 43, more fundamentally expanding the definition of gravely disabled to include not just those with mental health disorders or impairment due to chronic alcoholism, but also “a severe substance use disorder, or a co-occurring mental health disorder and a severe substance use disorder.” And the list of affected basic personal needs also lengthened slightly, adding personal safety or necessary medical care to food, clothing or shelter.
For the first time in the state’s history, it will be possible for a Californian to be involuntarily detained without committing a crime if a first responder has probable cause to believe that a substance use disorder is involved or if a person appears to be living in a manner that looks unsafe or if they have not availed themselves of obviously needed medical care.
Phillips said that he and a team of about 20 people have been working for months to meet with a wide range of people in the community — from law enforcement and medical providers to community members — to explain the nuance of the new grave disability definition.
“I’d say we’ve done well over 100 and probably close to 200 training sessions,” Phillips said. “One of my favorites so far was when some ladies asked us to come speak at a traditionally Black barbershop in Imperial. They were concerned about their brothers, their sons, their husbands ending up getting incarcerated or worse instead of being able to get treatment.”
For his part, Phillips says he is personally opposed to the new law because of its impacts on basic civil liberties.
“I do feel like, on some level, we are blaming the individuals for not availing themselves of services that we never really brought into fruition, and now we are deciding that we’ve got no choice but to increase the involuntary aspect and, once again, direct them toward resources that once again may not exist,” Phillips said. “And, it’s a strange time to be placing additional impact on providers who are already so heavily impacted without providing them additional resources to do so.”
It’s the resources aspect that has so far gotten the most attention.
Hospitals across the state cried foul at the idea of implementing SB 43 in 2024, begging county boards to delay the arrival as long as possible. Though the law allows local governments to punt the law to Jan. 1, 2026, the San Diego County Board of Supervisors opted to choose a middle ground, setting the start date for New Year’s Day 2025.
A big concern one year ago was that there would be a massive surge of detainees, especially those suffering from severe addictions, brought to already packed community emergency departments that are ill-equipped to treat substance use disorders. Some worried that a kind of maladaptive feedback loop would develop with intoxicated individuals sobering up at ERs only to be discharged and then picked up again once they indulged in another round of self-medication.
Those worries still exist, though experts say they believe that the onslaught may not be as fierce as many anticipated.
That is the conclusion of San Diego County researchers after studying how the law affected detentions in San Francisco and San Luis Obispo counties, where it took effect in 2024. They estimate that SB 43 will cause about 1,500 additional people per year to be held under the expanded definition of grave disability, though the daily number of additional 5150 holds may ramp up gradually as first responders gain their footing.
The county health department estimates that about 15,000 5150 holds occurred across the region during the 2022-23 fiscal year, the most recent for which data is available. The predicted 1,500 additional holds, then, would represent a 10 percent annual increase or an addition of four more detentions per day on average in a region that now averages about 40 per day.
Though formal reports of the first-year implementation of SB 43 in northern counties have not yet been produced, Dr. Nicole Esposito, the county’s chief population health officer, said that local professionals have worked in private conversations to understand how detention patterns have changed. She said they found that many of those detained under the new law were diagnosed with mental illnesses and substance use disorders, allowing them to be treated in locked psychiatric units.
“We’ve talked to San Francisco in particular, and they are definitely saying that the vast majority of the increase is actually in folks who have co-occurring diagnoses, and that is good news because we do have a new PHF opening,” Esposito said.
By PHF, she means psychiatric health facility. The county expects to open a new 16-bed, 24-hour center on the grounds of Tri-City Medical Center in early 2025. The worry was that SB 43 would cause law enforcement officers and other mental health professionals tasked with handling mental health calls in the community to pick up large numbers of residents who suffer from drug and alcohol use disorders, overwhelming the capacity of centers available to handle detox and treatment.
Discussions are underway, the physician added, to work with other organizations, such as Alvarado Parkway Institute in San Diego, to handle those with co-occurring mental illness and substance use disorder.
But implementation of SB 43 is likely to produce additional cases of severe substance use without mental illness and also cases of severe illness that must be treated in hospitals, Esposito acknowledged. As many have noted, the law does not come with its own additional funding source to compensate medical providers for the work. Toward that end, the county supervisors have approved spending $15 million in 2025 to increase compensation for hospitals treating those who need to be admitted or worked up in emergency departments.
And there is a plan to spare hospitals where possible. Esposito said those cases where a severe medical problem is not present will preferably be taken to the county’s crisis stabilization units, allowing professionals to make a diagnosis and refer those who need substance use treatment to the appropriate centers.
The county, Esposito said, has added 150 slots in opioid treatment programs over the past two years, which should help absorb the new law’s potential increases in substance use referrals. But plans to add an additional substance use recovery program with 89 new beds for residential treatment is not expected to be ready until July 26. Additional beds for recuperative care are also in the works, with 33 expected to be “operational by February 2025,” according to a county SB 43 report.
The question is, will it be enough? That would depend on the current occupancy levels of existing mental health and substance use treatment centers. But such information, when it can be found, is at least one year old. County officials said in late December that they would provide updated occupancy rate information on the various types of facilities that will be impacted by SB 43, but that information was not available as of Dec. 24.
As to San Francisco’s experience being predictive of what San Diego County will experience in 2025? Some are skeptical.
Samuel Jain, a senior policy attorney with Disability Rights California, a nonprofit advocacy group, said that neither San Francisco nor San Luis Obispo, the only two counties in the state that launched SB 43 in 2024, have provided much information on how the process has gone so far. While San Francisco may have seen a relatively low volume of additional 5150 detentions under the expanded definition of grave disability, that may be because needed services to treat such detentions is not widely available.
“With respect to San Francisco, it’s unclear if they’re actually fully implementing SB 43, just because a lot of legal structure was not in place around the biggest expansions that the law makes around being able to hold people for standalone substance use disorder in locked facilities,” Jain said. “So, I think it’s really like (to be determined).
“What’s it going to look like? It could vary quite a bit, county to county.”
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