Connecting state and local government leaders

San Antonio's Mental Health-Centered Policing

San Antonio, Texas

San Antonio, Texas Jo Ann Snover / Shutterstock.com

 

Connecting state and local government leaders

Diverting 100,000 people away from jail and ERs and moving them into psychiatric treatment—one 911 call at a time.

We've got a lady that’s cut­ting her­self with a knife right now.”

Of­ficer Ernie Stevens looks at the laptop that’s blink­ing with this shift’s first call. His part­ner in the driver’s seat, Of­ficer Joe Smarro, punches the ad­dress in­to the GPS.

“Hold her down un­til we get there. Then we’ll take over re­spons­ib­il­ity,” Ernie says in­to the phone.

Joe and Ernie are two of the six qual­i­fied of­ficers that San Ant­o­nio’s po­lice de­part­ment de­ploys from its spe­cial­ized men­tal-health unit. They go out in pairs, dress in plain­clothes, and re­spond to crises that might be rooted in men­tal ill­ness.

It’s easy to see they’ve bon­ded, hav­ing tag-teamed in the midst of high emo­tion­al in­tens­ity for over five years.

Four patrol cars are already parked at the scene, their strobe lights rov­ing. “Yup, you can see how they’re re­spond­ing,” Ernie says, ex­as­per­a­tion lat­ent in his tone. “Just be­cause there was men­tion of a knife.”

The of­ficers speak re­spect­fully of their fel­low patrol­men—jobs they once held—but it’s clear the pair op­er­ates from a broad­er defin­i­tion of “dis­turb­ance.”

“All patrol sees in this call right here is ‘knife,’” Joe says. “So they’re im­me­di­ately think­ing in terms of tac­tics. It’s ‘I might have to get my gun out,’ or ‘I might have to shoot some­body.’

“But when I see this call, I see that this is someone who’s really hav­ing a bad day. This is someone who is really up­set. Something’s happened in the last 24-48 hours that’s caused her to get to this point, to where she’s cut­ting her­self. And chances are this is not the first time this has happened. We’re deal­ing with a cycle here, and something’s caused this cycle to re­sur­face. We need to fig­ure out what’s go­ing on.”

This type of psy­cho­lo­gic­al in­sight in­to a volat­ile situ­ation is the end res­ult of a dec­ade of re­train­ing by San Ant­o­nio’s po­lice force.

As the rest of the coun­try re­mains em­broiled in a heated de­bate on crim­in­al justice, the city of 1.4 mil­lion has quietly reached the fore­front of po­lice re­form by pri­or­it­iz­ing men­tal-health-centered ap­proaches and gain­ing the trust of its res­id­ents and pub­lic-ser­vice pro­viders.

Since 2005, San Ant­o­nio has re­quired its en­tire po­lice force to en­roll in a weeklong pro­gram called Crisis In­ter­ven­tion Train­ing (CIT), which helps of­ficers bet­ter un­der­stand and re­spond to the nu­ances of men­tal ill­ness. It’s also helped spon­sor a 37-acre treat­ment cen­ter to handle ci­vil­ians in vari­ous stages of men­tal ill­ness and sub­stance ab­use, giv­ing those be­ing di­ver­ted away from jail sup­port in man­aging their chal­lenges.

On this par­tic­u­lar call, Joe and Ernie enter the house and move past the armed of­ficers. There’s a wo­man on a couch, cry­ing. A man shifts awk­wardly in the kit­chen. Joe walks up to him as Ernie goes to­ward the wo­man.

“OK,” Ernie says as he sits down catty-corner from her. “You’re Jes­sica? What’s go­ing on? My name is Ernie.”

She struggles to catch her breath, look­ing wary and spent.

Jes­sica of­fers Ernie an agit­ated list of ex­plet­ive-laced com­plaints about her boy­friend’s trans­gres­sions dur­ing an eight-year re­la­tion­ship. She un­leashes an­ger and ex­haus­tion in equal meas­ure. Ernie stays calm, fo­cused on her.

“I can see you’re up­set,” he says. “Let me ask you something. One piece of in­form­a­tion we re­ceived was that you were cut­ting your­self. Was that—…”

“I told you be­fore that I did,” Jes­sica cuts him off with de­fi­ance, lump­ing Ernie in with the patrol of­ficers who first reached her house.

“I’m sorry,” Ernie says softly. “Did you try to cut your­self today?”

“No.” She swal­lows con­vuls­ively.

“OK. Have you ever re­ceived any kind of coun­sel­ing or ther­apy in the past?”

“I used to,” Jes­sica says. She says she was raped at age 18 and be­came preg­nant. Her foster par­ents took her off meds to pro­tect the baby, and the only thing she’s tried since is marijuana.

“So you feel over­whelmed?” Ernie asks. “Would that be fair to say?”

Jes­sica nods.

“OK” Ernie says. “Would you agree with me if I said, hon­estly, you don’t want to kill your­self, you just want this pain to go away?”

Jes­sica nods, gulp­ing. She ex­plains that she used to cut her legs, “just so I could feel bet­ter.” She openly ac­cuses her boy­friend of sleep­ing with an­oth­er wo­man when she is out of the house and of mak­ing her and the kids stay away from morn­ing un­til 6 p.m.

She’s a gush­ing faucet of pain, but Ernie keeps his fo­cus.

“OK, all right,” he says. “I can see that point of view. What I’m wor­ried about is the way that you handle these types of stressors in your life. When you’re up against a crisis like this, and something hap­pens, how are you equipped to deal with it?”

Jes­sica ex­plains that she usu­ally leaves and goes to a friend’s house, that she could nev­er af­ford coun­sel­ing and is afraid of its con­di­tions.

“They tell me that if I’m go­ing to harm my­self…” her voice dwindles off. And then, “I don’t want them to take my kids away.”

Ernie re­sponds swiftly.

“Let me put that fear at ease, OK? Hear me: There’s no way at all that I’m go­ing to even con­sider tak­ing your chil­dren away from you. All I want to do is get you help so you’re equipped to deal with life when it comes at you like this.”

The con­vic­tion in Ernie’s prom­ise seems to break through to Jes­sica.

“Well, then, if someone’s go­ing to check me, can I be hon­est with you and show you what I did?”

Ernie nods, hav­ing waited, it seems, for this break­through. Jes­sica stands up, takes off her out­er shirt and lifts the cam­isole un­der­neath. Ernie sighs heav­ily. Her chest is covered by a jig­saw puzzle of 50 bleed­ing gashes, some of them deep.

“Did you show the patrol of­ficers this?”

“No,” Jes­sica says.

Ernie’s eyes nar­row as he leans closer. “Let me see this for a second. They may want to su­ture these and put a couple of stitches in there. We need to get help. This is something we don’t want you to do. They can take care of this at the crisis cen­ter.”

Then he looks in­to her eyes.

“Listen to me, Jes­sica. I’m heart­broken. If you were my wife, my sis­ter, I’d be heart­broken.”

Her eyes well up, hear­ing a truth about her value that’s been bur­ied. And then…

“This is nor­mal for me,” she says limply.

“Ori­gin­ally, I didn’t want to get in­to this line of work,” Ernie says back in the patrol car, after Jes­sica has been checked in to the crisis cen­ter, called Res­tor­a­tion.

“Deal­ing with a men­tally un­stable con­sumer was my biggest fear. I’d been a patrol of­ficer for 13 years when a buddy signed me up for this train­ing, called CIT. I just said yes be­cause to do it would mean I’d get a week­end off.”

CIT was at that time new to San Ant­o­nio, hav­ing been in­tro­duced in 2005 as part of an ini­ti­at­ive Bex­ar County was un­der­tak­ing to stave off fines from an over­crowded jail.

A con­stel­la­tion of fresh mu­ni­cip­al lead­ers came on the scene in the early 2000s—in­clud­ing the dir­ect­or of men­tal-health com­munity ser­vices, a new po­lice chief, and a new county judge (who had pre­vi­ously been San Ant­o­nio’s may­or)—and put their heads and polit­ic­al skills to­geth­er to launch a deep listen­ing ef­fort between law en­force­ment of­ficers and men­tal-health pro­fes­sion­als. The idea was to get these two cul­tures to bet­ter un­der­stand one an­oth­er and then hone in on what could be done to stop the cycle of in­car­cer­a­tion for men­tally ill per­sons.

Some time in­to these con­ver­sa­tions, it be­came clear that the needs of the first re­spon­ders—e.g. patrol­men and wo­men—had to be pri­or­it­ized. Men­tal-health and law en­force­ment lead­ers ori­gin­ally thought they could build men­tal-health ser­vices in­side the jail. This proved in­ef­fect­ive: Too few in­mates were be­ing re­moved. So in­stead they tar­geted the most com­mon trans­ition vehicle for those with men­tal ill­ness: squad cars.

Up to that point, po­lice academies were not of­fer­ing courses in how to deal with men­tal-health crises. Though of­ficers of­ten ex­per­i­enced an av­er­age of one such crisis per day while on duty, most settled for fum­bling their way through the “cra­zies,” pre­fer­ring a quick jail book­ing to the murk­i­ness of a men­tally ill per­son’s world.

“As soon as I got [to CIT], I did not want to be there,” Ernie re­mem­bers as we drive to the next crisis call, this one from a moth­er who says her 17-year-old son is threat­en­ing to harm him­self and her. “I didn’t feel com­fort­able.”

Be­sides un­ease when faced with un­pre­dict­able psychoses, there was also the fear of be­ing labeled a “hug-a-thug” or “so­cial work­er.” Ernie had been trained to be tough, to com­mand and con­trol. But on the fourth day of the train­ing, he was in­tro­duced to an older wo­man named Jean­ine who de­scribed what it was like to live with a schizo­phren­ic son. Her testi­mony was riv­et­ing.

“‘One day, one of you of­ficers will have to come to my house and you might have to shoot and kill my son,’” Ernie re­calls her say­ing, still shak­ing his head at her resig­na­tion. “‘And I want you to know that if that hap­pens, that’s OK. Be­cause I want you to go home safe to your fam­il­ies. You don’t know what it’s like to live with this.’

“At that mo­ment, everything changed for me,” Ernie re­mem­bers. “To see her re­solved to the fact that her son would even­tu­ally be killed by a po­lice of­ficer, and to know she couldn’t pos­sibly be alone … I just thought, there’s no way that this can be.”

For Joe, re­morse also set in quickly after join­ing.

Night­mares haunted him for the first couple of months; tak­ing on sev­en or eight men­tal-health calls per day dis­turbed his sense of real­ity. But per­spect­ive gradu­ally re­turned as he and fel­low of­ficers re­cog­nized pat­terns in their calls and their dis­cre­tion in man­euv­er­ing crises grew in deft­ness and sens­it­iv­ity.

With the help of Joe, Ernie, and the rest of what is now a six-per­son men­tal-health squad, San Ant­o­nio has di­ver­ted more than 100,000 people away from jail or emer­gency rooms in­to ap­pro­pri­ate treat­ment—all without the use of force.

We get out of the car, about 10 minutes after leav­ing Jes­sica safe at the crisis unit. An­oth­er wo­man is cry­ing, this one in a dilap­id­ated park­ing lot, dart­ing her eyes to find her hooded son who is schizo­phren­ic and al­legedly threat­en­ing vi­ol­ence. Joe walks up to get more in­form­a­tion from her as Ernie rounds the corner and care­fully ap­proaches the cli­ent.

“Hi, Vic­tor? What’s go­ing on? My name is Ernie.”

The suc­cess of San Ant­o­nio’s jail-di­ver­sion pro­gram has at­trac­ted na­tion­al at­ten­tion, and those who vis­it from oth­er jur­is­dic­tions of­ten walk away think­ing Crisis In­ter­ven­tion Train­ing is a ma­gic lever to be im­ple­men­ted every­where. There’s a strik­ing hu­mane­ness to these of­ficers, a nu­ance to their abil­ity to build trust with those in the throes of crisis that makes this out­side im­pulse un­der­stand­able, es­pe­cially in the cur­rent cli­mate of an­ger to­wards po­lice be­ha­vi­or. 

Without ro­bust treat­ment ser­vices also avail­able, however, even a CIT-trained po­lice force will have no choice but to wait 8-14 hours in an emer­gency room, or to book the per­son in the loc­al jail.

When Ernie and Joe dropped off Jes­sica at the Res­tor­a­tion crisis unit, they knew they were ush­er­ing her in­to an ar­ray of re­sources, wheth­er or not she ul­ti­mately de­cided to pur­sue treat­ment. Loc­ated just north­w­est of down­town, Res­tor­a­tion is a fully out­fit­ted crisis-care and re­cov­ery cen­ter run by San Ant­o­nio’s Cen­ter for Health Care Ser­vices (a quasi-gov­ern­ment agency fo­cused on men­tal-health and sub­stance-ab­use solu­tions), ad­ja­cent to a 37-acre cam­pus called Haven for Hope that provides longer-term res­id­ence and med­ic­al and be­ha­vi­or­al care for the home­less, ad­dicts, and the men­tally ill.

When someone like Jes­sica is brought in by law en­force­ment, her case-man­age­ment needs are as­sessed. Is men­tal ill­ness co-oc­cur­ring with sub­stance ab­use? Will she need to see a psy­chi­at­rist right away? What are all the chal­lenges to her get­ting and main­tain­ing ac­cess to treat­ment? Is it child care for her chil­dren? Is it food stamps? What is her re­la­tion­ship with her peers, cowork­ers, and fam­ily?

“We don’t want to be the end-all and be-all for every­body,” says Kath­leen Dor­ia, a con­tract em­ploy­ee at the Cen­ter for Health Care Ser­vices. “But what re­sources can we be the li­ais­on for to keep this fra­gile case man­age­ment to­geth­er?”

Jes­sica looked both nervous and re­lieved as she waited for the ver­dict on her case. Journ­al­ists are not al­lowed to in­ter­view cli­ents once ad­mit­ted, but Ernie says it’s likely she was placed in the Josephine Re­cov­ery Cen­ter, Res­tor­a­tion’s 16-bed crisis res­id­en­tial and res­pite fa­cil­ity for men and wo­men, which is fo­cused on provid­ing crit­ic­al cop­ing skills to sus­tain func­tion­ing and re­in­teg­rate in­to the com­munity. What she does after that is up to her.

“I fear she’s go­ing to go back to that same situ­ation be­cause she feels like she’s trapped in it,” says Ernie, as he re­lives the 15-20 minutes he and Joe spent de-es­cal­at­ing her crisis at home. “This may be a Band-Aid on an open wound for her. There are re­sources in place to help her, but she’s got to be will­ing to up and leave [her cur­rent situ­ation].”

This struggle to achieve prop­er agency is what the rest of the Cen­ter’s wrap­around ser­vices are de­signed to sup­port. From its crisis-care unit and re­cov­ery cen­ter, to its Mom­mies Pro­gram that treats preg­nant and par­ent­ing wo­men who use or ab­use sub­stances, to its sober­ing and de­tox­i­fic­a­tion pro­grams and an in­teg­rated primary-care clin­ic com­plete with coun­sel­ing and ther­apy ser­vices, all of the pro­grams are in one loc­a­tion. Many staff mem­bers are “peers” who once found them­selves in sim­il­ar straits, and at­tend along­side pa­tients to of­fer le­git­im­ate em­pathy and a glimpse of what’s pos­sible.

The com­mon thread that binds all the avail­able tracks—in­clud­ing Haven for Hope’s more in­tens­ive 90-day treat­ment for home­less and men­tally-ill pa­tients—is an ori­ent­a­tion to­ward em­power­ing the pa­tient, to get her in the driver’s seat of her re­cov­ery.

Scott Ack­er­son dir­ects Haven for Hope, across the street from Res­tor­a­tion Ser­vices, and he’s con­vinced that this per­son-cent­ric ap­proach needs to pre­cede tac­tic­al check­lists. “I’ll ask a pa­tient, ‘What do you live for?’” Ack­er­son says. “A com­mon re­sponse is, ‘I want to get my kids back.’ OK, then that’s your goal. Your goal is not med­ic­a­tion com­pli­ance. If you have is­sues with men­tal ill­ness or ad­dic­tion, do those need to be ad­dressed? Ab­so­lutely. But that’s not your goal. Your goal is to get your kid back…. The only way a per­son can re­cov­er is if they’re want­ing and will­ing to re­cov­er.”

This drilling-down in­to the needs and iden­tit­ies of people who have been stripped of their scaf­fold­ing is the philo­soph­ic­al and cul­tur­al strain that seems to run through every piece of San Ant­o­nio’s learned-in­ter­ven­tion and treat­ment strategies. There’s a strik­ing con­sist­ency to the way Joe and Ernie listen and speak when they’re on a call, to the way the nurses and dir­ect­ors of Res­tor­a­tion’s crisis unit listen and speak, to the way Scott in longer-term care listens and speaks. They fo­cus on re­la­tion­ships, listen­ing deeply, and want to help each per­son re­cov­er a sense of his or her true self.

San Ant­o­nio is not slow­ing down in lever­aging what’s worked in cre­at­ing an un­usu­al con­tinuum of care from po­lice in­ter­ven­tion to treat­ment and re­cov­ery. This next year, the city plans to per­man­ently re­move 400 jail beds in or­der to cre­ate an­oth­er 400 beds for the Cen­ter for Health Care Ser­vices’s treat­ment pro­grams. So far, the Bex­ar County jail has emp­tied 500 beds since the di­ver­sion pro­gram began. In the last year alone, from Dec. 21, 2014 through Nov. 30, 2015, the Cen­ter for Health Care Ser­vices es­tim­ates that 9,270 in­di­vidu­als have been di­ver­ted from jail.

The push for on­go­ing im­prove­ments is rooted in a con­fid­ence that the unique col­lab­or­at­ive cul­ture de­veloped across San Ant­o­nio’s pub­lic-ser­vice sec­tor will con­tin­ue to bear fruit. Lead­er­ship has been sig­ni­fic­ant—mo­tiv­ated doers see­ing the same prob­lem at the same time—but a city eth­os of non-ter­rit­ori­al­ity and cross-sec­tor ap­pre­ci­ation has been the mor­tar al­low­ing for on­go­ing gains.

Most not­ably, a po­lice force is ex­per­i­en­cing a very real sea change in mind-set and dis­pos­i­tion. The quiet pas­sion of Joe and Ernie has not only earned the re­spect of their fel­low of­ficers, it’s provided a needed safety valve for men­tally un­stable po­lice­men and wo­men with­in the de­part­ment. In a year of heightened na­tion­al scru­tiny on the powers and pre­pared­ness of law en­force­ment, the pair once ri­diculed for their “hug-a-thug” skills are now leaned upon for their abil­ity to listen and provide coun­sel for the psychoses that may be bur­den­ing their col­leagues on patrol. Lives have ar­gu­ably been saved as job posts are now at­tached to a peer-to-peer web of psy­cho­lo­gic­al sup­port.

Wheth­er oth­er cit­ies will suc­cess­fully ad­opt San Ant­o­nio’s ap­proach de­pends some­what on those loc­al cul­tur­al en­trench­ments that pre­cede the ex­tent of the in­car­cer­a­tion prob­lem. Ra­cial dy­nam­ics, a city’s size, the pre­ced­ence of cross-sec­tor col­lab­or­a­tion, and the will to in­vest in wrap­around treat­ment ser­vices are all vari­ables that can af­fect each jur­is­dic­tion’s chance of empty­ing jail beds and re­du­cing deaths. But for now, San Ant­o­nio’s les­sons are worth study­ing. In a ra­cial and crim­in­al-justice de­bate defined by heat, this grow­ing Lone Star city provides some light.

Anne Snyder is a contributor to National Journal's Next America editorial venture, where this article was originally published.

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