Why San Francisco Can’t Get More People Into Treatment
Published March 31, 2025
San Francisco faces many challenges, but perhaps none is as visible or as heartbreaking as our drug crisis. We've struggled for years to effectively address addiction and its consequences on our streets – and yet despite good intentions and significant resources, we've fallen short. Here's why we have not been able to get the most vulnerable on our streets into treatment.
The Treatment Mandate Gap
One of the fundamental issues we face is that San Francisco has no reliable mechanism to mandate drug treatment for those who need it most. This isn't just a policy oversight, it reflects a deeper ideological divide that plays out in our courtrooms daily.
Judges, public defenders, and prosecutors frequently find themselves at an impasse: should someone struggling with severe addiction be forced into treatment, or does personal autonomy continue even when someone lacks capacity to make decisions? This philosophical deadlock means that many individuals cycle through our emergency systems without receiving the sustained care they desperately need.
Public defenders, by their own admission, seek the least penalty possible for their clients. One District Attorney insider told us that since Jeff Adachi was elected in 2003, the Public Defender's office has operated under the motto "getting people off since 1996." They often actively avoid recommending diversion programs like drug treatment because if clients violate treatment requirements they'll end up back before a judge, making the defender look ineffective.
The Push to Decriminalize Drug Use
It used to be that doing life-threatening drugs like heroin, meth, and fentanyl on the streets would get you arrested in San Francisco. Illicit drug use was a felony, meaning you would be arrested for it and held accountable in court. Judges would then determine if a person was to go to jail or enter a diversion program where they would receive mandatory drug treatment. While many agree that jail is not the appropriate solution for someone addicted to drugs, it was often where people would get sober because of the zero-tolerance policy for substance abuse.
The push to decriminalize drug use first happened under District Attorney George Gascon (2011-2019). Gascon ordered that possession of meth be charged as a misdemeanor, instead of a felony, thereby changing the penalty for possession of meth from jail to a simple ticket. The suspect would then be immediately released. As someone familiar with the history said to us, "We used to be able to keep people in custody, which would often save their lives because they'd get sober in jail."
Felony charges are necessary to divert drug offenders into treatment. This isn’t about mass incarceration or even punishing addicts harshly – felony charges are what enable treatment mandates. San Franciscans often demand “criminal justice reform,” which is commonly taken to mean treatment over incarceration. But once drug possession was charged as a misdemeanor instead of a felony, there was no longer a pathway to treatment.
Gascon was able to prosecute meth as a misdemeanor because it was considered a “wobbler” offense, meaning you could either prosecute it as a misdemeanor or as a felony. Gascon’s emphasis on prosecuting drugs as misdemeanors eventually became the basis for Prop 47, a statewide law that was passed in November 2014. Under Prop 47, drug possession became a misdemeanor throughout California, instead of a felony (read more in our Prop 47 blog post).
The Path to Requiring Treatment: Conservatorship
There is one path to mandated treatment: conservatorship. However the major caveat is that conservatorship in San Francisco is only used for people with severe mental illness. While we were not able to find evidence that conservatorship is used to help people addicted to illicit drugs get into treatment – the process for mental health conservatorship paints a picture of the legal hurdles you need to clear to mandate treatment.
When someone is placed under a conservatorship, it is mandatory they undergo treatment for their mental illness. This path is process heavy, in no small part because it has been taken advantage of historically. There is a long, sad history of the unethical treatment of mentally ill people which led to the deinstitutionalization movement, but closing mental institutions without alternatives has led to predictable side-effects and a broken approach to conservatorship.
The conservatorship process is notoriously difficult to navigate in San Francisco. Even when someone is clearly unable to care for themselves, the legal hurdles to establish conservatorship are so high that only the most extreme cases qualify. As a clear example, despite San Francisco being home to about 8,000 unsheltered homeless and with roughly 800 overdose deaths per year, as of April 2024 the City had only been able to request conservatorship for 22 people, and half of those were dismissed. Meaning only 11 people qualified for conservatorship. By the time someone clears all the hurdles and they’re finally getting treatment, permanent damage has often already occurred.
San Francisco has two types of mental health conservatorships:
- The Lanterman-Petris-Short (LPS) Act conservatorship for the gravely disabled due to a serious mental illness and/or chronic alcoholism,
- The Murphy conservatorship for individuals who are defendants in criminal cases, have a mental illness, and are unable to understand the nature of the proceedings;
To mandate one of these mental health conservatorships, the following actions have to be taken.
The Mental Health Conservatorship Process
Citation: https://sf.courts.ca.gov/divisions/probate-court/mental-health-conservatorship
| Step | Professional Treatment Staff | Office of Public Conservator | Probate Court | Proposed Conservatee |
|---|---|---|---|---|
| 1 | Investigation request made to the Office of the Public Conservator | |||
| 2 | Conducts an investigation | |||
| 3 | Formal request made to the Probate Court based on investigation | |||
| 4 | Probate Court establishes a temporary mental health conservatorship lasting 30 days | |||
| 5 | Proposed conservatee receives written notice of temporary conservatorship 5 days before it starts | |||
| 6 | Probate Court appoints an attorney to represent the proposed conservatee | |||
| 7 | Prepares a comprehensive written report of the proposed conservatee’s medical, psychological, financial, family, vocational, and social condition, based on information from the person’s family, close friends, social worker, and psychiatrist/therapist. | |||
| 8 | Investigates all possible alternatives to conservatorship – if the investigation concludes in recommending conservatorship, the Public Conservator must state what specific powers should be denied | |||
| 9 | Receives the report | Receives the report | ||
| 10 | A hearing is held where attorneys from the City Attorney Office present evidence supporting the conservatorship. If the proposed conservatee objects, a psychiatrist or psychologist must testify | |||
| 11 | May ask for a jury trial, call others to testify, or may testify themselves | |||
| 12 | If the Judge grants the conservatorship, the Judge will appoint a conservator who will determine which, if any legal rights, will be removed from the person | |||
| 13 | A mental health conservatorship expires after one year, but may be renewed year-by-year if the treating medical team makes a formal request to the Probate Court to continue the conservatorship and the Judge determines it is necessary | The conservatee receives a full evidentiary hearing and legal representation on the renewal petition | ||
| 14 | While in conservatorship, the conservatee may petition the Court at any time for a hearing to challenge the conservatorship, on the claim that they no longer meet the legal criteria for the conservatorship. They may also petition the Court for a hearing to contest any of the rights denied under the conservatorship |
Note that with the passage of Prop 36 last November, judges get a new suite of tools to enforce treatment. We will dig into what that means in the coming weeks.
We’ll also dig into the arcane process that has got in the way of our city from helping the most vulnerable get into treatment. We’ll try to get to the core of the question: what’s actually stopping the city from meaningfully helping people addicted to illicit drugs and those suffering from untreated mental health conditions on our streets?
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