Both sides agree that the city needs to do more to stem a complex crisis fueled by an affordable housing shortage, a drug epidemic and limited mental health resources. All this in one of the most expensive cities in the country, where the homeless population has jumped 17 percent since 2017.

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“It’s hard, it’s really an issue of freedom and personal agency,” said Lena Miller, program director of the Bayshore Navigation Center, a shelter in the city. “On the other hand, what do you do when a person is having a break with reality and can’t really take care of themselves?”

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The city’s Board of Supervisors voted 10 to 1 to implement S.B. 1045, a bill passed by state lawmakers last year that expands the use of a mechanism known as conservatorship, which gives a court-appointed guardian the authority to make decisions for a person judged “gravely disabled.”

Conservatorships have been used in California since 1972 to involuntarily treat people grappling with mental illness and alcohol abuse. The new law lets courts “conserve” those who use other substances or have entered psychiatric emergency services at least eight times in a year.

Today, roughly half of psychiatric emergency cases are related to methamphetamine use, according to Rachael Kagan, communications director for the San Francisco Department of Public Health.

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“We see a need to update our conservatorship program in San Francisco because the current one does not contemplate the needs of people with substance abuse disorder,” Kagan said. “The clinicians who serve these people now are really in need of this tool."

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But opponents worry that it will lead to prolonged involuntary confinement. While eight of these occurrences — known as a 5150 hold — will not automatically lead to a conservatorship, a person may be held for up to 72 hours and a medical professional can request additional holds.

“What they’re not taking into account is the huge incentive police will have to 5150 people,” said Jennifer Friedenbach, executive director of the Coalition on Homelessness. She argued that even if only a handful of people ultimately qualify for a conservatorship, the new law will allow for the de facto detention of homeless and mentally ill people.

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In a 2018 statement, the ACLU’s disability rights program director, Susan Mizner, called conservatorship “the biggest deprivation of civil rights aside from the death penalty.”

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Members of the all-Democratic board’s progressive faction expressed concerns, but ultimately all but one supervisor supported the legislation after adding amendments to narrow its scope — and after the bill’s sponsors threatened to put it on the ballot if it didn’t pass.

Although the last-minute changes mean that even fewer people will likely be conserved — a key amendment requires that they first go into outpatient treatment — the state lawmaker who wrote S.B. 1045 has already introduced a new bill in Sacramento that could land another 50 city residents in conservatorship each year, according to Department of Public Health estimates.

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State Sen. Scott Wiener (D), a former San Francisco supervisor, has championed the issue at the state level, with the local support of San Francisco Mayor London Breed and Board Supervisor Rafael Mandelman. In a statement after the bill passed, the mayor hailed the move as an important part of her plan to address mental health and substance abuse problems.

“This is an important step that will help people [on] our streets get the treatment they need rather than continuing to cycle in and out of the emergency room, and often the criminal justice system,” she wrote. “Conservatorship will allow us to finally break this cycle by providing sustained care."

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Angelica Almeida, who directs the Department of Public Health’s assisted outpatient treatment program and will run the new program under S.B. 1045, emphasized the legal protections conserved people have. Although they can be held in a locked room and lose control of their property, conserved people can’t be forced to take medication and are represented by a public defender. Almeida’s office has a responsibility to ensure they are held “in the least restrictive setting” possible.

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She echoed that the expanded use of conservatorship can be an important tool to stop the cycle of people being held involuntarily during drug-related episodes, being released after sobering up and using drugs again.

“What we know as providers is that as this cycle continues, a person deteriorates," she said. The new law, Almeida said, allows her and her colleagues to provide longer-term support to patients “on their journey to recovery and wellness.”

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Yet those with a ground-level view of San Francisco’s overlapping crises of mental health, substance abuse and homelessness have no illusions that there’s an easy fix. Kenneth Kim, director of behavioral health services at GLIDE, a nonprofit in the city’s Tenderloin neighborhood, said it will take a comprehensive and well-funded effort to make a significant dent in the problem.

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“This use is really out of desperation, which is unfortunate," Kim said. “This could mean institutionalizing people where that isn’t appropriate.”

Miller, who also serves as chief executive of Urban Alchemy, a nonprofit organization that employs formerly incarcerated people, said the mix of addiction, mental illness and extreme poverty or homelessness is a problem that society hasn’t fully grasped yet. She compares S.B. 1045 to recycling a few plastic bottles to avert climate change.

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“We’ve never seen this before, we’ve never had to deal with this before, and we’re not dealing with it now.”