Crisis Clinics Are on the Rise

A model treatment program for severe mental illness in San Antonio inspires others.

The seriously mentally ill are now more likely to end up in jail than in treatment. Yet in San Antonio, a quiet revolution in treatment has been taking place over the past decade.

Leon Evans, head of the city’s mental health department, is the leading force behind the change. Just over a decade ago, San Antonio’s Bexar County Jail was being sanctioned by the state of Texas for severe overcrowding and deplorable conditions.

Evans realized the problem was that the seriously mentally ill were being routed to jails, causing overcrowding, rather than to treatment. With the assistance of the city’s police force, court, and hospitals, he created an interlocking system of intervention programs to help.

The first step: training police how to handle mental illness. “We decided we would develop a culture where we would train law enforcement officers in crisis intervention,” Evans says.

The 40-hour program he developed trains law enforcement officers to recognize the symptoms of mental illness. With it, officers “recognize that somebody who is ill, who has strange behavior or is acting out” needs help rather than confrontation, he says. “Rather than get in their face and start shouting orders at them, they step back, they use de-escalation and talk-down procedures, and usually things go well.”

Make that very well. The city’s mental health unit began operating six years ago. “In that six-year period,” Evans says, “they’ve only had one minor use of force. They’ve never shot anybody. They haven’t had hard take-downs.”

That’s in sharp contrast to trends nationwide. Some groups estimate as many as half of people shot and killed by police each year suffer from mental illness.

Officer support for the program has grown over time. At his first training, Evans says, “You heard things like, I’m a cop — I’m not a social worker.” Now, the program is taught by experienced law enforcement officers who share its benefits with those they’re teaching. “You have law enforcement officers telling others that these programs will not only help to protect the community, but they also help to protect the officer.”

With the support of the past and current police chiefs in San Antonio, more than 6,000 officers have undergone the training — “upwards of 90 or 95 percent” of the Bexar County police force, Evans says.

“It’s pretty expensive, but they know that the return on investment is very high because this is really helping law enforcement officers to go back to that good community policing and have some other skills to deal with the public rather than just the military command voice and command presence.”

Still, police training wouldn’t do much good, Evans realized, if the homeless and mentally ill had nowhere to go for treatment. So the city pooled its resources and built the Restoration Center, which opened in 2008. The center now diverts more than 18,000 each year — people who used to go to jail or emergency rooms, or were put back on the street — to treatment. The Restoration Center also houses a sober unit, detox unit, mental health crisis unit, and a treatment center for minor medical problems.

All told, the innovations have dramatically changed the city. “In this past year, we’ve had up to 1,000 empty beds in the county jail,” Evans says.

They’re attracting attention, not just nationwide, but around the world. Representatives from all 50 states and half a dozen countries have visited San Antonio. “Two or three times a week,” Evans says, “people are coming and getting a feel for what they can do back in their home communities.”

Similar prorgams modeled on San Antonio's have been adopted in municipalities across the country, including in Connecticut and Los Angeles County, which houses one of the nation’s largest jails.

Another sign of success? The program’s revocation rate — a measure of how many arrested return to jail or prison. Generally, 40 to 60 percent of felons on parole are back in jail three to five years after their release. For those with mental illness, Evans explains, the rate is a bit higher.

San Antonio’s revocation rate is just 6.6 percent. “If you can get somebody to treatment in the first place,” Evans says, “their treatment works.”

It also saves money. Treating severe mental illness in jail or prison is much more costly than treatment on an outpatient basis. The new diversion programs save more than $10 million a year. “The state saves a lot of money, they free up space in prison for violent offenders, and you’re not criminalizing somebody for an illness,” Evans says. “If you can save the taxpayer’s dollars and improve the public safety, who’s against that? That’s not being soft on crime, either. That’s just the opposite — that’s being right on crime.”

For Evans, the reward is more personal. He's worked with residents who are now living productive lives, he says. “They’re wonderful people. When treatment works, that’s what gets me excited — actually seeing these people get into treatment and reestablishing their relationships with family and friends and waking up in the morning and looking forward to the day rather than looking forward to being under a bridge and self-medicating with alcohol and drugs.”