Breaking the Cycle

It's expensive and time-consuming, but a court can help cure the hard-core homeless problem in San Francisco

It was a Thursday afternoon in June, and a pretty typical day at the Behavioral Health Court — which meant that only the newcomers were surprised when one of the defendants took out his trumpet and began to play.

He was a middle-aged man, with his head shaved smooth and his shirt tucked in neatly. He came before the judge holding a small black instrument case. The defense lawyer said later that he had started saving for the trumpet soon after getting released from jail.

The Hon. Mary Morgan sets a tone of maternal authority in Behavioral Health Court.
Paolo Vescia
The Hon. Mary Morgan sets a tone of maternal authority in Behavioral Health Court.
Public defender Jennifer Johnson carries a caseload of 100 mentally ill clients.
Paolo Vescia
Public defender Jennifer Johnson carries a caseload of 100 mentally ill clients.

Judge Mary Morgan leaned forward from the bench. "So, do we get a treat?" she asked.

"Yes, your honor," replied the man. He brought the trumpet to his lips, and launched into a breathy rendition of "Over the Rainbow." He flubbed a few notes in the first verse, but added trills as he gained confidence. For a few minutes, the dozens of impatient defendants waiting their turns stopped talking and fidgeting in the wooden folding chairs. The judge, a kindly woman with curly gray hair and glasses, watched with a smile. The song seemed an apt choice for a roomful of people looking for a place where they won't get into any trouble.

Standing beside the defendant was Jennifer Johnson, a dynamic and overworked public defender who keeps her 100-plus mentally ill clients in line. The cases she handles at the Behavioral Health Court run the gamut. "Low-level theft, some assault or family violence, drug cases — we have a smattering of everything," she says. "People who are symptomatic get involved in all sorts of situations that get them in trouble." Most of her clients are charged with felonies, and would face state prison if they dropped out of the program. Because of objections from the district attorney, the court doesn't take defendants charged with extremely violent crimes — "no rape or murder or mayhem," as one staff member put it.

Johnson doesn't use words like "coerce" or "leverage," because she's well aware that advocacy groups are concerned that patients' rights are diminished in these courts. But watching the court in action, there's no other way to put it: The court, which has been operating for five years, takes the people who are most in need of mental health care, and uses the threat of jail time to get them into treatment. While participation in the court is entirely voluntary, most defendants agree to sign up when they're told that it means the charges against them will be dismissed or reduced. To stay in court, each defendant has to comply with the treatment plan his caseworker draws up, which often includes medication. That's what got Winters to start taking the antipsychotic medication he'd been avoiding for decades.

Once a defendant has agreed to take part in the court, it's largely up to the case manager to keep him coming back. Steve Winters remembers his first case manager fondly, and cracks into a broad grin when he's mentioned. "He was a slave driver, he was!" he says happily. The success of each troubled client is largely dependent on whether or not they trust their case manager, and believe him when he says that a better life is possible. Winters' first case manager helped him get a subsidized room in the Ambassador Hotel, and went with him to buy a TV.

The final element at the Behavioral Health Court is Judge Morgan, who sets a tone of maternal authority — she is firm but benevolent, and unfailingly courteous. She praises a man who has faithfully attended his Alcoholics Anonymous meetings and calls for a round of applause, and she tells a defendant who is feeling blue that he is a "valuable person." When an ashamed woman talks about a recent drug relapse, Morgan doesn't yell at her, much less send her back to jail. Instead, she gives her encouragement: "Everybody can fall down," the judge says, "it's only a few people who can pick themselves back up."

After a court session earlier in the year, Morgan explained to visitors why she thought the court worked for deeply troubled people who had resisted treatment for years or decades. "When they come to this court, they're held accountable for what they've been doing by people who really want to see them succeed," Morgan said. "Most of these folks, they're used to being kicked around. When they come in here and everybody applauds, it may be the first time in their life they've gotten that kind of approval."

Everyone hopes that the Behavioral Health Court will save the city money over the long run, but it's not a simple equation. When people agree to be in the program, they're held in jail for weeks or months while they wait for a bed to open up in a treatment program. There's also the expense of the intensive case management, provided by a San Francisco General Hospital outpatient program, which keeps defendants stable over the following years.

A new study by researchers from UCSF's Langley Porter Psychiatric Hospital took the first step in proving the court's efficacy. Researchers compared participants in the Behavioral Health Court with other mentally ill adults who had been booked in jail around the same time. When they compared recidivism rates, they found that 18 months after leaving the court, graduates were 40 percent less likely to have been charged with a new offense, and 54 percent less likely to have been charged with a violent crime.

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