Breaking the Cycle

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

Steve Winters' single room in the Tenderloin's Ambassador Hotel is a dismal scene. The bare mattress shoved against the wall is a dirty gray, a heap of clothes inhabits one corner, and the bathroom is a little too gross to describe. But Winters brags about his room. "It's got a refrigerator," he says proudly. "I feel like Jeffrey Dahmer with that refrigerator."

Winters suffers from paranoid schizophrenia. Although he's now on medication, he still has the delusions and obsessions that have been his companions since he was an adolescent. Conversations start normally, but veer abruptly off course — suddenly he's reviewing the Zodiac Killer's string of grisly murders, or he's ranting about a racist Georgia politician who was arrested for several church bombings. His illness — and its lack of treatment — has defined his life for most of his 53 years.

For about 20 of those years, Winters lived homeless in San Francisco, a shambling, unmedicated wreck who cycled through the city jail for a succession of petty crimes. The courts had placed on him what is known as a "stay away" order from a street corner in the Inner Sunset where he routinely harassed shopkeepers and their customers.

Paolo Vescia
Paolo Vescia
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.
Jo Robinson, director of Jail Psychiatric Services, says inmates stand a better chance of not coming back if referred to Behavioral Health Court.
Paolo Vescia
Jo Robinson, director of Jail Psychiatric Services, says inmates stand a better chance of not coming back if referred to Behavioral Health Court.
Steve Winters.
Paolo Vescia
Steve Winters.

In one year, he was evaluated by jail psychiatric workers 18 times, and each time he was released back out onto the street instead of being sent to a treatment program. He didn't slip through the cracks — he didn't want to get better, and no one could force him to.

Winters was living a life punctuated by incarceration. He says he has been confined to mental hospitals in North Carolina, Georgia, and Louisiana — and they weren't so bad, he says; they were better than jail. He's known penitentiaries in North Carolina and Georgia, and has become very familiar with the San Francisco jail since he started visiting it in the late 1980s. Toward the end of his drifter days, the locked doors stopped bothering him. "When you're young, jail seems worse than it does when you get older," he says, rocking back and forth.

For those 20 years on the city's streets, Winters was the type of hard-core homeless guy who gave San Francisco politicians heartburn, and made tax-paying citizens feel simultaneously guilty and resentful. He was part of a troubling problem that everyone wishes would go away.

Now, although he still looks like a street-dweller with his long, greasy gray hair and grungy sweatshirts, he's a success story. He gets his shot of medication every two weeks, and lives a stable life under the roof of the Ambassador Hotel. An examination of his case shows exactly what it takes to get one troubled homeless person off the street. It shows that there are solutions to San Francisco's homeless problem — but they're expensive and time-consuming, and it's an open question as to whether citizens are willing to pay the bill.

Winters went through the Behavioral Health Court, a program that takes mentally ill defendants off the path to prison, and hooks them up with mental health care. In the unusual courtroom, the defendants come to court every few weeks to report on their progress, and a judge tries to keep them on the high road through a combination of praise, counseling, and stern warnings. It worked for Winters. Since he "graduated" from the program three years ago, he hasn't been arrested a single time, and he hasn't returned to the mental ward at San Francisco General Hospital.

He got into court because he finally committed a crime that had serious repercussions — he was charged with attempting to derail a train, a felony. Initially he was let out on probation, but when he continued to get arrested, the district attorney's office decided to throw the book at him and send him to state prison. That's when the staff at the Behavioral Health Court found him, and invited him to join the program. Winters was told that if he participated, he would likely avoid his prison term entirely, and his probation could be reduced. That was enough incentive to sign up.

But some advocates for the mentally ill worry about the mental health courts that are popping up all over the nation. The National Mental Health Association published a report in 2004 discussing the possibility that mental health courts are forcing patients to accept treatments — and medications — that they wouldn't accept under other circumstances. The report noted that many of the courts impose "treatment compliance" as a condition of release from jail, and failure to comply can result in sanctions such as incarceration. "The qualified right of a person with mental illness accused of a crime to refuse a particular treatment, including a particular medication, should be protected," the report concluded.

However, Winters' case seems to show that sometimes, a little coercion is just what the doctor ordered. It's hard to get a paranoid person like Winters into treatment, notes his caseworker, Kyong Yi, because he often won't trust people who offer help, and gets nervous when he's told to take pills. "That's what's great about behavioral health court," says Yi. "Using that legal leverage, they could get him in the door where he wouldn't go otherwise."

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.

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.

Jo Robinson, director of Jail Psychiatric Services, sums up the argument for the court: "It's labor-intensive, and expensive — but it's what works." Some Sacramento legislators have caught on; earlier this year state Sen. Darrell Steinberg introduced a bill to encourage the creation of mental health courts throughout the state.

However, when dealing with such troubled clients, smooth and steady recoveries are rare. Less than 15 minutes after the trumpet serenade on that June afternoon, the emotional atmosphere of the court took a dip. A tiny, angular woman in a long tan coat came to stand before the judge with a Spanish interpreter by her side. She was jumpy and agitated. "I don't know if I'm well or not," the woman said right away. "My body is going crazy."

"Did you take all your medicine this afternoon?" asked the judge in her measured tone.

"I've taken all my medicine, but my body is dislocated," the woman said through the puzzled interpreter. "My nose is in my head, and my ears are in my mouth."

The room quieted again. The judge calmly asked the woman's caseworker to approach the bench, but the woman was already frustrated. She wheeled around and strode out of the room, making angry, dismissive noises through her teeth. A uniformed deputy and the woman's case manager walked swiftly after her. It was a reminder of how close many defendants still are to the edge.

Court carried on, but a few minutes later the case manager was back with the woman. Judge Morgan gave the woman some sympathy — "I know it must be very upsetting when it feels like your body is disorganized or out of place," she said, and gave the woman her instructions.

"If you don't go see your psychiatrist tomorrow, it's going to be very hard for you to stay in Behavioral Health Court," said Morgan.

"What happens if I don't?" said the woman.

"Back to criminal court," said Morgan grimly.

Winters' story begins in Winston-Salem, N.C., where he was raised by a hard-drinking stepfather and a hardworking mother, he says.

He often tells the story of what happened to his useless right eye, which has a milky white film covering the blue iris. When he was 10 years old, he got shot in the eye with a BB gun, he says. "That BB didn't feel too good, but it didn't blind me," Winters says. The damage was done by the handkerchief soaked in rubbing alcohol that his stepfather told him to press against the injured eye.

"It was that rubbing alcohol," Winters says. "I said, 'It's burning, it's burning!' Daddy said, 'Keep it on a little longer! We're going to sue them!'" Winters says the family did sue, and got $11,000 in a settlement. "My stepdaddy, he got about $3,500 of that money for his expenses," he says.

Winters quit school in the ninth grade, and got a job at McDonald's, where he worked for almost three years. Winters thought about learning a vocational trade like brick-making, "but it just didn't work out as well as I hoped," he says. Instead, he starting getting into trouble with the law in North Carolina, most significantly when youthful urges caused him to break into a boarding house, intending to visit two girls who were staying there. He says he didn't get very far; still, the cops called it burglary with intent to rape and he ended up in the state penitentiary for a couple of years.

It's impossible to get Winters to give a linear account of his life — he doesn't think that way — but the stories he tells can be pieced together into a loose narrative. He lived in Atlanta when he was a young man, living in cheap hotels and working as a dishwasher or as a temporary laborer. He went to live in New Orleans, but got hauled back to North Carolina by a probation officer. He wound up in a mental hospital in North Carolina for a spell, and again in Atlanta when a diversion program sent him to the mental hospital instead of the state penitentiary.

He tried living in New York City for a few months, he says, but it was too hard.

"It's hard to make a buck in N.Y.C.," he says. "Hustling gays — that's a demoralizing job. It's hard to turn a trick in N.Y. I guess you have to look like Richard Gere." Winters says he isn't gay, but that never mattered when he needed a bit of quick cash.

His next move was a better fit, he says. Back in the temporary labor pool in Atlanta, he met a man called Hippie Bill, from San Francisco. "He said the best thing I could do was live in San Francisco," Winters says. "He said the police are more liberal." So more than 20 years ago, Winters and two friends piled into a cheap car and drove west.

He does remember what happened on his second day in the city, when he picked up a trick in Civic Center Plaza. "He said, 'Ever do any fist-fucking?'" Winters remembers. "I said, 'I don't think I can do that.' He said he'd give me $25. Then, when he finished, he couldn't find his wallet!"

That was Winters' welcome to his new home, where he'd stay for the next 20 years. He got his monthly Social Security check delivered to the post office — Winters is considered both mentally and physically disabled, on account of his bad eye and a bad leg from getting hit by a car in Atlanta. He became the typical San Francisco street guy, occasionally getting a room in the Tenderloin for a few days, but mostly sleeping in Golden Gate Park or at shelters, he says. "Lot of times I'd blow my money on girls and weed," he says.

The police incident reports tell Winters' tale from there on, with a steady drumbeat of arrests. (Police records from before 1990 were purged, so Winters' rap sheet runs from 1990 to 2003.) Some of the crimes were as petty as it gets — like a 1991 arrest for breaking into an Alcoholics Anonymous meeting hall and stealing $5. Others have an edge of violence to them, like another arrest that same year for lighting matches in a Tenderloin building and dropping them on the floor.

By 1996, he had adopted the Inner Sunset as his neighborhood, and hung out at Ninth Avenue and Irving Street to sell copies of Street Sheet, the newspapers printed by the Coalition on Homelessness. Over the next eight years, he proceeded to thoroughly wear out his welcome. Police reports show that he harassed passersby, and for a while in 1999 he made a habit of slapping people in the back of the head (he was arrested for battery). By 2001, merchants were complaining that someone was routinely tipping over trash cans on the sidewalk; when the police staked out the corner, they saw Winters methodically roll each can to the doorway of a store before dumping it.

Winters was arrested for public nuisance in that instance, but was out of jail again probably within 12 hours. The trouble continued — store owners came to work to find their windows coated in cooking oil, and neighbors complained of public defecation and Winters' "erratic behavior and threatening manner." A judge issued the stay-away order to keep Winters from troubling the merchants at Ninth and Irving, but in March 2003, he was arrested at that corner on two subsequent days.

Winters downplays the constant trouble he was in, either out of embarrassment or because he sincerely doesn't remember; his case worker notes that he has very little insight into his mental illness and its effects. "I guess I wasn't the best neighbor in the Sunset; they had their problems with me," says Winters. "I guess they got tired of a bum, basically."

So what happened to Winters after each of those arrests? According to Jo Robinson, the director of Jail Psychiatric Services, he likely received a psychiatric evaluation almost every time he was brought in. Certainly in the last few years of Winters' time as a vagrant, the jail psychiatrists got very familiar with him. According to Winters' case manager, he was evaluated in jail 18 times between April 2002 and March 2003.

But Winters' petty crimes kept him in jail for a couple of days at most. And, like many others who cycle endlessly through the Hall of Justice, he appeared to prefer an unmedicated life on the street to anything the psychiatrists were offering. "We try to get them into services, but a lot of them don't want services," says Robinson. "We'll talk to them each time we see them. We'll ask them, "How about this time? Are you ready?'"

Robinson says that 11 percent of the jail population has a serious mental illness like schizophrenia or bipolar disorder, and almost 25 percent of the population is on some psychotropic medication (which includes commonly prescribed drugs like antidepressants). According to a spokeswoman for the sheriff's department, the San Francisco jail is the biggest provider of mental health services in the city.

The three psychiatric units are as therapeutic as the staff can make them. The inmates can hang out in "socialization areas" during the day, playing checkers or chess at picnic tables. They can attend individual and group therapy sessions, or try art therapy or yoga. They even have periodic celebrations for the inmates — a party in June featured puppet shows and karaoke.

While Robinson makes the inmates sound like kids at a day camp, she says the image that the outside world has of her clients is quite different. "I still think there's a stigma attached to mentally ill people who come through the jail," says Robinson. She believes they're no different than mentally ill people who come to treatment through the hospital, or through private doctors. "They're the same people — it just depends on what door they come in," she says. "There's this idea that they're all horribly violent. But it's due to their mental illness that they've committed some crime."

The crime that eventually got Winters into court and into treatment was most likely the result of a paranoid fantasy, but Winters doesn't remember what it was. "They said I tried to wreck the Muni train, but they were exaggerating a little bit," Winters says. "I guess I threw a steel rod pretty much right in front of it. I don't know why I did that," he says, with a genuinely puzzled air.

According to the incident report, on April 18, 2000, Winters wedged a metal pole in the Muni tracks at 14th Avenue and Judah Street. A Muni worker saw the pole and pulled it out before a train came, but as soon as he put it down, Winters snatched it up and put it back on the tracks. The Muni worker had to take the pole out again and guard it until the police came, as Winters kept making grabs for it.

Winters says he waited in jail a long time, and was told that he might get a sentence of up to 25 years for the felony charge of train wrecking. Instead, he got five years of probation, according to Johnson, the public defender. But he went straight back to his usual corner of Ninth and Irving, where his petty crimes began to be counted as probation violations.

By March 2003 those violations had added up and Winters was being held in custody — but that's when the Behavioral Health Court intervened. The program was new, and Winters was one of the first people to sign up. "Without Behavioral Health Court, Steven would have wound up in state prison," says Johnson. The state prisons are already crowded with mentally ill prisoners, and last year a federal judge found that the state violated the constitutional rights of these prisoners by providing inadequate care.

Instead, Winters made it through the program in about a year, and his probation was terminated early when he "graduated." Three years after that graduation, Winters still goes to see his current case manager, Kyong Yi, every Wednesday. They meet at Yi's office, and walk together to Winters' room at the Ambassador Hotel, where she assigns him cleaning tasks. Sometimes she goes shopping with him for necessities like garbage bags and cleaning supplies. "My job is to support him in building a life for himself that he enjoys," Yi says. There is no loftier goal than complete autonomy: "I can't imagine Steve not being a client here," Yi says. "I think the transition for him would be disastrous."

Winters lives off his "government check," as he calls it. Until he got his room at the Ambassador Hotel, the check was $900 a month; it went down to $770 a month because he now has cooking facilities in his building — namely, a communal microwave. Winters doesn't complain, though, and seems proud that he can make his own meals. "I use that microwave to warm my hot dogs up every night," he says. "I been living on hot dogs entirely, about four, five, six hot dogs a day — $1.29 a pack, eight in a pack."

Yi has Winters' rent payment deducted automatically from his check so that he won't forget to pay it. From what's left over, he gets $42 each Monday and Friday, a lot of which he spends on good weed from the medical marijuana clubs, bought secondhand. He gets an extra $10 when he takes his biweekly shot of medicine — an important inducement, because Winters doesn't like medicine. "Risperdal — they started me on that stuff at jail, but I was spitting out those pills," he says. Yi says the switch to a supervised shot contributed greatly to Winters' stability, though he won't admit it. "I don't know what the Risperdal's for," he says, "they just figure I need it. Nerves, I guess."

At Yi's office, Winters gets to call home to his 74-year-old mother in North Carolina. "My momma tells me, take your medicine, Stevie, be good!" he says. And he is being good. Last Halloween, he showed the Tenderloin that he has civic spirit. "I got one of those $5.99 bags of M&Ms, gave 'em to the trick-or-treaters going down Eddy Street." After 20 years as a San Francisco outsider, he's not just a law-abiding citizen, he's a good neighbor.

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