“At that point, approximately eight undercover policemen jumped out of their cars and arrested me,” Pauline later recalled. Convicted of grand theft for the robbery, Pauline served fifteen months in Central California Women’s Facility, the largest women’s correctional facility in the United States.

The Road to Deinstitutionalization

In 1955, more than 500,000 people in the United States were housed in state mental hospitals. Mass deinstitutionalization began in the 1960s, and, by December 1998, only 57,151 people remained institutionalized in state mental hospitals.[1] The most popular reason for deinstitutionalization was recognition that community-based care for persons with mental illness would be more humane, more therapeutic, and more cost-effective than institutionalization.[2] Mental health advocates were concerned that hundreds of thousands of people with disabilities were shuttered in isolation with unnecessary care.

In place of institutionalization, community-based treatment is now embraced as the method of choice for treating the majority of cases of psychiatric illness in large part due to Title II of the ADA, which requires the maximum community integration for healthcare by states. See Olmstead v. L. C., 527 U.S. 581 (1999).

In today’s economic climate, the resources of community-based organizations that provide services to those with psychiatric illness are limited. To complicate matters, people with mental illness often do not seek out these community-based services in the first place - some may deny or be unaware that they have a mental illness, and some may attempt to self-medicate with alcohol or other drugs. All too often, people with psychiatric disabilities who are unwilling or unable to receive services from community-based providers or who are unable to continue to meet the requirements of participation in such programs end up interacting with first responders.

Yet the police and emergency medical technicians are usually not well-trained to effectively deal with people with psychiatric disabilities. Their only options in these situations are to release them or to enter them into custody against their will, perhaps due to their being perceived threats to themselves or others. The psychiatric service components of public hospitals and jails have become the intake mechanism for psychiatric services for those that refuse voluntary services. Many have even made the case that correctional facilities, by and large, have replaced state mental hospitals[3], and there is evidence to support that claim: A special report from the U.S. Department of Justice in 2006 revealed that, “[a]t midyear 2005 more than half of all prison and jail inmates had a mental health problem….”[4]

Since so many people with psychiatric illnesses are cycling through the criminal justice system, new programs that intervene at the point of arrest for hard-to-serve clients and that are based on collaboration between community-based treatment services and the criminal justice system have gained increasing support.

The San Francisco Behavioral Health Court

One such model that intervenes post-arrest and pre-trial is the mental health court model, examples of which have sprung up around the country in major cities to address the unmet needs of arrestees with mental health issues. San Francisco’s Behavioral Health Court is one such example.

Upon incarceration, prisoners in San Francisco County, California, are all given medical evaluations. Prisoners who have psychiatric issues are then evaluated by Jail Psychiatric Services (JPS). If JPS concludes that a prisoner’s misdemeanor or felony could have occurred due to behavior connected to their mental illness, they may be eligible for voluntary participation in the Behavioral Health Court (BHC). Eligibility is contingent upon further evaluation by BHC’s legal and medical teams and, in the case of violent crimes, sometimes requires approval by the District Attorney. Procedures are in place to assure that BHC is used appropriately and not just as an “easy out” of incarceration.

Diversion to the BHC in place of being tried in criminal court is entirely voluntary, but the requirements to remain in the program and graduate are intensive. Participation combines involvement in a supervised residential recovery program and compliance with personalized treatment regimens. The participants must appear before California Superior Court Judge, now Honorable Mary Morgan, on a regular basis. The frequency of visits and the intensity of services depend on the progress the participant has made. Judge Morgan receives reports from the residential recovery programs and comments on participants’ progress. She also listens to participants who have concerns or problems with their individualized treatment and addresses those concerns or problems in turn.

Examining BHC's Effect on Recidivism Rates

In 2007, Dale McNiel, Ph.D., and Renee Binder, M.D., of the University of California, San Francisco (UCSF), conducted research evaluating the effectiveness of mental health courts by studying San Francisco's Behavioral Health Court. They observed 170 BHC participants over a period of two years in comparison to over 8,000 people who served jail terms and had mental illnesses comparable to participants in the BHC group.

Eighteen months after entry in the program, individuals in the BHC group were 26% less likely to commit any new crime than their incarcerated counterparts, and they were also 55% less likely to commit a new violent crime.[5]

When Pauline returned to San Francisco from Central California Women’s Facility, she immediately resorted to her old way of life: living homeless on the streets, with no income and an untreated mental disability. Pauline suffers from bipolar disorder and, eventually, developed an addiction to illegal drugs. On June 3, 2007, Pauline was arrested again for commercial grand theft and was set to return to state prison. While being held in county jail, Pauline was given the opportunity to participate in Behavioral Health Court instead of serving her prison term. Pauline agreed to comply with the stipulations of BHC and enrolled into the program on October 31, 2007.

A Look Inside: BHC Hearings

I recently attended a BHC hearing held in San Francisco’s Hall of Justice. When I entered the courtroom, it was replete with other BHC participants, family members, and case managers. As I struggled to find a seat, I noticed a BHC participant, Sean Lawrence[6], speaking directly to Judge Morgan in a comfortable and friendly manner. Sean was enthusiastic about the progress he had been making recently and gushed about a new job he had just started. Judge Morgan pointed out some specific things she was pleased to see in his report and then led the room in a round of applause – something she does after every positive hearing.

Not all reports to the court were favorable. In one case, a man, reeking of alcohol, stumbled up to the podium. With one eyebrow raised, Judge Morgan calmly stated, “I got a very bad report for you, Mr. Alvarez. You have not been taking your medication, and you have not shown up to [your residential recovery program] for a week.”

Alberto Alvarez attempted to excuse his lack of participation by insisting that he had been pursuing medical treatment from an unauthorized clinic. Judge Morgan’s expression was stern and unsympathetic, suggesting that she had heard this before from him. Alberto was raising his voice by this point, sensing that he was about to get “kicked out of Behavioral Health Court and sent back to criminal court.” Indeed, Judge Morgan proceeded to order him sent into custody; within seconds, three officers entered the usually inviting courtroom, handcuffed Alberto, and escorted him out. Clearly, Judge Morgan has no problem disenrolling people who are not making the effort to recover.

Of the twenty hearings I witnessed, the majority were positive, and Judge Morgan was never short on praise for the hard work participants had put into their rehabilitation. Participants sometimes receive other incentives to continue complying with their treatment plans, including reduced frequency of court appearances, less restrictive treatment plans, certificates of achievements, and other forms of positive behavioral reinforcement.

Involvement in Behavioral Health Court helped transform Pauline Clark. From the beginning, she never missed a single court hearing with Judge Mary Morgan.

“I think Judge Mary Morgan is a very great person… with a deep understanding for people like myself with mental illnesses and substance abuse [problems] that really need help. I always looked forward to going to court,” Pauline said.

In addition to her perfect attendance in the courtroom, Pauline complied completely with her mental health treatment plan as well as her drug rehabilitation regimen despite several years of addiction.

BHC's Role in Helping the Homeless

Whereas the average American may not directly feel the effects of improperly treating and imprisoning millions of people with mental disabilities, other consequences of hasty deinstitutionalization are more clearly evident. Anyone who has walked through downtown San Francisco knows that homelessness is a huge issue here. According to a 2003 story from the San Francisco Chronicle, there are 8,000 - 15,000 homeless people in San Francisco alone. Of those people, 3,000 to 5,000 are “hard-core” homeless - in other words, they do not sleep in shelters and live full-time on the streets. About 40% have mental illnesses.[7]

According to the previously mentioned UCSF report, 34% of the BHC participants studied were homeless at the time of their arrest. Based on this data, BHC serves not only San Francisco’s mentally ill population but also provides desperately needed rehabilitation and treatment for many of the city’s homeless.

Looking Forward

Due to BHC’s limited capacity, there are still countless jailed people with mental disabilities who never receive the treatment they need. According to Lisa Lightman, Director of San Francisco’s Office of Collaborative Justice, people who elect to join BHC are put on a waiting list until there is space, which usually takes about two months. Clearly, the demand for BHC services outweigh current capacity. Mental health courts are one of the most highly regarded models currently in place to provide mental health treatment to people whose struggles with mental illness have led to frequent contact with the criminal justice system, and differences in recidivism rates demonstrate the model’s effectiveness. The expansion of mental health courts, both in capacity and number, will help result in less criminalization of mental illness, increased effectiveness of mental health services, reduced costs, and more positive outcomes.

Pauline graduated from Behavioral Health Court in October 2008 and was one of the graduates making a speech at the graduation. Noting that she had so much working against her upon her enrollment to BHC, Judge Morgan introduced Pauline: “To be honest, I never expected Pauline Clark to be as thoroughly successful as she was.”

Pauline received a standing ovation after her short speech. Many notable people were in attendance, including San Francisco Supervisor Bevan Dufty, representatives from the Office of the District Attorney, San Francisco County Jail, and the Public Defender’s Office.

Today, Pauline spends her time sharing her story with others and volunteering for KQED, a local public television affiliate. She currently lives in co-op housing and is still attending Alcoholics Anonymous meetings.