Families ACT! Report - in Search of Solutions To Santa Barbara's Revolving Door Final Edit

In Search of Solutions to Santa Barbaras Revolving Door
A Report and Recommendations by Families ACT!
January 2012
Table of Contents
Executive Summary ..............................................................................................................................................................iiiii 1. Introduction ..........................................................................................................................................................................1 A. B. A. B. C. D. A. B. C. D. E. F. G. H. I. A. B. C. D. A. B. C. A. B. A. B. C. A. B. C. D. E. F. G. H. I. J. K. What is the Purpose of This Report? ..................................................................................................................... 1 About Families ACT! .............................................................................................................................................. 1 Definition................................................................................................................................................................. 2 Prevalence and Risk Factors ................................................................................................................................. 2 Integrated Treatment and The No Wrong Door Approach ................................................................................... 4 Patients, Street People or Criminals? .................................................................................................................... 5 Cycles of De-institutionalization and Re-institutionalization-A Return to the 1840s .............................................. 6 Defunding Mental Health Care ............................................................................................................................... 7 The Criminalization of Drug Use: a 1200% Increase in Incarceraction of Drug Offenders .................................... 8 The School-to-Prison Pipeline ............................................................................................................................. 9 U.S. Incarceration Rate Highest in the World ......................................................................................................... 9 Californias High Recidivism Rate ........................................................................................................................ 11 Co-occurring Disorders as a Factor in Recidivism ............................................................................................... 12 Paths to Public Safety: Retribution or Rehabilitation? .......................................................................................... 12 Corrections as the New Goldmine ........................................................................................................................ 12 Who Participated? ................................................................................................................................................ 14 An Opportunity for Collaboration .......................................................................................................................... 15 Drug -and Alcohol- Related Deaths ...................................................................................................................... 15 Critically Important Data ....................................................................................................................................... 16 Safety Net or Labyrinth? ....................................................................................................................................... 19 Falling Through the Cracks .................................................................................................................................. 19 A Series of Catch 22s .......................................................................................................................................... 20 The Need for a Centralized, Planned, Sustained Effort to Close the Gaps ....................................................... 25 Voluntary Treatment, Involuntary Treatment or Court-Ordered Treatment .......................................................... 26 A Serious Shortage of Beds ................................................................................................................................. 27 Sober Living Homes ............................................................................................................................................. 28 The Haves and the Have Nots ............................................................................................................................. 28 Years of Challenge ............................................................................................................................................... 30 Crisis and Recovery Emergency Services Walk-In Clinic (C.A.R.E.S.) ............................................................... 30 Assertive Community Treatment (ACT) ............................................................................................................... 30 SOARS ................................................................................................................................................................. 31 Meeting Criteria .................................................................................................................................................. 31 Diagnosing Is Not a Perfect Science .................................................................................................................... 31 Crisis Calls............................................................................................................................................................ 32 Call 911 .............................................................................................................................................................. 33 Blood Alcohol Level .............................................................................................................................................. 34 The Lanterman-Petris-Short Act (italics ours) ...................................................................................................... 34 LPS Conservatorship ........................................................................................................................................... 35
2. Co-Occurring Disorders ......................................................................................................................................................2
3. Historical Factors.................................................................................................................................................................6
4. The Santa Barbara Task Force on Co-Occurring Disorders ..........................................................................................14
5. Mapping the Gaps ..............................................................................................................................................................18
6. 2011 Grand Jury Report on Homeless Mentally Ill .........................................................................................................25
7. Emergency, Transitional and Treatment Beds in Santa Barbara ..................................................................................27
8. Alcohol Drug and Mental Health Services (ADMHS) ......................................................................................................30
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9. Unserved, Underserved and Trapped Populations ........................................................................................................36 A. B. Whose Mandates? ............................................................................................................................................... 36 Stigma, Moral Judgment and Ignorance of the Facts ........................................................................................... 36
10. A Cost Comparison? .......................................................................................................................................................37 11. What IS Working? ............................................................................................................................................................38 A. B. C. D. E. F. G. H. I. J. A. B. C. D. E. A. B. Santa Barbara City Housing Authoritys Supportive Housing ............................................................................... 38 Phoenix of Santa Barbara (Mainstream Behavioral Health) ................................................................................. 38 WillBridge of Santa Barbara ................................................................................................................................. 38 Mental Health Associations Fellowship Club & Recovery Learning Center - ...................................................... 38 Santa Barbara Jails Sheriffs Treatment Program (STP) ..................................................................................... 38 Restorative Court.................................................................................................................................................. 39 Restorative Policing .............................................................................................................................................. 39 Substance Abuse Treatment Court (SATC) & Methamphetamine Recovery Services ........................................ 39 Common Ground Volunteer Training ................................................................................................................... 40 Ad Hoc Programs Serving the Homeless and Forensic Populations ................................................................... 40 Better Linkage and Coordination .......................................................................................................................... 41 Radical Reform in our Mental Health Care System .............................................................................................. 41 The need for Advocates & Case Managers ......................................................................................................... 42 AB-109: From Punishment to Rehabilitation-Breaking the Revolving Door ......................................................... 43 Meaningful Work / Reduced Recidivism ............................................................................................................... 44 New Jail or Alternatives to Incarceration? ............................................................................................................ 46 Potential Funding Sources ................................................................................................................................... 46
12. What is Needed? ..............................................................................................................................................................41
13. Funding for Alternatives .................................................................................................................................................46
14. Model Programs ...............................................................................................................................................................48 15. Findings and Recommendations ...................................................................................................................................50 Conclusion .............................................................................................................................................................................54 Appendix A: Case Stories .....................................................................................................................................................56 Appendix B: Santa Barbara County Substance Abuse Treatment Court .........................................................................58 Appendix C: The Story of Rick and Gibby ...........................................................................................................................59
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Executive Summary
ntreated mental illness and co-occurring substance misuse are at the core of Santa Barbaras overcrowded jails and prisons, burgeoning homeless population, and recent spikes in our suicide and alcohol- and drug-related deaths. To a large extent the crisis we face is not unique to Santa Barbara and has its roots in historical factors and policy decisions made over the last four decades at the federal and state level. Deinstitutionalization, tough drug laws and mandatory sentencing, the criminalization of drug use as well as homelessness, a punitive rather than rehabilitative criminal justice system, severe cuts to social services and debts incurred by our county mental health department have contributed to the crisis we face today.
In May of 2008, Families ACT! convened The Santa Barbara Task Force on Co-Occurring Disorders to address the need for alternatives to the costly revolving door so familiar to Santa Barbara residents suffering with co-occurring mental health and substance use disorders. This population cycles in and out of jail, prison, emergency rooms, shelters, sober living houses and our streets and is at great risk of dying of suicide, overdose or neglect. The goal of the Task Force was to foster much needed communication and collaboration between criminal justice and treatment providers, document the extent of the crisis and identify obstacles to and opportunities for, effective low-cost, high-impact solutions with an emphasis on residential treatment. A broad spectrum of stakeholders including families, criminal justice agencies and service providers were invited to the table and met roughly every other month for two and a half years. Based on data gathered from Task Force participants, interviews conducted with stakeholders, and a review of working models in other communities, Families ACT! has identified systemic flaws, specific underserved populations, and specific obstacles to effective recovery which these populations face in Santa Barbara. Families ACT! is recommending a series of policy changes, innovative solutions and sustainable funding options to help break the revolving door cycle in our county. Among the challenges Santa Barbara County faces are gaps in services to the dually-diagnosed subpopulation deemed to be dealing primarily with substance use disorders and/or considered less than severely and persistently mentally ill. Many are not considered eligible for Social Security Disability benefits. Neglected by Alcohol, Drug and Mental Health Services (ADMHS) they tend to cycle through the criminal justice system on felony drug charges. Those who are chronically homeless typically face misdemeanor charges related to illegal camping, open containers, petty theft or urinating in public. Effective innovative programs have been put into place to serve these populations, such as the Drug or Treatment Court and Restorative Courts, the Restorative Policing program, homeless jail discharge planning and Justice Alliance. Key elements are needed, however, to maximize the effectiveness of these systems. We have identified several critical gaps in services to this subpopulation, including adequate integrated mental health and substance abuse treatment case management and mentoring acute, transitional and long term residential treatment beds supportive housing meaningful volunteer or work opportunities
Families ACT! proposes various policy reforms, including but not limited to: a radical reform of alcohol, drug and mental health treatment service delivery to bring the department to the people it purports to serve, reallocate resources from middle management to direct services to ensure adequate mobile crisis response, acute hospitalization and street outreach to the homeless population affected by mental health disorders
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a refocusing of Probation and AB-109 funds on rehabilitation programs in contrast to punitive supervision and incarceration a redirection of funding from the District Attorneys office to holistic programs within the public defenders office
Innovative and costeffective solutions proposed include:
A system-integration/Ombuds Office charged with streamlining a fragmented delivery system, improving intra- and inter-system communications, coordination and collaboration between service providers (including law enforcement and judicial systems) Expand Restorative Justice & Restorative Policing Programs A Cadre of Trained Volunteer Mentors, System Navigators, Paraprofessionals A pilot WORK FIRST Program Engage the local business community (Downtown Organization, Milpas Association) in finding solutions A Community Enterprise Center incubate local sustainable businesses Keep Homeless Shelters Open to Residents 24 hours a day with daytime programs More Acute/Psychiatric Beds as demonstrated by a nearly tragic case of Ben Warren held in the county jails isolation cell after two suicide attempts, self-mutilation which required sutures and a refusal to eat or drink. A Crisis Residential Center to receive patients who would otherwise meet criteria for hospitalization or from the psychiatric units, thus providing a less restrictive and less costly option after they are stabilized. A Step-Down Residential Treatment Center -- for persons exiting the detox program, the jail (serving discrete populations or blended with patients exiting the PHF Unit) Expand the number of Licensed Social Model Residential Treatment Homes based on the Phoenix of Santa Barbara model with 24/7 staff for persons with mental health disorders on SSI SSDI disability benefits Establish one or two new houses with 12 beds each yearly. Facilitate development of a Therapeutic Community based on a modified Delancey Street ModelFacilitate establishment of a local businesses in conjunction with a Delancey-model residential educational center housing 15-35 residents. Enhance the Effectiveness of Sober Living Homes Invest in strengthening the therapeutic impact of existing homes by providing residents with case management, a continuum of treatment options, job training and employment. Cottage Hospital at one point a willing participant in a large collaborative effort to write a SAMHSA grant for a treatment center to serve people without private insurance, simple ways that Cottage can help immediately are: o o Provide 2 scholarship beds at 5 East --146 patients/yr for 5 day stay Provide 2 scholarship beds at Cottage Residential Center Inpatient 28-day Program 2 beds for 28 days each would allow 24 patients per year
Deposit Fund to help facilitate people moving into shared rentals
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1. Introduction
A. What is the Purpose of This Report?
This report is a grassroots response to a pressing need in our Santa Barbara community. The purpose of this report is to: 1. Define and describe the constellation of complex issues that surround the treatment of people suffering from co-occurring mental health and substance use disorders in Santa Barbara County. 2. Document the work and findings of the Santa Barbara Task Force on Co-Occurring Disorders that was convened by Families ACT! in May 2008. 3. Identify underserved populations and summarize critical gaps in our current system which contribute to a cycle which is referred to as a revolving door. 4. Review successful models in other communities for possible adoption in Santa Barbara. 5. Demonstrate how untreated mental illness and co-occurring substance misuse are at the core of our overcrowded jails and prisons, burgeoning homeless population, and the spikes in our suicide and alcohol- and drug-related deaths. 6. Provide a series of recommendations for policy change and implementation strategies that will address the crisis we face and help close the gaps.
B. About Families ACT!

Families ACT! is a grassroots organization formed in 2007 by Santa Barbara families impacted by the injustice, lack of compassion and inefficient treatment of people with mental health and substance use disorders. Several mothers who had lost their young adult dually-diagnosed sons, began to meet in March of 2006. In the spring of 2007, the moms hosted a standing-room-only public forum designed to engage the community-at-large in a discussion about the interrelationship between our overcrowded jail and the tragic lack of services for Santa Barbara residents with co-occurring mental health and substance use disorders. Families ACT!s mission is to serve and empower individuals and families struggling with dual disorders, prevent homelessness, suicide and overdose, and be the catalyst for effective alternatives to incarceration for this population. Its objectives include prevention and intervention as well as systemic reform. Families ACT! believes that addressing needs at an early stage is cost-effective and, that addressing needs at any stage, will save lives. Read our story: The Revolving Door, Santa Barbara Independent, Feb. 8, 20071
http://www.westentech.com/fact/docs/The_Revolving_Door_Article.pdf
January 2012
2. Co-Occurring Disorders
A. Definition
For the purposes of this report, we are concerned with adults who are struggling with dual diagnosis, also known as the co-occurrence or co-morbidity of psychiatric disorders and substance use disorders. The term dual diagnosis is convenient, if somewhat misleading, as persons with dual disorders are often not diagnosed or not correctly diagnosed--for years. According to the National Institute on Drug Abuse (NIDA), The term co-morbidity also implies interactions between the illnesses that can worsen the course of both.2 Psychiatric disorders can predispose a person to use or misuse substances, and substance misuse can cause or aggravate psychiatric disorders. NIDA defines a mental disorder as a mental condition marked primarily by sufficient disorganization of personality, mind, and emotions to seriously impair the normal psychological or behavioral functioning of the individual. As such, drug addiction is in itself considered a mental disorder: In fact, the DSM, which is the definitive resource of diagnostic criteria for all mental disorders, includes criteria for drug use disorders, distinguishing between two types: drug abuse and drug dependence. Drug dependence is synonymous with addiction. By comparison, the criteria for drug abuse hinge on the harmful consequences of repeated use but do not include the compulsive use, tolerance (i.e., needing higher doses to achieve the same effect), or withdrawal (i.e., symptoms that occur when use is stopped) that can be signs of addiction.3 Addiction is characterized by NIDA as a chronic, often relapsing, brain disease.4 In Santa Barbara, the population with co-occurring disorders includes young adults still living with their parents as well as chronically homeless men and women who have lost or become estranged from their families. These populations represent both ends of a spectrum of individuals who are falling through the cracks of our eroding system of care. They are at different stages on the same continuum. It is our position that, we must treat the person as a whole--although it may be useful to attempt to discern exactly how each disorder is manifesting and what the relationship is between the two kinds of disorders in the life and psyche of an individual. Addressing both manifestations of disregulation, is the only way to effectively address the challenges the individual faces and the distress his or her dilemma is causing for the collectivefor our community as a whole.
B. Prevalence and Risk Factors

According to Kenneth Minkoff, a national expert in dual diagnosis and public sector managed care, when treating mental health disorders, co-occurring issues and conditions are an expectation, not an exception.5 The Epidemiological Catchment Area Study of the early 1980s and the National Comorbidity Survey (NCS) of the early 1990s6 revealed that the odds of having a substance use disorder were
2 3 4
InfoFacts: Comorbidity: Addiction and Other Mental Disorders, National Institute on Drug Abuse (NIDA), March 2011 NIDA Research Report Series. Comorbidity: Addiction and Other Mental Illnesses, Oct 2010, p. 2 National Institute on Drug Abuse (NIDA), InfoFacts: Understanding Drug Abuse and Addiction, Revised March 2011. 5 http://www.kenminkoff.com/ccisc.html 6 Mental Health: a Report of the Surgeon General, 1999
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significantly higher among patients with psychotic illness than among those in the general population7 and that, compared with the general population, people addicted to drugs are roughly twice as likely to suffer from mood and anxiety disorders, with the reverse also true.8 The most recently available estimates from SAHMSA are that 5.4 million U.S. adults have cooccurring substance use and psychiatric disorders, and that only 10% of these receive care for both conditions concurrently.9 According to reports published in the Journal of the American Medical Association (JAMA), nationally: Roughly 50% of people with severe mental disorders are affected by substance abuse.10 37% of alcohol abusers and 5 % of drug abusers also have at least one serious mental illness.11
Risk factors include involvement with the criminal justice system and homelessness. According to the U.S. Bureau of Justice statistics: 65.8 % of local jail inmates met criteria for a substance use disorder in 2006.12 64% of jail inmates in 2005 had mental health problems (defined by a clinical diagnosis, having received mental health treatment during the prior 12 months or experiencing subclinical levels of symptoms based on the DSM-IV).13 32.9 % of state prison and county jail inmates in 2005 had a mental health disorder (defined as any past diagnosis or history of treatment of a psychiatric disorder).14
In addition:
According to The National Institute on Drug Abuse, in the United States as a whole, a substantial portion of jail and prison inmates have co-occurring disorders: 25.5% of local jail inmates in 2006 had co-occurring mental health problems and substance use disorders. 15 16% of jail and prison inmates have severe mental health and co-occurring substance abuse disorder.16 72% of local inmates with a serious mental illness had a co-occurring substance use disorder, dependence or abuse, according to a 2011 review of U.S. Department of Justice statistics. 17 As many as 50% of all veterans diagnosed with PTSD also have a co-occurring substance use disorder (SUD),18
Substance Abuse and Co-occurring Disorders Knowledge Asset, Web site created by the Robert Wood Johnson Foundations Substance Abuse Policy Research Program, Mark P.McGovern, Ph.D., Mar 2010 http://www.saprp.org/knowledgeassets/knowledge_results.cfm?KAID=12 8 Ibid. InfoFacts March 2011 9 Ibid. Substance Abuse Policy Research Program citing on 2008 SAMHSA research 10 National Alliance on Mental Illness (NAMI) 2005 11 Ibid. 12 U.S. Bureau of Justice Statistics Reports, Prisoner in 2006 & CASA analysis of Survey of Inmates in Local Jails (2002) 13 Friedmann, P. D., Taxman, F.S. & Henderson, C.E. (2007) cited in CASA, Behind Bars II p. 26 14 Ibid. 15 The National Center on addiction and Substance Abuse(CASA) at Columbia University (2010). 16 Ibid. 17 2011 report based on a review of medical literature and Department of Justice statistics (presented at 2011 Annual Meeting of the American Academy of Psychiatry and cited in Clinical Psychiatry News: Severe Mental Disorders Highly Prevalent in Jails, Prison.) Refersto SAMHSA statistic.
18
Op. Cit. NIDA Research Reports Series: Comorbidity p. 9
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In addition, Jail inmates with mental health disorders are twice as likely as inmates without mental illness to have been homeless.19 An estimated 50 percent of homeless adults with serious mental illnesses have a cooccurring substance abuse disorder.20
In Santa Barbara County: 7 out of 10 drug court participants have co-occurring chemical dependency and mental health problems.21 72% of Santa Barbara County inmates had current or prior drug or alcohol charges on 2/2/10.22 The percentage of our dually diagnosed offenders rose over 70% in six years.23
C. Integrated Treatment and the No Wrong Door Approach

In terms of treatment, co-morbidity or co-occurrence present complex challenges. The social stigma once attached to mental illness now seems more pronounced in the case of substance disorders. Nora D. Volkow M.D., Director of the National Institute on Drug Abuse, hopes that commonalities in the genetic, environmental and neural bases of both sets of disorders, will serve to dispel this stigma. According to Dr. Volkow, It is often difficult to disentangle the overlapping symptoms of drug addiction and other mental illnesses, making diagnosis and treatment complex. Correct diagnosis is critical to ensuring appropriate and effective treatment. Ignorance of or failure to treat a comorbidity disorder can jeopardize a patient's chance of recovery. 24 In the words of the National Alliance on Mental Illness (NAMI), Those who struggle both with serious mental illness and substance abuse face problems of enormous proportions. Mental health services tend not to be well prepared to deal with patients having both afflictions. Often only one of the two problems is identified. If both are recognized, the individual may bounce back and forth between services for mental illness and those for substance abuse, or they may be refused treatment by each of them. Fragmented and uncoordinated services create a service gap for persons with co-occurring disorders. 25 Ideally, according to Kenneth Minkoff, [The expectation] that persons with mental health disorders are struggling with drug and alcohol use must be included in every aspect of system planning, program design, clinical policy and procedure, and clinical competency, as well as incorporated in a welcoming manner in every clinical contact, to promote access to care and accurate screening and identification of individuals and families with multiple co-occurring issues. 26
19 20 21
Op. Cit. Bureau of Justice Statistics Special Rep ort: Mental Health Problems of Prison and Jail Inmates Op. Cit.NIDA InfoFact. Santa Barbara County ADMHS data,2006. 22 Data provided to Families ACT! by Sergeant McWilliams of the SB Sheriffs Department on 9/21/11 23 ADMHS Data, 2006 cited in Santa Barbara County Alcohol, Drug and mental health Services Clean and Sober Drug Court (CSDC) SAHMSA Grant Application, March 2010. 24 Op. cit. NAMI 25 Ibid. 26 KenMinkoff.com
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In Search of Solutions to Santa Barbaras Revolving Door Research reported by Mueser, et al. in 199727 and Mercer-McFadden, et al. in 199828 showed that treating co-occurring disorders through separate service systems is ineffective. Parallel or sequential treatment models are less than ideal. According to NAMI, Effective integrated treatment consists of the same health professionals, working in one setting, providing appropriate treatment for both mental health and substance abuse in a coordinated fashion. The caregivers see to it that interventions are bundled together, with no division between mental health or substance abuse assistance. The approach, philosophy and recommendations are seamless... 29 The No Wrong Door philosophy in dual diagnosis treatment requires that each provider accept the responsibility to provide clients with, or link them to, appropriate services, regardless of where the client enters the system. It requires that relationships be built between providers and agencies to prevent clients from falling through the cracks between the jail, county mental health, detox centers, shelters, hospitals, etc. 30
D. Patients, Street People or Criminals?

Current practices in Santa Barbara County are a far cry from the No Wrong Door approach and Minkoffs recommended seamless and welcoming integrated approach to dual disorders unless one considers sitting behind bars at the county Jail a welcoming experience. The challenges currently faced by many persons with co-morbidity, are considerably graver than just the lack of integrated treatment. In Santa Barbara, we have a silo effect operating, despite the fact that the Alcohol Drug Program (ADP) was housed under the same roof with mental health services for many years. Increasingly, persons with co-occurring disorders are being turned away from ADMHS. For this reason, among others, they are now at greater risk of becoming involved with the criminal justice system, than in the past. (Treatment has gone backwards!) Once a dually-diagnosed person enters the criminal justice door and has an encounter with law enforcement, he or she often becomes so entangled with the courts, probation or parole, that he or she may not ever enter a treatment door. As traumatized, self-punishing or self-medicating individuals, this population begins to think of THEMSELVES as criminals, further reinforcing a low sense of self-esteem. If they become involved with the treatment courts, they may be invited to enter an inpatient or outpatient treatment program, sometimes with the risk of flash incarceration or increasingly severe penalties hanging over their heads--then the issue becomes the shortage of residential treatment beds.
27
Integrated treatment for dual disorders:A guide to effective practice, Kim TornvallMueser, Douglas L.Noordsy, Robert E. Drake. 28 Substance Abuse Treatment for People with Severe Mental Disorders, A Program Managers Guide, New HampshireDartmouth Psychiatric Research Center, 1998 29 Op. cit. NAMI 30 More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States, May 2010 Report by the Treatment Advocacy Center, p. 1, http://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_study.pdf
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3. Historical Factors
he crisis Santa Barbara now faces as evidenced by an overcrowded jail, increasing visible homelessness and homeless deaths and spiking overdose deaths, is not unique to our community and has its source in historical and political realities beyond the control of local jurisdictions. Deinstitutionalization, the international drug trade, drug laws and mandatory minimum sentencing legislation put into place in the 1980s and 1990s, as well as federal and state disability regulations and the current state of our economy, have all shaped the complex realities we now confront.
A. Cycles of De-institutionalization and Re-institutionalization:

A Return to the 1840s A report published in May 2010 by the Treatment Advocacy Center, determined that in the United States, 40 percent of individuals with serious mental illnesses have been in jail or prison at some time in their lives. The report concludes: we have now returned to the conditions of the 1840s by putting large numbers of mentally ill persons back into jails and prisons.31
The report also notes that: For the approximately half of discharged patients who have ended up homeless or in jails and prisons, [deinstitutionalization] has been a personal tragedy. Although
31
More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States, May 2010 Report by the Treatment Advocacy Center, p. 1, http://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_study.pdf
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deinstitutionalization was well intentioned, the failure to provide for the treatment needs of the patients has turned this policy into one of the greatest disasters of the 20th century.32 At a 1973 hearing in the California State Senate, The San Joaquin County sheriff testified prophetically that a good deal of mental illness is now being interpreted as criminality. This was the case in our country back in the 1800s as well, until Dorothea Dix took over a reform movement that led to the establishment of mental hospitals and a more humane treatment of mentally ill persons. Thanks to her tireless advocacy, mentally ill individuals were treated in hospitals for over one hundred years. Then, once again, the pendulum swung back the other way. A process of deinstitutionalization began in California in 1956 under Republican Governor Goodwin Knight, and the state mental hospitals began to empty out. This process continued through the 1960s under Democratic governor Edmund Pat Brown, and was well underway when Ronald Reagan vowed to close them in the 1970s. Liberals and conservatives, each for their own reasons, whether based on civil liberties or cost-cutting, aligned to close state mental hospitals. The institutions themselves began to close in the 1990s in large numbers. From 1955 to 1980 the population in state mental hospitals fell from 559,000 to 154,000! According to a report by the Kaiser Commission on Medicaid and the Uninsured, Looking backa primary problem was that mental health policy-makers overlooked the difficulty of finding resources to meet the needs of a marginalized group of people living in scattered sites in the community. Funding streams were uncoordinated. Even when needs were eventually recognized, it was difficult to braid together a comprehensive service package.33 This same report cites the fact that 136,000 people with severe mental illness where incarcerated in 2000. 34
B. Defunding Mental Health Care

As the demand for mental health and alcohol and drug treatment services increases in the wake of a growing epidemic of behavioral disorders, the U.S. public mental health service system is being dismantled. Between 2009 and 2011, more than 2/3 of states cut mental health funding from their general funds.. Radical cuts in mental health and substance abuse treatment have taxed emergency rooms, and contribute to the heavy involvement of law enforcement, jails, prisons and the courts in the lives of people struggling with disorders. In 2001, the states were spending 30% less on mental health care, adjusted for inflation, than in 1955, and state funding accounted for less than 2% of all dollars spent on mental health care. Psychiatric hospitals and departments were already closing their doors due to Medicare reimbursement reductions. 35 More state hospitals had closed in the 5 years from 1990 to 1995 than in the preceding 20 years.36 Mental Health Policy advocates warned a decade ago, that: States cannot be allowed to shirk their historic responsibilities to provide a safety net for indigent patientsregardless of diagnosis. Their support is particularly needed for residential and rehabilitation services. Turning public care over to the managed care industry is not a solution; indeed, it simply exacerbates the problem.37
32
More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: a Survey of the States, Treatment Advocacy Center, May 2010, p.11 33 Learning From History: Deinstitutionalization of People with mental Illness as Precursor to Long-Term Care Reform, The Kaiser Commission on Medicaid and the Uninsured, p.2 34 Ibid., p. 13, citing Frank, Richard G, Glied, Sherry A., Better but not Well: Mental Health Policy in the United States since 1950, The Johns Hopkins University Press 35 Bazelon Center for Mental Health Law: Disintegrating Systems: The State of the States Public Mental Health Systems. Washington, DC, Bazelon Center for Mental Health Law, 2001 in Response to the Presidential Addressthe Systematic Defunding of Psychiatric Care: A Crisis at Our Doorstep, Paul S. Appelbaum, M.D., American Journal Psychiatry 2002; 159:1638-1640. 10.1176/appi.ajp.159.10.1638 36 Ibid. 37 Ibid.
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Those who foresaw the collapse of mental health care a decade ago looked to mental health parity legislation as a possible solution. When the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was passed in 2008 after a twelve year fight, Patrick Kennedy, who has struggled with depression, alcoholism and drug abuse , hailed it as one more step in the long civil rights struggle. "For far too long, he added, health insurance companies have used the stigma of mental illness and substance abuse as an excuse to deny coverage for those biological disorders. 38 Unfortunately, Medicaid is exempt from parity because it is an entitlement program and not subject to the provisions that regulate private insurance.
C. The Criminalization of Drug Use:

A 1200% Increase in Incarceration of Drug Offenders Today, persons with dual disorders in California are inherently at risk for involuntary confinementin a jail or a prison. This is because drug use itself has become a crime. For someone on probation, alcohol consumption is frequently off-limits as well, and often grounds for re-arrest. Harsh drug laws and mandatory sentencing laws passed in the U.S. in the 80s and 90s have contributed to an astounding 1200% increase in the numbers of drug offenders incarcerated between 1980 and 200839 and a 290% increase in the overall incarceration rate40 during this period. In 2009, 55% of federal prisoners and 21% of state prisoners were serving time for drugs.41 During this same period of time, the number of people In Santa Barbara County alone, 7,639 cases (44% of total) in Fiscal year 2008-09 and 8,422 cases (47% to total) in Fiscal Year 09-10 involving drugs or alcohol, were handled through the District Attorneys office in Superior Court. 339 of the total cases for these two years ended in state prison sentences. In 2010, 1,818 cases were filed involving transients in the County of Santa Barbara. There were eight mental health cases handled in FY20 08-09 and 37 cases in FY 2009-10. Despite the unprecedented decline in violent and property crimes since the early 1990s, the rate of incarceration linked to alcohol and other drugs has continued to grow. More substance- involved offenders are crowding our prisons and jails than ever before as the nations criminal justice system maintains a costly loop of untreated addiction and criminal recidivism.42 In 2006, 2.3 million American adults were incarcerated prisons nationwide (up 32.8 percent from 1.7 million in 1996. 43: o o o Federal (0.2 million) State (1.3 million) Local (0.8 million) in correctional facilities
By 2006, there were 1.9 million substance-involved offenders behind bars in America; an increase of 43.2 percent from 1996.44
38
After 12 years, Wellstone mental health parity act is law, Fred Fromer, Associated Press, October 3, 2008. Minnesota Public Radio new 39 Jim Webb, U.S. Senator from Virginia http://webb.senate.gov/issuesandlegislation/criminaljusticeandlawenforcement/Criminal_Justice_Banner.cfm 40 See Appendix B 41 th A Nation of Jailbirds, Lexington. The Economist, April 4 , 2009. 42 Op. cit., Behind Bars II, p. 9 43 Ibid. 44 Ibid. Behind Bars II, p. 9
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Substance-involved inmates are those who either had a history of using illicit drugs regularly, met medical criteria for a substance use disorder or were under the influence of alcohol or other drugs when they committed their crime.45
D. The School-to-Prison Pipeline

Families ACT! constituents are concerned that the presence of police officers on Santa Barbaras public school campuses reflects a trend toward zero-tolerance disciplinary policies that tend to criminalize minor infractions and target minority children in particular. According to an Education Department report released in March 2012,46, more than 70 percent of students involved in school-related arrests or cases referred to law enforcement nationwide were Hispanic or African-American. The Education Department findings released in March 2012 come from a national collection of civil rights data from 2009-10 of more than 72,000 schools serving 85 percent of the nation. The data revealed that 42 percent of the referrals to law enforcement involve black students and 29 percent involved Hispanics, while 35 percent of students involved in school-related arrests were black and 37 percent were Hispanic. Black students made up 18 percent of the students in the sample, but represented 35 percent of students suspended once and 39 percent of students expelled. Students with disabilities made up only 12 percent of students in the sample, but nearly 70 percent of students physically restrained by adults were students with disabilities. Black students represented 21 percent of students with disabilities. The data revealed that 44 percent of students with disabilities are subjected to mechanical restraints.
E. U. S. Incarceration Rate Highest in the World

The overcrowding of our jails and prisons and the fact that the US has the highest incarceration rate in the world are facts relevant to our local crisis. To a large extent, persons who use and abuse substances, many of whom have co-occurring mental health disorders of varying degrees, are those who have filled our jails and prisons since the early 1980s. Twenty-four percent of the people in state and federal prisons in the U.S. in 2006 were there because their most serious offense was a drug offense. 47 Punishing this population may take them out of circulation for a time, but does not necessarily work as a deterrent. A 2002 study found:
45 46 47
Ibid. p. 10 http://www.ed.gov/ #3 Civil Rights Data Collection March 2012 survey of schools/ cited in Finding Direction. Source: Organization for Economic Co-Operation and Development, Factbook 2009: Economic Environmental and Social Statistics (Paris, France: Organization for Economic Co-Operation and Development, 2009)
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In Search of Solutions to Santa Barbaras Revolving Door no evidence that imprisonment reduced or delayed recidivism, either for felony offenders generally or for drug offenders specifically. To the contrary, we found that offenders sentenced to prison failed more often and more quickly than offenders placed on probation and that incarcerated drug offenders had significantly higher recidivism rates than any other offenders. 48
Note: U.S. population grew by only 2.8 times during the same period.
48
The Effects of Imprisonment on Recidivism Rates of Felony Offenders: A Focus on Drug Offenders, Spohn, Cassia and David Holleran, Criminology, Vol 40, No. 2 (2002): p. 329-58
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In just 26 years, between 1980 and 2006, the number of Americans under state correctional control for drug offenses increased fourteenfold, while the number of violent offenders increased only threefold.49 Twenty-one percent of state prisoners in 2001 were behind bars for nonviolent drug offenses, compared to 9% in 1985, whereas 57% of inmates are serving time for drug offenses. 50 Incarceration rates for blacks and Latinos are more than six times higher than for whites and sixty percent of Americas prison population is either Latino or African American. One out of twelve working-age African American males is in prison and 21 percent of those between 25 and 44 have been imprisoned. If current trends continue, one-third of all black males will go to prison during their lifetimes. 51 According to Glenn Greenwald, multiple, complex factors contribute to this racial disparity, but it is clear that Americas harsh laws and the unequal enforcement of them play a large role.52
F. Californias High Recidivism Rate

Californias recidivism rate of 67.5% is among the highest in the nation.53 More than three-fourths of convicted California felony offenders are placed on probation rather than being sentenced to prison.54 However, in the mid 1990s one in every seven adult probationers in California had his or her probation revoked and was sent to state prison, which contributed to the burgeoning of the states prison population. California probations high failure rate has been blamed on the fact that probation has been underfunded since Proposition 13 passed in 1978 and Proposition 4 passed in 1979. Probation
49 50
With Liberty and Justice for Some, Glenn Greenwald, Metropolitan Books, Henry Holt and Company, LLC, 2011. P. 242 The Politics of Injustice, Crime and Punishment in America Katherine Beckett and Theodore Sasson. 200 thousands Oaks, CA: Pine Forge Press, Sage. 51 Ibid. pp 242-243 52 Ibid. p, 243 53 California Department of Corrections And Rehabilitation, 2010 Adult Institutions Outcome Evaluation Report, p. 11 54 Tim Findley, Story Behind the DecisionDramatic Prison Reform, San Francisco Chron., January 7, 1972, at 1, 26.
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officers were incentivized to recommend incarceration rather than probation to reduce their heavy caseloads, transfer the financial responsibility to the state and avoid the liability posed by a probationer who might reoffend. 55Radical probation reform legislation was passed in 2009 tying state funding to a demonstrated reduction in recidivism and revocation rates among felony probationers. SB 678, which passed both houses of the state legislature without a single No vote and its companion legislation, the California Budget Act of 2009, were designed to address this chronic underfunding and to promote the development of evidence-based supervision practices. According to a former Sacramento Superior Court Judge, the principal reasonjudges are sentencing too many non-violent offenders to prison is the absence of effective community corrections programs providing intermediate punishments and necessary and appropriate treatment and rehabilitation services.56 The states notorious recidivism rate is in part a reflection of probation policies and practices, which, since the 1980s until the very recent past, focused on punishment, surveillance and detection of often minor probation violations.57 Three quarters of departments responding to a 1995 survey of California probation departments considered enforcement of the terms of probation as the top priority, whereas only eight percent regarded rehabilitation and social reintegration as the top priority. 58
G. Co-occurring Disorders as a Factor in Recidivism

A Rand Corporation study reveals that more than half of inmates in California prisons report having had a recent mental health problem and two-thirds report having a drug abuse problem.59 A retrospective study of more than 79,000 Texas inmates, found that inmates with psychiatric disorders were significantly more likely than inmates without psychiatric disorders to be incarcerated repeatedly compared to the general population.60 A 2009 guide to improving outcomes for people with mental health disorders on probation or parole found that people with mental health and co-occurring substance use disorders are twice as likely to incur probation violations and have their community supervision revoked.61 If we do not address mental health, substance use and related factors contributing to our high incarceration rate, such as isolation, poverty and inability to find a job, we will not make a dent in recidivism.
H. Paths to Public Safety: Retribution or Rehabilitation?

Will Public Safety be enhanced through tough on crime policies or by investing in rehabilitation? A recent report entitled Finding Direction: Expanding Criminal Justice Options by Considering Policies of Other Nations compares the criminal justice policies and social, economic, and governmental structures of five countries Australia, Canada, England and Wales, Finland and Germany to the United States. 62 It found that:
55
Reforming Adult Felony Probation to Ease Prison Overcrowding: An Overview of California S.B. 678, January 2011. From the Selected Works of Jessica Feinstein. 56 Ibid, p. 12 57 Nora Harlow & E. Kim Nelson, Management Strategies for Probation in an Era of Limits i-iii (National Institute of Corrections, rev. April 1986); Nieto, supra note 4, at 7, Cited in Federal Sentencing Reporter, Vol. 22, No.3, Feb 2010, Probation Reform in California: Senate Bill 687, Roger K. Warren, p. 187 58 Op. Cit. Nora Harlow 18-19. 59 Behind Bars II, Substance Abuse and Americas Prison Population, February 2010. 60 American Journal of Psychiatry 2009;166:103-9 61 Improving Outcome for People with Mental Illnesses under Community Corrections Supervision: A Guide to ResearchInformed Policy and Practice, Council of State Governments Justice Center, NY, NY 2009 62 Finding Direction, Expanding Criminal Justice Options by Considering Policies of Other Nations (Executive Summary), Justice Policy Institute, p. 3
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In Search of Solutions to Santa Barbaras Revolving Door with its tough on crime politics and a belief in the deterrent effect of harsh sentences; the United States has implemented criminal justice policies based on retribution and incapacitation instead of rehabilitation. Furthermore: The U.S. has an adversarial system that encourages conflict and incentivizes winning. It budgets over twice the amount of money for prosecution as it spends on public defense. England and Wales allocate approximately 4 times as much funding for public defense as for prosecution. The following recommendations from Finding Direction are relevant to our current dilemma. Scale back sentence lengths, especially for possession of small amounts of illegal substances. Such broad sentencing structures are significant contributors to the number of people in prison in the U.S. and are not the best or most cost-effective way to protect public safety. Rely first on a public health strategy to address drug abuse, including treatment and harm reduction. Refocus [probation] and parole toward social work rather than policing. Include a behavioral or mental health component to reentry services.as well as sociological factors like housing, employment, and education. Prioritize spending on strengthening and expanding institutions such as education and employment, especially as they have been shown to not only decrease incarceration, but also improve public safety. Positive methods of promoting public safety may be more effective, especially in the long run
In short, rehabilitation as opposed to punishment is needed to ensure public safety and reverse our high recidivism rate. Persons now being prosecuted for personal possession of illegal substances should be offered behavioral health treatment and helped to find housing, employment and educational opportunities in order to break the revolving door cycle. Restorative policing and restorative courts are proving invaluable in our community. Perhaps its time for restorative supervision. In the words of LaDonna Thompson, Kentuckys Corrections Commissioner, we cant afford to keep building prisons as a short-term solution to public safety. What were after is lasting public safety. And the way to get there is to have effective reentry programs. Incapacitation by itself will not do it. According to Max Williams, the Director of Oregons Department of Corrections, We should look at some immediate markers that we know have a linkage to recidivism look at the barriers to effective reentryessentials like housing, employment, and continuity of health and mental health care. 63
I.
Corrections as the New Goldmine

As in many other areas of American life today, the interest of the corporation threatens real public safety. Incarceration has become big business. According to the 2007 Pew Report entitled Public Safety, Public Spending, national spending on corrections grew from $9 billion in 1980 to $60 billion in 2007.64 Prisons are the fourth-largest state budget line item after health, education and transportation. A 2008 investigative report in the Boston Phoenix documented the substantial investment prison corporations have made in fighting drug policy reform. Corrections Corporation of America (CCA) spent over $2.7 million between 2006 and 2008 lobbying for harsher legislation and generated
63 64
Reducing Recidivism, Public Safety Performance Project, the Pew Center on the States, December 2011 Public Safety, Public Spending, Public safety Performance, A Project of The Pew Charitalbe Trusts, p iv
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In Search of Solutions to Santa Barbaras Revolving Door $133 in net income in 2010.65 In 2008 Geo Group earned $61 million, up from $38 million in 2007 and reported earning of $20 in the first quarter of 2009. 66 This industry and their executives and lobbyist gave $3.3 to candidates and state political parties in 44 states to help craft the penal system to their advantage.67
65 66
Freedom Watch: Jailhouse Bloc by Harvey Silverglate and Kyle Smeallie, December 9, 2008 The Phoenix.com/Boston Corp Watch 2009 67 National Institute on Money in State Politics 2004
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4. The Santa Barbara Task Force on Co-Occurring Disorders
n May of 2008, Families ACT! convened the Santa Barbara Task Force on Co-Occurring Disorders to sound an alarm bell and address the critical need for alternatives to the costly revolving door so familiar to Santa Barbara residents suffering with dual disorders who cycle in and out of our jail, prisons and emergency rooms, who sleep in shelters, sober living houses or on streets, and are increasingly dying of suicide, overdose or neglect. Although Families ACT! was founded by parents of young adults, and advocates for families who are still actively struggling to help find recovery and compassionate and effective treatment for loved ones, we recognize the needs our loved ones share with those who may have lost or become estranged from their families and have become chronically homelessness. The goal of the Task Force was to 1) foster communication and collaboration between all stakeholders including very different sectors of our county who currently interface with people with co-occurring disorders, 2) document the extent of the crisis and 3) identify obstacles to and opportunities for effective, low-cost, high impact solutions with an emphasis on transitional residential treatment beds. The Task Force was unique. It was conceived and hosted by a fledgling grassroots organization with fresh eyes but very limited resources and no experience in public policy reform. Despite drastic funding cuts, competition for dwindling resources, controversial ballot measures, and other obstacles to collaboration encountered by participating departments, programs and agencies over the course of the nearly two and a half years that the Task Force met, the initiative established the need for fundamental changes in the way we treat persons with mental health and substance use disorders. Participants got an education in politics and an overview of the disjointed patchwork of agencies and programs serving persons with co-occurring disorders. The groundwork was laid for the county to pick up where the Task Force left off and work to create a more humane, cost effective and efficient way to organize our service delivery system, mitigate the effects of the revolving door syndrome and better serve our dually diagnosed population.
A. Who Participated?
The Task Force met every other month from May 2008 through October of 2010. A broad spectrum of stakeholders including family members, consumers, city and county government agencies and community-based service providers were invited to participate. While the mix of attendees varied from meeting to meeting, attendance was consistently good. Participants included representatives from:
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Santa Barbara City Council Santa Barbara County Board of Supervisors Public Defenders Office District Attorneys Office Superior Court County Sheriffs Department Police and Narcotics Probation Departments Alcohol, Drug and Mental Health Services (ADMHS) City Housing Authority Cottage Hospital Hotel de Riviera Bringing Our Community Home (BOCH) Council on Drugs and Alcoholism (CADA)
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Phoenix of Santa Barbara New Beginnings Counseling Center Stalwart Clean and Sober Recovery Road City College Alcohol and Drug Counseling Program
B. An Opportunity for Collaboration

One of the goals of the Task Force was to provide family members an opportunity to meet face to face with staff from county staff ADMHS, Sheriffs Department, Probation and Superior Court who seem to have so much power in deciding the fate of their loved ones. Another implicit goal was to begin to build a bridge between treatment providers and the criminal justice systema task which has increasingly fallen to grassroots advocates due to the preoccupation of various county agencies with their own survival. The Task Force meetings provided valuable opportunities for family members, members of the criminal justice system and service-provider systems to bridge the gap in information and communications, to learn each others unique languages and perspectives and to lay the groundwork for closer collaboration. Family members who participated in the Task Force noted the contrasting nomenclature used by the various participants, depending on whether they were members of the medical profession or the criminal justice system. Depending on their point of view, they described the same person as a patient or as an offender; as needing accountability or as needing to have their delusions treated or their anxiety or insomnia managed as they withdrew from alcohol or drug dependence. While some agencies were initially unprepared to share their demographics, many participants provided data which became part of the Task Force Fact Sheet. The focus of the Task Force was largely on South County, due to logistics and limited funding, although the data collected was county-wide. The possibility of hosting a similar initiative in North County was considered.
C. Drug -and Alcohol- Related Deaths

Data provided by agencies and community-based providers participating in the Task Force revealed a number of disturbing trends and documented glaring gaps in our safety net with a concomitant growth in the role the criminal justice system has come to play in interfacing with our target population. 68 Several indices provide alarming evidence of the toll on our community of untreated mental health and substance use disorders: Santa Barbara County suicides and drug and alcohol deaths spiked in 2009: Drug and Alcohol Deaths data for 2011 is pending, but 23 deaths were reported in the first six months 4 Latino young men committed suicide within 5 months in the Fall of 2009.69 Deaths of individuals who were on dozens of prescription drugs tripled from 2008 to 2009, reflecting an alarming national trend. In 2009 Santa Barbara County reported 143 unintentional (nonfatal) poisonings, 226 selfinflicted/suicide poisonings and 485 ER visits for poisonings.
68 69
See Appendix A Expert Advises Santa Barbara on Suicide Spike, Santa Barbara Independent, 2/24/2010 http://www.independent.com/news/2010/feb/24/expert-advises-santa-barbara-suicide-spike/?print
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Of the 45 deaths among homeless population in Santa Barbara between1/1/09 and3/31/10:70 20% were related to illicit drugs 18% were directly attributable to alcohol 38% were alcohol-or-drug-related 65% were related to some form of substance abuse (alcohol, illicit substances, tobacco, or polysubstance abuse). 89% of decedents had a mental health diagnosis
Santa Barbara social worker Ken Williams became the chronicler of homeless deaths while Families ACT! queried the Coroners Office for over a year regarding how many Santa Barbara county residents as a whole were dying of overdoses and suicides. The files were provided to Families ACT! Advocates and Isabelle Walker of the homeless blog, and several months later, an official document was filed as required every three years by the Coroners office with the state of California Alcohol and Drug Programs. Both drug and alcohol deaths and suicides spiked in 2009. These figures included 4 suicides among young Hispanic youth/men and 45 deaths (including several in the first 3 months of 2010) among the homeless. If you include accidental deaths possibly related to drug and/or alcohol intoxication, there were 111 deaths related to drugs and alcohol in 2009. Toxicology screens of many who died of fatal overdoses point to an epidemic of prescription drug abuse aided and abetted by at least one local physician who was prescribing profound doses of narcotics such as OxyContin, Fentanyl and Dilaudid.71
D. Critically Important Data

Data that has been gathered by advocacy groups and volunteers in Santa Barbara in recent years reveal the extent to which mental illness and substance are factors in homelessness and incarceration.
70
Death and Violence Against Homeless Persons in Santa Barbara County: January 1, 2009 through March 31, 2010. August 2010 report, revised July 29, 2010 71 http://www.huffingtonpost.com/2012/01/06/julio-gabriel-diaz-candy-_n_1189376.html?view=print&comm_ref=false
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In Search of Solutions to Santa Barbaras Revolving Door Roger Herrouxs Report on Homelessness Services in the County of Santa Barbara 2/200 In 2005 the Public Health Department treated 4.082 unique homeless individuals 33% had some degree of mental illness over 50% had substance abuse problems
Santa Barbara Common Ground Homeless Vulnerability Index Survey 1/2010: Of 1,143 completed survey, based on self-reporting: 57% mentally ill 34% severely mentally ill 42% had a drug problem 51% had an alcohol problem 77% had been in jail in last year 24% had been in prison in last year
Snapshot of Santa Barbara County Jail Population of 1073 on 2/2/10: 15% on mental health medications 72% had current or prior drug or alcohol charges
This kind of data is critically important in monitoring the health of our community and should be easily accessible to officials and members of the public. These demographics in themselves are indicative of a community in crisis. They are grounds for a coordinated initiative to take stock of the current status of our system of care and the options we have at our disposal to weave our social safety net back together again. During the course of the three and a half years that Families ACT! conducted Task Force meetings and mapped the gaps in our safety net, data requested from ADMHS, the Sheriffs Department and the Superior Court was not always available or readily provided. In several cases, it took several months and in at least one case over a year to have the request filled. Toward the end of 2009, the Coroners Department was unable to provide figures documenting the number of drug-and alcohol-related deaths for most of the preceding year, citing a lack of staff. 2009 did prove to be a record year in terms of the number of deaths from various causes, but it wasnt until Families ACT! advocates mentioned the difficulty they were having getting the data in public testimony at the Board of Supervisors hearing, that the Coroners Office agreed to make it available in un-tabulated form. Later, the same representative from that office admitted that they were rethinking their classification and color-coding methodology. When Sergeant Sandra Brown took over as Supervisor of the Coroners Office, a new system of classification was instituted retroactively whereby a new category, Alcohol and Drug Deathswas created, which did not include deaths involving various sorts of accidents possibly but not conclusively related to the use of alcohol and/or drugs. Alcohol and Drug Deaths for 2009 totaled 75, whereas our records of Alcoholand Drug- Related Deaths for 2009 had totaled 111.
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5. Mapping the Gaps
he Task Force meetings afforded Families ACT! the opportunity to conduct a series of interviews with a variety of stakeholders including service providers, family members and persons who have fallen through the cracks in the safety net or found themselves caught in the revolving door.
Our objective was to examine myths circulating about how the system works, to identify and shed light on some of the most glaring gaps involving ADMHS, the criminal justice system and Cottage Hospital and the interface between them, to document the need for reform and to recommend specific changes in policies and practices designed to stop the revolving door and better serve our dually diagnosed population. Adults with co-occurring disorders in South Santa Barbara County might interface with: Alano Club Alcoholics Anonymous Alcohol Drug and Mental Health Services (ADMHS): - C.A.R.E.S clinic - Calle Real Clinic - Assertive Community Treatment (ACT) - Psychiatric Health Facility (PHF) City or County Housing Authority Cottage Hospital Police Department Probation Department Sheriffs Department (County Jail) Superior Courts; Treatment and Restorative Courts Courts: commissioners, judges, public Defenders and district attorneys Probation Department The California Department of Corrections and Rehabilitation (parole) The California Department of Rehabilitation Public Health Department Social Services Department Neighborhood Clinics New Beginnings Counseling (inc. Safe Parking Program) The Rescue Mission & Bethel House Casa Esperanza Homeless Shelter The Salvation Army Hospitality House Hotel de Riviera Council on Drug and Alcoholism (CADA) & Project Recovery & Detox Center Phoenix of Santa Barbara Sanctuary Mental Health Association (Friendship Center & Garden Street Apartments) The Warming Centers set up on some winter nights at specific churches Sober Living Homes: esp. Stallwart Recovery on Castillo Street Casa Serena Bringing Our Community Home Independent Living Center Legal Aid Foundation Recovery Road
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The Sobering Center Vista del Mar Hospital (Aurora Behavioral Health Care) in Ventura WillBridge of Santa Barbara
Many people fall through the cracks between these city/county agencies and private providers. Santa Barbara Mayor Helene Schneider speaking in 2010 about youth suicides remarked that: Right now, so many agencies are working to help the same people, but people sometimes need to talk to five or six different agencies before they can get the proper help. How is that benefiting the person in need?72 This statement applies in the case of the dually diagnosed population of Santa Barbara.
A. Safety Net or Labyrinth?

Gaps identified by stakeholders included high caseloads, overwhelmed, maxed out systems and the lack of communication between bureaucracies, agencies, and community- based organizations. Because the service delivery system is so fragmented and because treatment services are delivered by an array of different departments, agencies, clinicians and non-profit providers, information gaps abound between providers and between systems and in the community at large. In an effort to bridge some of these gaps, we have attempted to shine a light on aspects of the local continuum of treatmentand lack thereofrelevant to people with dual disorders which need to be corrected with no further delay.
B. Falling Through the Cracks

As a grassroots organization which has sprung out of the intolerable injustice and inefficiency of our broken system of care; as a group of parents who have watched our family members bounced around from one bureaucracy to another, literally shackled like chattel or hospitalized for a few days and released back onto the streets; as mothers and fathers who have lost their children to suicide and overdose, Families ACT! is in a position to provide an on-the-ground report of what persons with mental health conditions and their families endure in Santa Barbara on a daily basis. The following stories are but a sample of real life scenarios occurring daily in the lives of our family members: CASE #1 - A client of C.A.R.E.S. with co-occurring disorders is transported unconscious to Cottage Hospitals Emergency Room six times from five different shelters or residential treatment/detox settings in less than three weeks due to acute intoxication and possible suicide attempt. The client is immediately exited from three of the residential programs after these episodes and released from the ER six times without being admitted to a psychiatric ward. In one instance, discharged to the Police Department instead of the treatment center, booked into jail, released from jail seven hours later, picked up several hours after that unconscious again and admitted to the intensive care unit at Cottage Hospital within 12 hours of leaving the ER that morning. CASE #2 - A 30 year old un-medicated schizophrenic adult is standing on the street corner downtown near his sober living home with his new bicyclefor hours. Someone calls 911 and reports his suspicious behavior. As the police approach him, he jumps on the bicycle and pedals away as fast as he can. He is Tasered but continues pedaling. A few blocks down the street a blockade is set up. As he goes down he is Tasered 12 times. He is charged with resisting arrest and assaulting an officer. He goes to prison for
72
http://www.independent.com/news/2010/feb/20/suicide-increase-prompts-action/?printSurfsurvey
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over one year and never once contacts his parents, who have no idea what prison he is in or how he is or if he is until an advocate/attorney helps to locate him. CASE #3 - Part I. During a period of financial stress at ADMHS, a young suicidal C.A.R.E.S. client diagnosed with schizophrenia is admitted to the PHF unit but is reclassified before his discharge as primarily substance user. His case manager from C.A.R.E.S. convinces him to take a plea deal being offered to him and he is sent to state prison for a series of minor probation violations including not showing up at a court hearing. CASE #5 A 22 year old inmate at the Santa Barbara County jail with Aspergers Syndrome stops eating, drinking and talking. After engaging in self-mutilation and suicide attempts, he is placed naked in the jails safety cell until a representative of the family gains admission to the jail to alert family and community. After his mother and Families ACT! publicize his condition, he is transported to the hospital for forced fluids. After the mothers hold a press conference in front of the jail to draw attention to his plight, the Sheriffs Department claims that there were insufficient beds at the Psychiatric Health Facility to house him. See additional examples and the rest of the story for Case #3 in Appendix A.
C. A Series of Catch 22s

Numerous stakeholders mentioned the Catch-22s involved in getting help when a person with mental health and/or substance use challenges is navigating the systems, going between the jail, the courts, sober living houses or the Salvation Army, Detox Center, Probation or Parole. Others describe the loop that the chronically homeless tend to be caught in: from the streets to the jail to the shelter, to the ER, to the streets, to the jail, to the streets. Staying at the emergency or transitional shelters Guests at the Rescue Mission Homeless Guest Services have to vacate the premises by 6 am. Some are on medications and need more sleep and report being arrested for sleeping on the lawn of a park after exiting the Mission. Most guests at the Salvation Army Hospitality House have to vacate the premises at 9am. Many of these who suffer from untreated mental health and substance use disorders are left to their own devices for the entire day. Getting Sober Santa Barbara has no affordable medical detox program. A chronic alcoholic or drug user with multiple health issues may not be accepted at the existing detox facilities. Will there be a bed open at the Project Recovery Detox Center on the day when there is that little window of willingness not to use? Santa Barbara lacks a step-down or transitional residential treatment center for persons who are homeless or between homes and jobless or between jobs when they have completed the two weeks detox program and are very vulnerable. How many times will someone with dual disorders relapse while waiting to get into the Hotel de Riviera residential center? You need to be sober for 30 days to get in, and cannot get in (sober) straight out of jail or prison. Many residents of the Hotel de Riviera come from the Salvation Army Hospitality House where, unless they are in one of the mental health beds, they are required to be looking for work and will be exited in 90 days if they do not find work. Those who do get to transfer to Hotel de Riviera are discouraged from working so that they can focus on their recovery.
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The word on the street is that Project Recovery Detox is now free to homeless men, but women have to get to North County and pay $750. Adult male finds a few weeks of sobriety and realizes he has been self-medicating an underlying mood disorder for years. He calls the C.A.R.E.S. walk-in mental health clinic, is hastily assessed on the phone and told to call back when he has six months of sobriety. Anxiety is at the root of addiction in many cases, but most effective anti-anxiety medications are not allowed in jail, in residential treatment centers or sober living houses, because of the potential for abuse by the patient and others. Suboxone, Naltrexone, Methadone and other substances have proven useful in the treatment of drug addiction and should be more widely available under controlled circumstances to assist addicted individuals in their recovery and to protect them from unnecessary risk of incarceration.
Getting and Losing Disability Benefits Case workers, advocates and family members will attest to how excruciatingly difficult it can be to convince someone with a mental health disability to apply for benefits and reapply if they are incarcerated or turned down. The more severely impaired they are, and therefore the more critically they need benefits, the more difficult it typically is. In addition, You cannot apply for disability benefits from jail or prison If you have applied for (or have received) benefits, and are incarcerated for more than 30 days, you will probably need to start all over again. Most people who apply for benefits are turned down the first (and often the second) time. In 1996 Congress passed Public Law 104-121, which terminated SSI and SSDI benefits to individuals disabled primarily by drug addiction and alcoholism.73
Human Rights Violations The disregard for human rights of people with mental health and dual disorders is becoming commonplace as a result of legislation, policies and practices adopted over the last forty years. Being on parole or having a felony on your record affects a persons right to vote, serve on juries, and be free of discrimination in employment, housing, education, and in terms of receiving public benefits. Young adults who have experienced a first break, or initial psychotic episode denoting the presence of schizophrenia, bipolar condition, severe anxiety or depression are frequently using substances or behaving in ways that draw the attention of law enforcement and become caught up in a judicial system which imposes certain conditions and can side track the individual and their family and divert them from a path to treatment. Persons who are using medications which are working well for them are often denied them when they are incarcerated. Others who refuse medications necessary to their mental stability are placed often naked in the jails safety cells and observed like an animal in a cage. Under California H&S code 11590, drug offenders are required to register at the Police (or Sheriffs) Department as a controlled substance offender and provide a sample of their DNA from a saliva or cheek swab sample to be kept on file. For five years, any address change must be provided within 10 days.
73
At the time of the legislation, approximately 210,000 of all SSI and SSDI recipients (1.5 percent) were classified as drug- and alcohol-disabled. Alcohol & Drug Abuse: The Impact of Terminating Disability Benefits for Substance Abusers on Substance Use and Treatment Participation, Katherine E. Watkins, M.D., M.S.H.S.; Deborah Podus, Ph.D. Psychiatric Services 2000; 51:1371-1381
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In Search of Solutions to Santa Barbaras Revolving Door Vulnerable drug offenders are often propositioned by law enforcement to be used as informants, which puts them in compromising and sometimes life-threatening situations. Despite the fact that the Santa Barbara Police, Probation and Sheriffs departments have recently demonstrated great willingness to collaborate in finding solutions to the dilemma we face, they have been challenged in ways they have not been trained for in dealing with such a large population of offenders with mental health and substance use disorders, The county department in charge of serving persons in need of alcohol, drug or mental health services is not defending its target population from ending up in a state prison. A young Latino dually diagnosed client at the Countys Calle Real Mental Health Clinic traumatized by the death of several family member is facing a prison sentence for a series of minor drug violations. The prosecutor uses a letter from his psychiatrist at ADMHS stating that he missed many appointments and opining that he was malingering. The judge sentences him to state prison for two years.
HIPAA Regulations Ironically, in a system fraught with so many human rights violations, the Health Insurance Portability and Accountability Act (HIPAA) regulations designed to protect the privacy of a clients health information often act as yet another hurdle to getting help for someone who is mentally or behaviorally disregulated to the point that they pose a danger to self and others: Young adult client of ADMHS with schizophrenia has gone off of her medication and has been seen wandering the streets for 11 months. She calls her mother and says she has checked into a motel. In fact she is in a psychiatric unit in another town but hasnt signed a release form, so personnel will not relay any information to her only real advocate in the worldher mother. See additional examples in Appendix A.
The Right To Remain Ill Extreme mental disregulation typically involves an inability to properly care for oneself, but the common interpretation of laws relating to grave disability protects many mentally ill people from being involuntarily confined or coerced into treatmentessentially protects their right to be abused, die alone on the street, or be arrested and sent to jail or prison. A young adult has been psychotic for over a year since she went off her medications. She is covered by insurance and shows up at the psychiatric wards of five hospitals within a several hundred mile radius and stays several days but does not agree to take regular medication or see a mental health professional on a regular basis. According to the Treatment Advocacy Center, approximately 50 percent of individuals with schizophrenia and 40 percent of individuals with bipolar disorder suffer from anosognosia, or the inability to perceive that they are ill, presumably caused by impairment of the right hemisphere of the brain.74 Some believe this is one of the main reasons why many persons with severe mental illness do not take their medications, although the intense side effects of many psychotropic medications is a likely alternative explanation for this phenomenon in many cases. In cases where it is clear that an individual benefits from medication it often takes decades for that person to realize that this is the case. In the interim, their life, and that of those they come into contact with, can be chaotic in the extreme. This is one of the most problematic aspects of the crisis we face. If you cannot force someone to stop drinking or to take their medications, and you cannot confine them for their own safety except in a jailthey will end up on the streets, in a jail or prison, or dead. At the same time, we can all conceive of the potential for abuse, should it become easier to medicate someone forcibly.
74
Treatment Advocacy Center: http://www.treatmentadvocacycenter.org/problem/anosognosia
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In Search of Solutions to Santa Barbaras Revolving Door Unless a county has agreed to make provisions for Lauras Law or Assisted Outpatient Treatment, someone with severe mental illness can generally not be forced to take regular medication. In 2003 Santa Barbara County opted not to adopt Lauras Law after ADMHS argued that it would be too costly and difficult to enforce. Instead, in 2010 ADMHS initiated a pilot program called ACTOE whereby 15 slots would be set aside in their ACT program for high risk clients. Despite the tremendous need perceived by family members for the kind of help Lauras Law would provide in certain cases, to date, ADMHSs regional manager reports that one client has benefited from this program. Cottage Hospital Negotiations broke down between The County of Santa Barbara and Cottage Hospital in 2007 when the Interim Director of ADMHS proposed to cut the daily rate paid to Cottage Hospital for the psychiatric admission of Medi-Cal clients by 40%--retroactively. The ER has become a staging area for patients who will be placed on 5150 hold (placed on an involuntary psychiatric hold) and provides 24 hours of stabilization for persons in a psychiatric crisis that will not be hospitalized anywhere. People with co-occurring disorders, many of whom are without insurance and many of whom are chronically homeless, fill the Emergency Room and waiting room. After doubling within a little more than a year between 2007 and 2009, Emergency Department traffic decreased by 10% between 2009 and 2011 whereas the length of time that psychiatric patients spend in the ED prior to transfer to a 5150 or discharge to CARES has increased by 55% from 2009-2011.75 In 2009, Cottage Hospital Emergency Department discharged 267 homeless patients to the streets, almost always at their request. Casa Esperanza received 306 Cottage Hospital patients between January and September of 2009. WillBridge of Santa Barbara received 15 during this period.. The Hospital donates money to both programs to accept their homeless patients. Casa Esperanza received $125,000. Casa Esperanza bills the hospital $39 for every medical bed night a patient spends at Casa. After that the beds will be provided for free. Once you set foot in the Cottage Hospital Emergency Department, EMTALA regulations require Cottage Hospital to stabilize you without asking about payment. But what happens after you are medically stabilized or what if you cannot be stabilized mentally and dont have insurance? The Probation Trap In Santa Barbara County, approximately 631 probation violators and 973 parole violators were booked into the County jail in 2009, whereas 560 and 858 respectively were in 201076out of a census of about 1,000 or 1,100 inmates at any given time. Often, minor offenses can lead to being violated, as numerous stakeholders will testify. In a snapshot taken on 2/2/10, 72% of the 1073 offenders in the county jail system as a whole had current or prior drug or alcohol charges.77 Families ACT! constituents and other stakeholders have independently observed the lingering effects of punitive rather than rehabilitative probation practices as they affected persons with cooccurring disorders in Santa Barbara County. Many stakeholders noted that, once a person with co-occurring disorders has been arrested, a cycle begins which tends to lead away from any of the doors to treatment. Too often this person instead enters a revolving door characterized by a series of Catch-22s. One is no longer a patient but an inmate, an offender, a parolee or someone who is on probation. A whole class of people who are not essentially criminal--young adults struggling with self-esteem issues, people wrestling with the effects of trauma, varying degrees of depression, anxiety, mood or thought disorders, those self-medicating with alcohol or drugs-- become at the same time fair game for law enforcement and neglected by mental health providers.
75 76
Personal communication between Families ACT! staff and Craig Park in 12/11. Figures provided to Families ACT! by Sergeant Tim McWilliams in January, 2012. 77 Figures provided to Families ACT! by Sergeant Tim McWilliams on September 21, 2011
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Furthermore, several family members have reported increased anxiety and even paranoid behavior in loved ones relative to being under the supervision or surveillance of probation or parole. Parents reported that young adult probationers would routinely pull the blinds down when they came to visit or keep their cell phone voicemail boxes full in fear of an intrusion by probation officers. More than one family reported symptoms of anxiety relative to bills received by unemployed young probationers from Probation for hundreds of dollars in unpaid probation fees. Some, detained on non-violent charges, opt for prison time in order to get out from under this debt.
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6. 2011 Grand Jury Report on Homeless Mentally Ill

A. The Need for a Centralized, Planned, Sustained Effort to Close the Gaps
In its July 2011 report entitled Homeless Mentally Ill Indigent Recidivism, This Recycling Is Not Good for the County, the Santa Barbara Grand Jury noted the lack of studies demonstrating what the county would save if the population of uninsured, indigent, homeless individuals recycling in and out of jail 78 were diagnosed, treated, housed and monitored from the very beginning79. As a result of the Board of Supervisors hearing on these findings, the County CEOs office has been charged with determining the relative costs of the revolving door as opposed to implementing effective treatment options for this population. We concur with The Grand Jury on the following points: Jail discharge planning is not equivalent to case management and follow-up.80 The elements are simply not in placeat the jail, with PHS, with ADMHSto complement the efforts of Restorative Policing and break the cycle.81 There is simply no way that adding more programs, services, housingas separate independent endeavorsis going to solve a problem that requires an organized, centralized, all- inclusive big picture effort.82 The cost of jailing and tending to the medical needs of [the homeless mentally ill population] on an ad hoc, recurring basis, is greater than the cost of a planned and sustained effort that addresses their problems at the outset. 83 There is no centralized, coordinating entity with the authority to marshal all public and private non-profit resources engaged in providing services to the mentally ill, indigent, homeless, and jail recidivist.84, the chronic homeless mentally ill need a lot of attention before they are ready for the type of housing being built by the city. Housing alone doesnt help if those in need cant receive treatment and be stabilized enough to succeed.85
The Grand Jury report noted the lack of mental health treatment beds in the community to treat sufficiently the number of chronic homeless mentally ill, and concluded that mental health beds should be provided in the county jail, where inmates can be involuntarily confined. The Jurys recommendations included the following:
78
Provide comprehensive evaluation, treatment and a long-range treatment plan for persons while they are incarcerated Provide comprehensive treatment for released inmates Provide ongoing case management and follow- up care
Homeless Mentally Ill Indigent Recidivism: This Recycling Is Not Good For The County, 2010-11 Santa Barbara Grand Jury Report, p. 1 79 Ibid. p. 3 80 Ibid. p. 7 81 Ibid. p. 9 82 Ibid. p. 10 83 Ibid. p. 2 84 Ibid. p. 18 85 Ibid.
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The Grand Jury assumed that insurance was not available to homeless mentally ill offenders. In fact, if they had an advocate helping them to apply, some of them might qualify for SSI, SSDI and Medi-Cal, depending on the severity of their mental or physical disability.
B. Voluntary Treatment, Involuntary Treatment or Court-Ordered Treatment

Although Families ACT! recognizes the value of involuntary confinement of a person who is extremely mentally dis-regulated and a danger to themselves or others, we would prefer to see a period of confinement, when necessary, not in a jail cell, but in a hospital or intensive residential treatment center devoted to healing and recovery with dignity and respect rather than punishment or correction. If we are dealing with non-violent, non-serious drug offenders or persons with mental health disorders who have not hurt anyone but themselves, why are they being treated like criminals? Why are their chances of finding employment and housing being compromised for life by having a felony on their record? Why did we close the mental hospitals if we are going to lock mentally ill people up in jails and prisons instead? Would it not be preferable if the confinement were not accompanied by felony for drug possession or other criminal charges that accumulate on a persons criminal record?. If we are spending $146 a day per mentally ill inmate, why not spend $100 a day (or $30 a day) on case management, job skills training and housing or a bed at a residential treatment center? New Jersey Governor Chris Christie recently announced a sweeping criminal justice reform calling for mandatory (and presumably locked) treatment of all low-level drug offenders. Participants in the program would receive counseling, medication to curb addiction and strict supervision.86 An estimated 62% of New Jersey prison inmates have a moderate to severe drug addiction.87 Former Santa Barbara Commissioner Deborah Talmage suggested that, for those persons with mental health and/or substance use disorders who are on probation, leaving a treatment center is typically considered a violation of the terms of probation and often grounds for re-arrest. Perhaps the best approach for now would be to increase the number of quality residential treatment centers we have in Santa Barbara County to house persons who are and are not on probation and require those who are under correctional control to complete a period of treatment there. Portugals experiment in treating substance use as a public health problem rather than a criminal one has proven immensely successful. The number of serious drug users has fallen by roughly half since the early 1990s.88 Legislation enacted in July 2001 required drug users caught with illicit substances to appear in front of a dissuasion committee composed of psychologists, social workers and legal experts who refer those whose drug use is problematic to treatment. According to Forbes: This is a far cheaper, far more humane way to tackle the problem. Rather than locking up 100,000 criminals, the Portuguese are working to cure 40,000 patients and fine-tuning a whole new canon of drug treatment knowledge at the same time.89
86 87
Wall Street Journal online WST.com 1/20/12 Ibid. 88 Ten Years After Decriminalization, Drug Abuse Down by Half in Portugal, E.D. Cain, Forbes, April 30-May 1, 7/5/2011 89 Ibid.
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7. Emergency, Transitional and Treatment Beds in Santa Barbara
A. A Serious Shortage of Beds

Despite the approximately 600 or so emergency shelter, sober living and treatment beds in Santa Barbara (South County), based on stakeholder interviews and the reports from the Restorative and Treatment courts, there is a serious shortage of actual residential treatment beds and supportive housing in Santa Barbara County for persons with mental health and behavioral disorders. An inventory of shelter, detox, single room occupancy hotels and other kinds of transitional, or drug and alcohol recovery beds in licensed and unlicensed facilities Santa Barbara (South County) includes:
Bethel House: 24 beds, faith-based residential drug and alcohol recovery for women Hotel de Riviera: 30-32 beds Co-ed for people who are dually diagnosed & homelesstwo-year stay Phoenix of Santa Barbara (changing its name to Mainstream Behavioral Health) in two facilities: Mountain House and Phoenix House with a total of 24 county funded beds, two private pay beds in two facilities: Mountain House and Phoenix House. Casa Esperanza: 100 beds in winter, 70 year-round, plus 30 special reservation beds, Fee is 1/3 of income, up to $300/mo. 1/3 goes into savings Casa Serena: 18 beds, 90- day stay at $2,300/mo, grad house $900/mo. A licensed social model rehab for women with substance use disorders. Alcohol/drug counselors on site, med cabinet: dispense meds 4 times a day. Faulding Hotel: 81 Single Resident Occupancy Units for single, low-income individuals Garden Street Apartments: 38 apartments for people with mental health disabilities New Beginnings Safe Parking Program: Safe place to park a vehicle Project Recovery Detox Center 12 beds Serves 275-300 annually Salvation Army Hospitality House. 78 beds - 60 male & 18 female beds including 15 Veteran beds, 10 CARES (Mental health) beds (lost 70-90 beds at ARC in Carpinteria) Sanctuary Psychiatric Centers of Santa Barbara $6,000/month Stalwart House an unlicensed sober living house for Dually Diagnosed: 18 beds Rescue Mission Homeless Guest Services 145 beds (120 beds for men and 25 beds for women at maximum capacity) Rescue Mission Residential Drug and Alcohol Recovery Program: 61 beds for men Transition House: residential and social services for homeless families WillBridge of Santa Barbara: 23 beds in several facilities
Total: approximately 600 beds in South County
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Supportive Housing: City Housing Authority (3,000 + units in South County) El Carrillo 61 formerly homeless adults Artisan Court 55 studio apartments for formerly homeless, youth aging out of foster care and low-income downtown workers Eleanor Apartments 14 units Independent Living
B. Sober Living Homes Many persons with substance use and co-occurring disorders returning from county jail or state prisons with or without disability benefits tend to end up (and are often court-ordered) into sober living homes, which are often a far cry from residential treatment. Residents pay high rents to live in crowded rooms and their deposits are forfeited when they relapse, making room for the next roomer and setting up potential for financial abuse. Sober living homes tend to be managed by persons who have a history of substance abuse and incarceration, who do not have academic credentials, professional training as a licensed counselor or clinical experience. Medications which can help break the cycle of addiction are often disallowed in these settings, because of their potential for abuse and the lack of intensive 24/7 supervising staff. Increasingly, sober living managers in Santa Barbara are getting certified in alcohol drug counseling at City College and protocols such as medication management are being developed to better serve residents with dual disorders. Given Santa Barbaras critical shortage of residential treatment beds, sober living homes could come to play a significant role in stopping the revolving door if opportunities were provided to their residents for case management and meaningful employment.
C. The Haves and the Have Nots According to the way ADMHS is currently operating, there are a limited number of slots for people who need acute hospitalization, case management, residential treatment, or Lanterman, Petris, Short (LPS) conservatorship. Parents and other family members with education, resources and connections, who learn how to navigate the criminal justice system and the labyrinth that is our mental health care system and get help from MHA, NAMI or Families ACT!, are more likely after years of struggle to end up among the few lucky haves whose loved ones have benefits, a case manager and a bed to call their own. Persons with mental illness and/or substance disorders whose parents are not as well educated, not as well connected, nor as culturally mainstream or whose parents have died or given up or lost track of them, do not fare as well. A small group of Assertive Community Treatment (ACT) program clients appear to be repeatedly hospitalized while others never make it into the Psychiatric Health Facility or Vista del Mar (where the County has contracted for bed days), let alone Cottage Hospitals 5 East Unit. ADMHS provides beds at Phoenix House or Mountain House for a scant 24 clients with mental health and co-occurring disorders who meet criteria for disability benefits. Some of these clients are enrolled in the ACT program while others are not, and the quality of their psychiatric care and case management may vary accordingly, but they get the best licensed social model residential treatment that Santa Barbara has to offer to someone with a mental health disability. Staff is on site 24 hours, seven days a week, engaging in a compassionate and natural manner with residents, who are free to come and go from the residences between scheduled meetings and activities.
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Unfortunately, it has taken up to nine years for some clients to obtain a county bed at Phoenix of Santa Barbara and hundreds of county residents who would benefit from this residential model will never have the opportunity to experience this level of care and acceptance in a group living setting. Instead, they are relegated to a perpetual revolving door which churns them through the criminal justice system, multiple visits to the ER and nights spent alone on the streets or in shelters where they are expected to leave the premises as early as 6 am and required to return at supper timebut not before.
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8. Alcohol Drug and Mental Health Services (ADMHS)

A. Years of Challenge
For all of the hard work that Santa Barbara Countys Alcohol, Drug and Mental Health Services (ADMHS) has put into serving the countys mentally ill population, the department has been plagued with serious challenges for years. ADMHS substantial debt to the state of California has contributed to the dysfunction of the safety net system as a whole. It may have contributed to the departments inability to engage with the community at large (and with the homeless population in particular), provide transparency and leadership, collaborate with the Sheriffs Department in devising effective programs for the forensic population with mental health conditions and with Cottage Hospital in terms of agreeing on a daily rate for the hospitalization of Medi-Cal clients. Numerous stakeholders have noted that the department has not prioritized our communitys most vulnerable populations and that it has, over the years abandoned essential services once provided by ADMHS, from mental health services in the county jail, to case reviews for residents of social model treatment centers, to med techs over the last few years. The Mental Health Commission has failed to provide critical oversight to the operations of the department. Several of its commissioners have been in positions of leadership on the board of the Mental Health Commission, which contracts with ADMHS, and this is a conflict of interest.
B. Crisis and Recovery Emergency Services Walk-In Clinic (C.A.R.E.S.)

One clearly positive accomplishment was the opening in 2006 of the departments walk-in Crisis and Recovery Emergency Services (C.A.R.E.S.) Clinic. The clinic was to operate 23/7 and to provide psychiatric urgent care and be a gateway to mental health services at the Calle Real Clinic. Instead, its doors are closed nights and weekends and it carries its own caseload. The two psychiatrists at the Calle Real Clinic will not or cannot accommodate a steady flow of cases coming in from C.A.R.E.S. Some persons being turned away from C.A.R.E.S. are now beginning to receive mental health evaluations and care through the Neighborhood Clinics. Outreach to the chronically homeless population in South County has only barely begun to address the needs of this population for alcohol, drug and mental health services.
C. Assertive Community Treatment (ACT) ADMHS Assertive Community Treatment (ACT) Model program provides intensive case management services delivered by a team to persons with severe and persistent mental illness. ACT programs in each of the three sections of the county were designed to serve 100 clients each but nearly filled up with old clients of ADMHS soon after they were created, leaving no room for the hundreds of residents of Santa Barbara with severe mental health disorders who need treatment and case management. Most ACT clients in South Santa Barbara County live alone in small apartment units or hotel rooms scattered around the community and many feel very lonely and isolated. Stakeholders report that the program is not efficiently managed. There is a constant turnover in the staff, and staff members with considerable experience and training have been at times employed to deliver medication to a clients apartment or drive them to the barbershop. Fully 30-40% of ACT programs census are elderly clients, because the Older Adults Response and Recovery Services (OARS) program was folded into the ACT program.
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D. SOARS
The SOARS Program helps people apply for Supplemental Security Income and/or Social Security Disability insurance (SSI/SSDI). Clients who will most likely qualify have severe mental illness, have not been able to work for a year, are legal residents of the U.S. have less than $2,000 in assets and no outstanding or unattended felonies. As they are applying for benefits and awaiting the outcome (for an average of 95 days), they receive medication management, case management and peer support. It should be a high priority for our county to assist the numerous persons who are chronically homeless, episodically homeless, at risk for homelessness and who are cycling through our revolving door, to apply for disability benefits. ADMHS 2012 data reveal that only 14 clients were assisted in securing SSI disability benefits over the course of nine months, from March 2011 to November 2011, through the Innovation funding streams SOARS Program, which costs $350,000 annually. In addition, $55,552 was received in Medi-Cal reimbursement for services provided for the 14 clients who received benefits. Even taking into account the very real challenge of persuading many persons with mental health challenges to apply, we should be making greater progress in our efforts to help those who are likely to qualify to secure disability benefitsgiven the scope of our communitys crisis and the substantial Mental Health Services Act (MHSA) Prop 63 funding which is going into this project.
E. Meeting Criteria
The Alcohol and Drug Program within ADMHS is not a full service program and the agency as a whole has determined that it is mandated to provide full treatment services only to persons who have a severe and persistent mental health disorder as defined by Medi-Cal, and, along with such a diagnosis, a level of impairment or dysfunction considered so severe and persistent that they cannot maintain a job, a home, and family relationships.90 According to the Surgeon Generals Report of 1999: Serious mental illness is a term defined by Federal regulations that generally applies to mental disorders that interfere with some area of social functioning. About half of those with SMI (or 2.6 percent of all adults) were identified as being even more seriously affected; that is, by having severe and persistent mental illness (SPMI) (NAMHC, 1993; Kessler et al., 1996). This category includes schizophrenia, bipolar disorder, other severe forms of depression, panic disorder, and obsessive-compulsive disorder.91 Distinctions are being made not only between clients who are severely mentally ill and only moderately or mildly mentally ill, but between clients who are persistently impaired or not, and finally between persons who are primarily substance users or primarily mentally ill. Even though a senior staff member estimates that over 80 percent of mental health clients have dealt with some degree of substance use, if the mental health problem is determined to be minor or secondary, ADMHS will not serve them with the full menu of services. These distinctions have consequences.
F. Diagnosing is not a Perfect Science How can a diagnostician know for sure who is severely ill and persistently impaired and who is primarily a drug user or alcoholic? Andrew Vesper, Regional Manager of Santa Barbara Alcohol Drug and Mental Health Services (ADMHS), concedes that diagnosing is not a perfect science:
90
Phone conversation. Families ACT! staff with Andrew Vesper, Regional Manager at ADMHS in Santa Barbara, CA, November 2011 91 Mental Health: A Report of the Surgeon General 1999.
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In Search of Solutions to Santa Barbaras Revolving Door Diagnosis entails getting a detailed history, and it is not uncommon for me to pull up history of someone and see three or four different diagnoses over a span of ten years, all by skilled diagnosticians. Ideally the person diagnosing want to be able to see what [the client] is like sober and not, and thats why it would be great if there were laws that allowed for more lengthy treatment for those with chronic alcoholism 92 One psychiatrist who was on staff at the Santa Barbara County jail stated no one has ever died from withdrawal from heroin and revealed that he often opted not to medicate inmates who presented with dual diagnosis unless medically necessary, so he could observe their behavior without the influence of drugs, and check their diagnosis or make a better diagnosis.93 The authors of a National Institute on Drug Abuse Report entitled Comorbidity: Addiction and Other Mental Illnesses echo this sentiment: when people who abuse drugs enter treatment, it may be necessary to observe them after a period of abstinence to distinguish between the effects of substance intoxication or withdrawal and the symptoms of comorbid mental disorders. This practice would allow for a more accurate diagnosis and more targeted treatment. Adding that: Steady progress is being made through research on new and existing treatment options for comorbidity and through health services research on implementation of appropriate screening and treatment within a variety of settings, including criminal justice systems.94 The idea that a jail or a prison is a good place to conduct research on co-morbidity strikes grassroots advocates as a dangerous one. Would it not be better that these kinds of determinations take place in a hospital rather than in a jail or a prison?
G. Crisis Calls
From the point of view of many family members and other advocates for persons with mental illness and co-occurring substance disorders: too frequently. a person (whether homeless or housed), who seems clearly to present an imminent danger to themselves or others, does not get the help he or she needs. In Santa Barbara, the word is out among frustrated advocates: If you call the Access Team in a psychiatric emergency from the field , you will be instructed to call 911 and uniformed law enforcement officers will respond. The Mobile Crisis Team may or may not eventually show up, but they probably will not. In Ventura County, THE CRISIS TEAM DECIDES whether or not to send law enforcement to respond to a crisis call on a case-by-case basis, depending on whether violence is considered to be a risk. When mental health professionals go to the scene they have the option to excuse themselves, so they sit in their van and decide to call law enforcement to the scene if they think it is indicated. In Santa Barbara County, there is much speculation among advocates about why the mental health personnel often do not show up and the reasons why more persons in crisis are not being hospitalized. In an effort to bridge the gap in communications and shed light on policies and practices which have remained a mystery to different sectors of the community, these questions were put to Andrew Vesper, Regional Manager at the county Alcohol Drug Mental Health Services (ADMHS), who responded:
92 93
Ibid. Personal communication at a meeting in the Santa Barbara County jail attended by Families ACT! staff in 2008. 94 Ibid.
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The mobile crisis team usually does not know whether there are beds available or not. Staff say that they dont even look at the stats regarding how many empty [psychiatric] beds there are. Ive told the police to tell me if they call us and the crisis team does not go out. We need to know about it. I have asked staff to detail if they dont go out, why they dont come out. I find it troubling if they dont come out. Staff log every time they go out. I do not have any evidence that they refused to go out. Overnight calls to the mobile crisis team are mostly hospital calls but staff is instructed to put a hospital assessment on hold if they are called out into the field on a crisis. The mobile crisis line is not available to the public because we want to keep it clear for law enforcement. A call to the Access Team number during the day goes to the CARES clinic unless its a child related issue (which gets forwarded to the childrens clinic). After hours different staff are on call. The persons covering the 24 hr line dont go out. They make a determination of whether the mobile crisis team goes out. If a significant event is going to occur soon. If something bad is going to happen in 10 minutes: law enforcement are the only ones who can get there.
H. Call 911
There are good reasons not to have law enforcement show up first on the scene in a psychiatric crisis, and the routine involvement of the police or sheriffs department unfortunately often inhibits friends or family members of dually-diagnosed persons in a crisis from calling for help. Family members are often nervous about an encounter between law enforcement and their loved one who is rapidly deteriorating (de-compensating), or suicidal, or may be in a state of great agitation, anxiety or depression. Families know that in Santa Barbara the law enforcement representative does not have the power to hospitalize or to order a 5150 hospitalization but does have the power to book someone into the county jail. Often they hesitate to call for help for fear that if a police car and uniformed officers show up on more than one occasion, they could get evicted from their rental unit or this could frighten or further agitate their loved one. This could result in their loved on being Tasered, charged with disturbing the peace or being under the influence, or in possession of a controlled substance and/or in violation of probation due to a drug offense --and booked into jail instead of into the hospital. When asked about the risk that the person experiencing a mental health crisis may be arrested or harmed by the police, Andrew Vesper responded: Sometimes the client does have to be handcuffed to get them to the hospital, but very rarely will police arrest someone in a psychiatric crisis. The only exception would be if there has been a serious assault by the client on a police officer. We rolled out the mobile crisis team 4 years ago. Only 5 times were we disappointed in our collaboration with policewhere a violent act occurred before we got there.
In reference to hospitalizing persons whose problem seems primarily related to drug use or alcoholism Vesper responded: If the client is uninsured and has only a substance use problem, there are no involuntary treatment services for this person. He/she does not qualify under regulations that mobile crisis demands and regulations for admissions to Psychiatric Health Facility (PHF Unit). LPS 5150 covers a broad sweep. The criteria for admission to the PHF are focused on the mental health piece: danger to self, danger to others, gravely disabled due to a
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mental health disorder. Currently there is no code for [chronic alcoholism]. We are concerned with an imminent danger to self: Is there is a specific danger? We cant use hospitalization to keep clients from substances. Every day that a patient is confined in the hospital we have to justify criteria. Every physician has to indicate that the client is still there because of danger to self or others. Some of the audit problems the PHF has had in recent years relate to this issue. Auditors have had a concern that certain patients at the PHF Unit were more of an alcoholic than someone with serious mental illness.95 Chronic alcoholics or substance abusers do not qualify for LPS conservatorship.
Andrew Vesper conceded: It is frustrating: you cant split the person in half. 96
I.
Blood Alcohol Level

The crisis teams in both Santa Barbara and Ventura counties agree that a client who is under the influence of alcohol or street drugs must be medically stabilized (as determined by toxicology screens) before they can be accurately be evaluated and assessed (for suicidality). The blood alcohol level has to have subsidedideally to .02. Bear at the crisis team in Ventura explains that: According to the California Welfare and Institutions Code, if he or she is deemed to be a danger to self or others, an individual can be involuntarily detained for 24 hours. There is a medical clearance form that says that, other than the psychiatric issue, you are ready to be discharged. If the patient is currently under the influence of alcohol, you cannot assess them until they can talk to you. A person will present differently under the influence than when sober. The PHF Unit has been told, in no uncertain terms, that it is NOT a detox center and cannot admit someone under the influence of drugs or alcohol.
J. The Lanterman-Petris-Short Act (italics ours)

The Lanterman-Petris-Short Act was passed in 1967 and went into full effect on July 1st, 1972. It was enacted to end the inappropriate, indefinite, and involuntary commitment of mentally disordered persons, developmentally disabled persons and persons impaired by chronic alcoholism, and to eliminate legal disabilities. It provided nonetheless for the prompt evaluation and treatment of persons with serious mental disorders or impaired by chronic alcoholism, 97 and, at times, treatment is construed to involve involuntary confinement. According to Vesper, statewide, no one has taken up the [need] to provide [involuntary hospitalization] services to persons with chronic alcoholism.98 However, the California Welfare & Institutions Code which regulates involuntary hospitalization (in section 5150.2 below) does include mention of people impaired by chronic alcoholism: 5150. When any person, as a result of mental disorder, is a danger to others, or to himself or herself, or gravely disabled, a peace officer, member of the attending staff, as defined by regulation, of an evaluation facility designated by the county, designated members of a mobile crisis team provided by Section 5651.7, or other professional person designated by the county may, upon probable cause, take, or cause to be taken, the person into custody and place him or her in a facility designated by the county and
95 96
Op. Cit. Phone Conversation Nov. 2011 Op. Cit. Phone Conversation Nov. 2011 97 Emphasis added 98 Op. Cit .Phone conversation Nov 2011
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approved by the State Department of Mental health as a facility for 72-hour treatment and evaluation. 5150.1 - No peace officer seeking to transport, or having transported, a person to a designated facility for assessment under Section 5150, shall be instructed by mental health personnel to take the person to, or keep the person at, a jail solely because of the unavailability of an acute bed, nor shall the peace officer be forbidden to transport the person directly to the designated facility. 5150.2 - Each county shall establish disposition procedures and guidelines with local law enforcement agencies as necessary to relate to persons not admitted for evaluation and treatment and who decline alternative mental health services and to relate to the safe and alternative mental health services and to relate to the safe and orderly transfer of physical custody of persons under Section 5150, including those who have a criminal detention pending. 5250 - If a person is detained for 72 hours under the provisions of Article 1,and has received an evaluation, he or she may be certified for not more than 14 days of intensive treatment related to the mental disorder or impairment by chronic alcoholism, under the following conditions: The professional staff of the agency or facility providing evaluation services has analyzed the persons condition and has found the person is, as a result of mental disorder or impairment by chronic alcoholism, a danger to others, or to himself or herself, or gravely disabled.
K. LPS Conservatorship
In March of 2008, the City of San Francisco was poised to implement a new policy that would facilitate the conservatorship of homeless persons determined to be gravely disabled. The program would require participants to take medications and accept confinement in a mental health facility for up to one year. Mayor Gavin Newsom justified the radical intervention on the basis that frustration is that a lot of these people are literally sentenced to death" and that there were people on the street that are not going to change unless there is a dramatic interruption in their routine."99 There was a precedent for such a program in California. Dr. Hilary Silver of Stockton San Joaquin County Mental Health Facility in Stockton, came to the same conclusion in seeking a solution to the revolving door of mental health care, where he saw the same individuals coming through the system over and over again. He found a sympathetic judge who facilitated the process for one thousand residents of the city when he came to the conclusion that in order to survive homeless persons needed to be confined in a private mental facility, helped to apply for disability benefits, and encouraged to take their medications.100 When asked about Lauras Law, Newsom expressed concern about the obstacle posed by the cost of the program, adding that, although he had not given up on it, " the reality is that we have a tool that we can use today," he said, "and I think there is a nobility, purpose and humanity to that101. Dariush Kayhan, San Franciscos homeless policy coordinator, was quoted in the article as asking: What's compassionate about walking past someone passed out in the street?"102
99
Conscience of a Conservatorship, New San Francisco policy would get the severely mentally ill and the chronically alcoholic into the kind of mandatory programs they need. San Francisco Chronicle by C.W. Nevius, March 11, 2008. 100 Ibid. 101 Ibid. 102 Ibid.
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9. Unserved, Underserved and Trapped Populations

A. Whose Mandates?
Whose mandate is it to hospitalize someone in a psychiatric crisis and under the influence of drugs or alcohol who is a danger to themselves? These are the people who are dying of completed suicide attempts and accidental overdoses and who are swelling the ranks of the homeless. They are our family members. They are our neighbors. And many of them live on our streets. There are three critically neglected overlapping populations in Santa Barbara County: 1) the forensic mentally ill population who are involved in the criminal justice system 2) the homeless; and 3) people who misuse substances. Clearly, these populations overlap. A day spent in any of our courtrooms will reveal the percentage of people who are going through the judicial system --at a great expense to all of us--on drug or alcohol charges or drug or alcohol-related charges. A night spent in the Emergency Room will reveal how many people in psychiatric crisis are being stabilized using costly emergency measures. A walk down State Street will reveal just how many untreated persons with mental illness there are in Santa Barbara. Taking into account that socalled resistance to treatment can pose an obstacle, one asks: What is being done to engage them in treatment? The experience of Common Ground, an innovative nonprofit organization whose staff reduced street homelessness by 87% in the 20-block Times Square neighborhood, have found that homeless people are not as treatment resistant as was once thought; that there are ways to build trust and engage most of themwith truly miraculous results in many cases.
B. Stigma, Moral Judgment and Ignorance of the Facts

Generally, both alcoholics and chronic drug users or abusers, regardless of whether or not they have a mental illness, are falling through the cracks of our local system of care. According to Mike Foley, director of Casa Esperanza Homeless Shelter, a huge part of the obstacle to finding the funding to treat this very large population stems from our attitudes about addiction; from stigma, moral judgment and ignorance of the facts about brain disorders.103 According to the National Institute on Drug Abuse, addiction is a mental illness: We need to first recognize that addiction is a mental illness. It is a complex brain disease characterized by compulsive, at times uncontrollable drug craving, seeking, and use despite devastating consequences behaviors that stem from drug-induced changes in brain structure and function. These changes occur in some of the same brain areas that are disrupted in other mental disorders, such as depression, anxiety, or schizophrenia. It is therefore not surprising that population surveys show a high rate of co-occurrence, or comorbidity, between drug addiction and other mental illnesses. While we cannot always prove a connection or causality, we do know that certain mental disorders are established risk factors for subsequent drug abuse and vice versa.104
103 104
Personal communication Comorbiity: Addiction and Other Mental Illnesses, Nora D. Volkow, M.D., NIDA Research Report Series, National Institute on Drug Abuse, p. 1
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10. A Cost Comparison
he table below compares the dramatic variation in the cost per day/night at various facilities in the greater Santa Barbara region. Clearly, the cost of a bed at a residential treatment center (e.g. Phoenix) is substantially less expensive than a night at Cottage Hospital and $30% less than a night in the County Jail. These figures suggest opportunities for significant savings.
Facility Bethel House/Rescue Mission Phoenix of Santa Barbara
Cost Free to local residents $100.88 a day buys a bed at the best residential treatment center in Santa Barbara (if you are on disability benefits) $146.12 a day is the cost of a bunk behind bars at the County jail.105 $800 a day for an acute psychiatric bed (County has 5 beds per day) $1,100 a day $1,200 per night without the cost of medical services. The cost savings of reducing repeated visits would go a long way toward providing some of the essential components of recovery. A 2010 analysis of 10,193 homeless single adults in Los Angeles revealed that the average public costs of the top 10% of homeless persons who make extensive use of hospitals and jail mental health and medical services, were reduced by 71% when permanent housing with on-site supportive services was provided for them.
Santa Barbara County Jail
Vista del Mar
Psychiatric Health Facility Emergency Room at Cottage Hospital
Permanent Supported Housing
105
Public Information Request data provided in 12/11 by the Santa Barbara Sheriffs Department to the Northern California ACLU.
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11. What IS Working?
A. Santa Barbara City Housing Authoritys Supportive Housing

City Housing Authority has in recent years created several housing developments which serve the portion of our target population who have disability benefits: El Carrillo, Artisan Court, and soonto- be Bradley Studios are examples of supportive housing-- with onsite mental health and life skills services. WillBridge transitional housing on State Street for chronically homeless individuals. The Placido property is a large house in downtown Santa Barbara, which will become the new location for Project Recoverys free, inpatient, social model detox services for people without insurance or the means to access medical detox or residential rehabs.
B. Phoenix of Santa Barbara (Mainstream Behavioral Health)

Licensed social model residential treatment with 24/7 staffing for people with mental health disorders- 26 beds in two houses, 24 of them county-funded for persons on disability benefits. 3 to 18 month stay at Phoenix House and unlimited stay at Mountain House. The goal at Phoenix House is to help clients recover from mental illness and live as independently as possible in the community. Outpatient Dual Diagnosis Treatment: individual, group and family counseling, case management, relapse prevention. Mainstream Outpatient Program
C. WillBridge of Santa Barbara

Residential treatment for homeless individuals with mental health and dual disorders.
D. Mental Health Associations Fellowship Club & Recovery Learning Center

Day center with activities, classes and lunch for people recovering from mental illness.
E. Santa Barbara Jails Sheriffs Treatment Program (STP)

The Sheriffs Treatment Program is a drug and alcohol counseling program offered to inmates in custody at the Santa Barbara County Jail. According to the Sheriffs website: National and Regional Statistics state that 75 to 80% of all inmates incarcerated have committed their crime as a direct result of using chemical substances (Alcohol and or Drugs) and that 75% of those inmates will be re-arrested the within the next two years for a similar offence as a result of Alcohol and/or Drug usage.106 The Santa Barbara Sheriffs Treatment Program provided to county jail inmates has demonstrated impressive results in terms of reducing recidivism rates among its participants. Within a three-year period from 2008 to 2010, recidivism rate of participants was 34% overall for male and female groups compared to 66% overall for male and female control groups.107
106 107
http://www.sbsheriff.org/stp.html Data provided to Families ACT! by the Santa Barbara Sheriffs Department on 1/20/12.
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Source: Santa Barbara Sheriffs Treatment Program
F. Restorative Court
In March 2011,The Santa Barbara Restorative Court began providing a jail diversion program for chronic offenders of minor municipal and state codes such as illegal lodging, being drunk in public, drunk and disorderly conduct. Commissioner Pauline Maxwell, Public Defender Jennifer Archer, Jail Discharge Planner Tona Wakefield, Legal Aid Attorney Emily Allen, Restorative Policing Officer Keld Hove work as a team to help defendants find housing, residential treatment (often outside of Santa Barbara), mental health care and to reconciliation with family . From March 2011 to December 2011 the court has handled 92 cases, 37 of which have been entered into a treatment program and 22 have been reunited with family.108
G. Restorative Policing
Police Chief Cam Sanchez created the Restorative Policing Program in 2004. The Program was expanded in the spring of 2011, when funding was approved by the City Council. Officers Keld Hove and Craig Burleigh, the five unsworn officers in yellow jackets and two in navy jackets who work with the homeless on our streets are examples of community policing at its best.
H. Substance Abuse Treatment Court (SATC) & Methamphetamine Recovery Services

Approximately seven out of ten participants in Santa Barbaras drug courts have co-occurring mental health problems.109 In 2010, the Alcohol Drug Program under ADMHS obtained a SAMHSA grant in the amount of $325,000 annually for 3 years to serve clients of the Clean and Sober Drug Court who have co-occurring disorders. The program is a partnership between ADMHS and SATC and three licensed community treatment providers.
108 109
Source: Meredith Cosden 2008
Personal communication with Santa Barbara Restorative Police Officer Keld Hove, 12/7/12 Santa Barbara County ADMHS data, 2006
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I.
Common Ground Volunteer Training

Common Ground came to Santa Barbara when a number of individual advocates for the homeless invited its main spokesperson to visit, and staff members from agencies such as the city Housing Authority and the shelters joined the effort and decided to attend a training in Albuquerque. They in turn trained 500 volunteers in Santa Barbara in January of 2011 to conduct a survey on the streets of Santa Barbara County designed to better understand the needs of Santa Barbaras homeless population and identify the individuals most at risk of dying. As a result, 100 homeless individuals were placed on a priority list for housing. One year later, in January of 2012, Common Ground volunteers initiated the first in a series of volunteer trainings designed to develop a cadre of community volunteers to assist our friends without homes. See Appendix C: Success Story: Rick and Gibby move into housing
J. Ad Hoc Programs Serving the Homeless and Forensic Populations

Local advocates for the homeless have taken the lead in conceiving and implementing programs in response to the crisis faced by people cycling through the revolving door in Santa Barbara. Programs such as jail discharge planning, the nighttime taxicab rides from the jail, the Freedom Warming Shelters and Common Ground s Homeless Vulnerability Survey and 2011 and 2012 volunteer trainings, are examples.
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12. What is Needed?

A. Better Linkage, Coordination and Oversight
Santa Barbara County and cities must create a dedicated office and/or positions to 1. coordinate and integrate the patchwork of disparate agencies and service providers who interface with persons with mental health and substance use disorders 2. work to prevent individuals from falling through the cracks between agencies/systems 3. document the needs and identify existing assets to meet needs. 4. Facilitate independent citizens oversight over the treatment of persons with mental health disorders by Police Department personnel, by Corizon Health Services and the Sheriffs Department personnel in the jail, by staff at Cottage Hospital Emergency Room, by the court system. The interface between service providers and our criminal justice system must be improved, and AB-109 Public Safety Reentry could interrupt the recidivism and revolving door cycles. Personnel in this office would create the woefully lacking linkages between institutions, agencies, shelters and programs. The office would alsomaintain a 24 hr. hotline, interface directly with our target population, track available beds (and shortages) and identify other resources and services to streamline service delivery. In Los Angeles County, the CEOs Service Integration Branch, is in charge of public record linkage, database construction and data mapping. They documented what this population was costing L.A. County by linking records across multiple health, mental health, welfare and justice public agencies. Documenting the scope of the problem and the cost of doing nothing--is only part of the task at hand, however. We need a service integration or air traffic control type of position and an ombudsman position with a 24-hr. hotline.
B. Radical Reform in our Mental Health Care System

The alternative to the revolving door syndrome is a seamless continuum of care. Investments we make toward such a continuum will be cost-effective in the long run. If we invest in the Sheriffs Treatment Program for inmates with drug and alcohol problems during their several month-long stay in the county jail, we must provide ongoing support for these people when they emerge from the jail. When a person is exited from a period of confinement in the PHF Unit, the detox center, the jail or state prison, he or she will need step-down treatment including, in many cases, case management or a dedicated advocate. If we find supportive housing for one of most vulnerable homeless persons, will they be ready to handle the responsibilities of tenancy? Interns or volunteers could be doing some of the work that the restorative police personnel does now for defendants in the restorative court: locating beds in treatment centers (often outside Santa Barbara) and possibly transporting the client there, helping the client reunite with family, connect with a psychiatrist, get medical or dental help, get to the State Department of Rehabilitation, locate a residential treatment or shelter bed, community service opportunities or a job. Santa Barbara County needs additional acute and/or crisis residential treatment beds, step-down transitional residential treatment beds (for persons exiting the PHF Unit, the prison or the jail);
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licensed social model residential treatment beds in centers with 24/7 staff; permanent supportive housing beds; drug and alcohol rehab beds; beds in shared- living households, medical detox beds and respite beds. Currently, residential treatment is driven locally by funding. Persons who receive disability benefits have more choices, but there is an acute shortage of quality residential treatment for this population as well as those persons lacking(public or private) insurance. Santa Barbara needs: More Acute/Psychiatric Beds as demonstrated by a nearly tragic case of Ben Warren held in the county jails isolation cell after two suicide attempts, self-mutilation which required sutures and a refusal to eat or drink. A Crisis Residential Center to receive patients who would otherwise meet criteria for hospitalization or from the psychiatric units, thus providing a less restrictive and less costly option after they are stabilized. A Step-Down Residential Treatment Center -- for persons exiting the detox program, the jail (serving discrete populations or blended with patients exiting the PHF Unit) An expanded number of Licensed Social Model Residential Treatment Homes based on the Phoenix of Santa Barbara model with 24/7 staff for persons with mental health disorders on SSI SSDI disability benefits Establish one or two new houses with 12 beds each yearly. Facilitate development of a Therapeutic Community based on a modified Delancey Street ModelFacilitate establishment of a local businesses in conjunction with a Delancey-model residential educational center housing 15-35 residents. Enhance the Effectiveness of Sober Living Homes Invest in strengthening the therapeutic impact of existing homes by providing residents with case management, a continuum of treatment options, job training and employment. Cottage Hospital at one point a willing participant in a large collaborative effort to write a SAMHSA grant for a treatment center to serve people without private insurance, simple ways that Cottage can help immediately are: o o Provide 2 scholarship beds at 5 East --146 patients/yr for 5 day stay Provide 2 scholarship beds at Cottage Residential Center Inpatient 28-day Program 2 beds for 28 days each would allow 24 patients per year
C. The need for Advocates & Case Managers

When someones judgment and ability to function are impaired due to mental illness and/or substances, an advocate can make the difference between hospitalization or incarceration, and sometimes between life and death. Advocates Advocating for and/or caring for an adult family member with serious mental health or cooccurring disorders in our current system is extremely taxing. Many family members are stressed to the breaking point as they seek help for their loved one. Ideally, clients need a case manager, advocate or mentor--in addition to a family member to advocate for them. A relationship with an advocate be it a professional case manager, a peer or paraprofessional advocate, or a trained community volunteer--can make a substantial difference. More than one local homeless person with a severe mental health disorder has one or more angels watching over them without crowding them.
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Homeless Advocacy Project In December of 2011, advocates called Mental Health Advocates and Providers (MHAP), approached the Director of ADMHS with a proposal for a low-cost pilot project to initiate a fullscale volunteer effort to assist Santa Barbaras homeless population. The Homeless Advocacy Project would work with Common Ground to hire a full-time coordinator to direct the volunteer project which has emerged as a community response to a gaping hole in our system of care. Trained volunteers would assist homeless individuals with: (1) access to available shelters, warming centers and local programs, (2) social security applications, (3) housing applications and the use of housing vouchers, (4) Medicaid applications, (5) getting proper care and appropriate releases from Cottage Hospital, public health clinics, CARES and ADMHS, (6) effective representation in, and adequate use of the legal system (including access to the Restorative Court and Drug Court?). It is imperative that we accelerate the rate of applications and approval of disability benefits, for persons with disabilities who are cycling through the revolving door. A greater number and wider range of service providers, advocates and volunteers, must be trained without delay, to assist with the application process.
D. AB-109: From Punishment to Rehabilitation-Breaking the Revolving Door

The 2011 Public Safety Realignment Act is Californias response to the U.S. Supreme Court decision on May 23, 2011, requiring reduced inmate crowding in 33 state adult prisons--to 127.5 percent of design capacity within two years(by May 24, 2013.) Realignment is an opportunity for California counties to reduce recidivism rates substantially, by investing in rehabilitation rather than supervision or punishment for non-serious, non-violent offenders with substance-use challenges. In Santa Barbara County, the general public and community treatment providers (other than ADMHS) were not participants in the initial program planning but there is a potential for collaboration going forward. What the Community Corrections Partnership decides to do with approximately the $7 million dollars will affect our entire community. The Probation department, which plays a leading role in realigning non-serious, non-violent offenders who will no longer be sent to state prison , could set the tone for an emphasis on high-impact, rehabilitative programming using AB-109 state funding. According to the Rand Corporations State-of-the-State Report: the current debate about Californias new 2011 Public Safety Realignment Plan has focused primarily on public safety concerns rather than on how well counties will be able to meet the rehabilitative and health care needs of individuals who will serve their sentence and be supervised at the local level. 110 The ACLU has referred to AB-109 as a paradigm shift: because jails were never designed for long-term detention, counties that respond to realignment by packing their jails are likely at even greater risk of costly lawsuits for conditions of confinement. Nor can counties simply build their way out of the problem; the funding is just not available for capital costs and ongoing operating costs. The state has pursued that failed strategy for over thirty years with devastating consequences, leading directly to the current budgetary
110
Understanding the Public Health Implications of Prisoner Reentry in California, State-of-the-State Report, Rand Corporation, prepared for The California Endowment, p. 4
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crisis and the need for AB- 109 realignment with a new approach focusing upon alternatives to incarceration.111 In a report entitled Public Safety Realignment: California at a Crossroads, the California branch of the ACLU finds after reviewing the realignment plans of 53 counties that the trend toward massive investment in jails instead of the kind of evidence-based practices such as mental health and drug treatment programs that have been proven to lower recidivism and a lack of state monitoring, data collection, outcome measurements and funding incentives to help counties successfully implement realignment 112 According to attorney Allen Hopper, director of the Criminal Justice and Drug Policy Project of the ACLU of California and co-author of the report: Its time to confront the fact that in California, over-incarceration is itself a disease, and the way to end it is to expand the use of mental health services, drug treatment and job training, and to reserve prison and jail for responding to serious crimes. The report documents the fact that most people in county jails have not been convicted of a crime. More than 71 percent of the 71,000 Californians held in county jails on any given day are awaiting a court hearing. Most of them do not pose a risk to public safety but are stuck behind bars because cannot afford bail. The report recommends the practice of conducting a pre-trial assessment to identify those who can safely be released on their own recognizance. It would be wise for the Community Corrections Partnership in charge of the AB-109 Public Safety Reentry program and realigning this population in Santa Barbara County, to invest in best-practices alcohol/drug treatment and perhaps the most cost-effective rehabilitation component: EMPLOYMENT. Providing this population with job skills, job coaching and meaningful work is one of the most important things we can do to break the revolving doorcycle and reduce recidivism.
E. Meaningful Work / Reduced Recidivism

National prevalence data estimates the unemployment rate among people with mental health disorders to be over 85%. For persons willing and able to work and not on Disability, meaningful work can be the key to stepping out of the revolving door. One obstacle cited by numerous people is the shortage of local employers willing to train or employ our target population. This shortage is becoming a more significant obstacle due to the current economic downturn and high unemployment rates. Families ACT! proposes a four-step strategy to develop meaningful work opportunities, social skills and affordable housing for persons facing obstacles to employment. Phase I Develop relationships with local businesses, trades people and entrepreneurs to provide job skills and on-the-job training. Phase II - Create a WorkFirst pilot program to address obstacles to meaningful employment. Provide a yearlong, wrap-around program with drug and alcohol treatment, case management, job skills training funded by the California Department of Rehabilitation, job coaching and job placement for 15 individuals with a history of substance use or co-occurring disorders who are housed in transitional shelters or sober living homes.
111
Community Safety, Community Solutions, Implementing AB 109: Enhancing Public Safety, Saving Money and Wisely Allocating Limited Jail Space, ACLU of California, August 2011 112 Public Safety Realignment: California at a Crossroads, California ACLU. March 2012
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Phase III Provide housing options and a deposit to successful participants in shared-living households in rental properties. Phase IV Develop a Community Enterprise Center which functions as an incubator of workerowned businesses offering goods and services in demand locally and beyond. Investing in this kind of a project is an investment in our local economy--in terms of jobs created, and reduction in homelessness and low-level crime. Useful Models for designing such programs and businesses include: Homeboy Industries Delancey Street Therapeutic Community Model with 40 years of experience. Integrated Recovery Network in Los Angeles case managers go into the Twin Towers Correctional Facility to mentor inmates and help them break the revolving door cycle Mondragon-style Worker Cooperatives (see United Steel Workers) Social Enterprise Model (see Bakersfield ARC) Palo Alto Downtown Streets Team - http://streetsteam.org/ - compensates homeless men and women in vouchers for cleaning the downtown By visualizing life on the outside, living in housing with health care and case management. IRNs recidivism rate is only 20%.
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13. Funding for Alternatives
f the City, the County and community-at-large agree on specific goals to begin to bridge some of the glaring gaps in services to the population cycling through the revolving door, potential funding is available from a number of sources. Difficult choices will be needed in the cold light of the facts.
A. New Jail or Alternatives to Incarceration?

Violent crime in Santa Barbara is the lowest in 26 years, Police Chief Cam Sanchez said on January 24th, 2012, during a presentation to the Santa Barbara City Council. Violent crimes in the city dropped from 430 in 2010 to 364 in 2011. Yet our jail is overcrowded, and filled with low level offenders whose offenses relate to mental health and/or drug/ alcohol misuse--creating costly recidivism. . One has to ask: is building an additional jail the best choice when violent crime is at a low, and more mental health services could reduce the jail population and recidivism rate? The County of Santa Barbara is setting aside $1 million per year or more between 2011 and 2018 for a new jail while the community desperately needs cost-effective treatment options to reduce recidivism. In addition, the County proposes to spend $8 million to qualify for state assistance in building the new jail and to spend almost $18 million a year to operate a new jail.
B. Potential Funding Sources

AB-109 - The County of Santa Barbara received $3.8 Million to manage the realignment population between October and June of 2011. In July it is projected that a minimum of $6.5 Million will be received for fiscal year 2012-13. Mental Health Services ACT (MHSA) Prop 63 Funding The Mental Health Services ACT requires that: Each plan and update shall be developed with local stakeholders including adults and seniors with severe mental illness [and] families of children, adults and seniors113. .If advocates agree on a plan addressing specific needs, certain gaps in our services could be bridged. Foundation Roundtable Local philanthropists are a potential source of funding for innovative, high-impact approaches to the revolving door syndrome. Weingart Foundation funds a large shelter on skid row in Los Angeles Cottage Hospital was once willing to participate in a collaborative effort to write a SAMHSA grant for a treatment center to serve people without private insurance Federal Government o o Community Development Block Grant Program (CDBG) Affordable Health Care Reform Act
113
http://www.californiaclients.org/pdf/Microsoft%20Word%20-%20Stakeholder%20Involvement%20Paper.pdf
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o o o
SAMHSA U.S. Department of Labor U.S. Economic Development Administration (EDA) - Bakersfield ARC got a grant from U.S. EDA and raised $600,000 targeted to low and moderate income people. Mandated state funds
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14. Model Programs

Integrated Recovery Network in Los Angeles (http://www.integratedrecoverynetwork.org/) IRN functions as a link which Integrates community clinics, community-based outpatient treatment providers and permanent supportive housing. It serves homeless and formerly homeless people who have co-occurring mental illness and addiction. Integrated Recovery Network case managers go into the Twin Towers Correctional Facility and mentor inmates to help them break the revolving door cycle, by visualizing life on the outside-- in housing with health care and case management. IRNs recidivism rate is only 20%. Palo Alto Downtown Streets Team (http://www.streetsteam.com) works to eliminate current and prevent future homelessness by helping Palo Altos homeless community rebuild their lives through volunteer work in exchange for food/housing vouchers and services. Participants sweep the streets, line soccer fields, perform janitorial work and run kitchens in the Palo Alto downtown area. Delancey Street (http://www.delanceystreetfoundation.org) Several therapeutic communities of 250 to a dozen residents for former substance abusers, ex-cons, homeless and others--is based on self-help. Tthe first program started 40 years ago. The minimum stay is two years, but many stay four. All residents receive a GED and are trained in three different marketable skills. Delancey Street does not receive ANY government funding. Bakersfield ARC (BARC - http://barc-inc.org/) BARC is a non-profit organization that has been providing essential job training, employment and support services for the developmentally disabled and their families since 1949, using the social enterprise model. It has a spawned a number of local business and recently received a grant from the US Economic Development Agency Spains Mondragon Worker Cooperatives (http://www.mondragon-corporation.com/ENG.aspx) An extremely successful model which has inspired the mayor of Richmond, CA and forged a collaboration with the United Steelworkers Union. CityWide in San Francisco provides case management and internships, serving the homeless mentally ill population of San Francisco. CityWide is housed in a wonderful building in the Tenderloin district where homeless individuals receive their medications, do laundry, sit in a morning circle, eat lunch prepared by homeless people and use computers for job searches. The following is taken from their website:114 Citywide Case Management Forensic Program is a UCSF/SFGH Department of Psychiatry program. Since 1981, it has provided comprehensive intensive outpatient services to San Francisco residents with mental illness. The Program works exclusively with clients involved in the criminal justice system. The Forensic Team works closely with Jail Psychiatric Services and is the primary provider for Behavioral Health Court (BHC). Staff is devoted to help stabilize and improve clients lives in the community. In October 1999, the City and County of San Francisco received the Mentally Ill Offenders Crime Reduction Grant from the California Board of Corrections. This grant created the Forensic Support System (FSS), an integrated model of services. The system
114
http://www.cw-cf.org/Home/citywide-forensics-project
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of services includes the Office of the Public Defender, Adult Probation, Parole Department and Jail Psychiatric Services to target mentally ill offenders. Clients must meet the CWCM eligibility criteria: Participants in the program must be between the ages of 18 and 59, and have had one of the following: 1. An Axis I or Axis II diagnosis of mental illness (excluding adjustment disorders and substance abuse diagnosis without a co-occurring mental illness) 2. Two psychiatric hospitalizations within 12 months 3. Resided in a rehabilitation or locked facility for 6 months 4. Have met eligibility criteria for Jail Psychiatric Services* The Citywide Forensic Program is funded by contract through the San Francisco Dept. of Public Health's Community Behavior Health Services; recipient of a SAMHSA grant to work with dually diagnosed women in BHC (WISH grant); MHSA award to create a Full Service Partnership (FSP) for individuals in BHC; and a Mentally Ill Offender Crime Reduction grant to provide Supported Employment services for participants.
Mental Health America Village in Long Beach (http://www.mhala.org/mha-village.htm). An innovative service system begun in 1990 for people with mental illness who are homeless, leaving jail or at risk of homelessness or incarceration. Modeled on an integrated services approach which brings together all the services and support people with mental illness need to live, work, learn and be involved in the community. The model values choice, equality between staff and the people they serve, encouragement of continued growth and an environment of high risk/high support. The program identifies quality of life outcomes measuring living, work, education, finance and social goals to ensure effectiveness and accountability. Psynergy, Inc. in Morgan Hill, California (www.psynergy.org). Psynergy runs Nueva Vista and Cielo Vista and Vista del Oro. It is a for-profit provider of licensed adult residential treatment based on the therapeutic community model, unlocked residential treatment centers as an alternative to acute and sub-acute hospitalization using braided funding streams. Psynergy, Inc. contracts with several counties in California to move clients to their facilities from state hospitals (such as Patton, Napa, Coalinga, Atascadero state hospitals) and IMDs (Institutions for Mental Diseases), generally for a period of transition toward community reintegration. The cost to the counties varies from $45 to $120 per day, representing a considerably savings compared to the cost of the IMDs and state hospitals. Ventura County Crisis Team - Ventura Countys Health Care Agency, describes itself as an "integrated system", focused on preventive care, linking customers to providers. Public health, behavioral health, mental health, drug and alcohol dependency, and dual-diagnosis care are all under its umbrella. The S.T.A.R. team came into existence in 2010 in response to the fact that the countys clinic and crisis response team were overwhelmed. S.T.A.R. and the crisis team work together. S.T.A.R does Screening, Triage, Assessment and Referral. With almost twice the population of Santa Barbara County, Venturas team has approximately 25 professionals to call on in a psychiatric crisis and several hospitals providing acute psychiatric beds. Ventura Countys Health Care Agency has adopted a Medical Home model which aims to ensure that services are coordinated across the whole system of care, integrating services between inpatient and outpatient services, medical and mental health services, and alcohol and drug treatment services.
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15. Findings and Recommendations

Issue 1
Are concerned and affected community members able to easily access demographic data from city and county agencies and easily and transparently track the scope and scale of the Countys delivery of health care services to our target population? Findings: No. City and County departments are not always able or willing to provide critical data to the public in a timely manner. Recommendations: All jurisdictions in Santa Barbara County need to implement a more efficient and effective data-tracking and reporting system to document the numbers and types of arrests, incarcerations, crisis calls, hospitalizations, court hearings and deaths involving persons with mental health and/or substance use disorderswhether homeless or not. Santa Barbara City and County public officials should receive regular reports from all county departments documenting demographic patterns and trends with respect to our target population. As part of the public record, this data must be available to the public in a timely manner. Santa Barbara County officials and administration need to ensure that data relevant to the delivery of health care and judicial services is readily available to the public.
Issue 2
Is our current system providing a comprehensive and coordinated continuum of care for our target population? Findings: No. Based on the data we collected and testimony of numerous stakeholders during our Task Force sessions, plus findings of the Santa Barbara Grand Jury in its July 2011 report, we find countless critical gaps in the continuum of service delivery to persons with mental health and substance use disorders. This is due in part to a lack of coordination between service providers and a lack of adequate interface between our law enforcement, criminal justice system, and county and private service providers. The complex of problems related to the treatment of our target population have reached such proportions that only prompt and bold action will provide a more integrated and effective continuum of care, prevent more citizens from falling into homelessness and reduce the burden on the criminal justice system. The proposed merger of BOCH and Common Ground is a step in the right direction, but the population but we need to address the needs of those with mental health and substance use disorders who are not yet homeless, and thus prevent homelessness and premature deaths in this sub-population. Recommendations: we recommend that the County of Santa Barbara: 1) Co-host a summit for private and public medical, mental health and behavioral health providers to collaborate in crafting a plan to address the needs of neglected populations, including at-risk, episodically and chronically homeless, forensic (criminal justice-involved) and substance-involved populations. 2) Create a centralized Ombuds Office to facilitate communication between and coordinate the delivery of services by, public agencies and non-profit service providers on behalf of individuals who have been regularly falling through the cracks. An Ombuds Office can prevent people from falling through administrative cracks and help close gaps in service delivery.
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In Search of Solutions to Santa Barbaras Revolving Door 3) Work with the City of Santa Barbara to create a Service Integration Branch. This office would also research working models in other communities which could serve as guides toward the long-term goal of designing a more cost-efficient and care-effective mental health delivery system for Santa Barbara residents. 4) Radically restructure the existing service delivery system to address the losses in human lives and dollars of the current revolving door--for persons with mental health and substance use disorders.
Issue 3
Is there sufficient staffing and support for the efficient, and effective delivery of services to people with co-occurring disorders? Findings: No. Santa Barbara County has a critical shortage of counselors, psychiatrists, case managers, paraprofessionals, and trained police who can be deployed to help those caught in the Revolving Door attain stability and recovery. The City and County have not prioritized our most vulnerable populations nor been sufficiently creative and proactive to leverage volunteers to support the monitoring, coordination and delivery of services to our target population. Recommendations: We recommend the County identify, and divert funding from middle management, inefficient bureaucracies and programs that are wasteful, inefficient and poorly managed to fund key direct -service elements and personnel missing from our current service delivery system. In addition, a cost-effective training program is needed to train and coordinate a cadre of volunteer and paraprofessional friends, mentors, and case managers. These volunteers and paraprofessionals would work with an Ombuds Office to assist people to step out of the Revolving Door and find support, stability and recovery.
Issue 4
Are there an adequate number of treatment beds to meet the needs of the population with severe and persistent mental health disorders? Findings: No. We agree with The Grand Jury Report of July 2011 that there are not enough mental health treatment beds in our county. Recommendations: We recommend that the City and County develop a continuum of residential options designed to serve various subpopulations at risk and break the costly revolving door cycle. As an alternative to incarceration for clients with intractable substance abuse patterns who are on probation, develop transitional residential facilities as a stepping stone to financial independence or permanent supportive housing. Transitional residential programs could be supported with funding from AB 109, and compliance with a period of residential treatment could be required as one of the terms of probation. Develop at least one additional licensed social-model transitional residential treatment center (similar to Phoenix of Santa Barbaras centers) annually for five years with at least 12 additional beds for those who qualify for state disability benefits. For the especially underserved who do not qualify (or do not wish to apply) for disability benefits, many of whom have substance use disorders and cycle through the criminal justice system, the County should increase the stock of transitional shelter or residential treatment beds paired with program designed to provide a self-sustainability for residents within one year--by providing case management, volunteer mentoring, job skills training, job coaching and an actual job.
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In the short-run, we recommend that the County consider negotiating with and partnering with sober living homes and organizations like the Salvation Army, (who could expand its operations to a nearby facility), who can provide beds and two meals daily, whereas other providers (potentially contracting with Probation with AB 109 funding provide an off-site day program offering more intensive case management, behavioral health services and employment.
Issue 5
Are our behavioral health and criminal justice systems collaborating to reduce recidivism and enhance rehabilitation of our target population? Findings: With the exception of the collaboration evidenced by the Restorative Policing Program and the Restorative Courts, on the whole, departments are working in silos, focused on their own agenda rather than the kind of system-wide collaboration that is needed to break the revolving door cycle. The Sheriffs Department is focused on advocating for a new jail and has contracted with a notorious private corporation based in Tennessee. ADMHS too willingly abdicated its responsibility to the mentally ill population in jail and has not yet initiated innovative solutions in partnership with the other members of the Community Corrections Partnership under AB 109. As evidences by our high recidivism rates, the PUNITIVE approach is NOT WORKING to deter those who cycle through the criminal justice system due to mental health and substance disorders. Many of these people will not qualify for disability benefits. Recommendations: We recommend an evaluation of our service delivery and criminal justice systems as a whole as they interface with our target population. We recommend a complete overhaul in the Countys policies and procedures for dealing with our target population, with an emphasis on streamlining the existing service delivery patchwork, emphasizing cost-effective treatment and rehabilitation and self-sustainability rather than the costly and ineffective punitive approach. We recommend that this crisis be recognized as a public health issue and that responsibility for addressing it rests on health providers, not law enforcement nor the criminal justice system, and that it MUST NOT be allowed to become the purview of private corporations providing for-profit services within jail prison settings. We recommend that the City and County form a joint workgroup to re-evaluate fiscal priorities, divert funding from practices, programs and department which contribute to the criminalization of vulnerable populations and invest in key missing components of rehabilitation: (1) Acute Psychiatric Hospital Beds (2) Crisis residential facilities (3) Transitional and step-down residential rehabilitation facilities for persons exiting the detox center, jail, prison, crisis residential and psychiatric facilities (4) An expansion in the number of licensed social model residential treatment beds (5) Pathways to recovery and independence by providing the population without disability benefits with skills training, job coaching and meaningful work in cooperative businesses (6) Shared living households assisting residents with initial deposit (7) A modified Delancey Street model rehabilitation community (8) Implementation of Lauras Law in the interest of rehabilitating a small percentage of people who cannot function without medication. (9) Training for culturally-diverse, para-professional volunteers and also first responders to respond with empathy in a culturally appropriate manner, to those cycling through the Revolving Door.
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(10) Investigate possible local taxes on alcohol and marijuana dispensaries to fund needed treatment and residential facilities. (11) Conduct a cost study on creating and staffing an Ombuds office. (12) Hire a dedicated grant writer /fundraiser to research / identify funding sources and write proposals to attain funding to address these recommendations.
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Conclusion
he closing of our mental hospitals known as deinstitutionalization, mandatory sentencing, harsh drug laws, vested interest in the prison industry and prison-related industries, the widespread use of prescription psychotropic and pain medication and the deterioration of our social fabric have led to the revolving door crisis our communities face today. As our criminal justice and prison systems have grown, our social services and social safety net have shrunkespecially in the current economic recession.
The end result of our confused priorities is that our jails, our streets, and our lives are filled with persons dealing with untreated emotional and mental illness--many of whom are self-medicating with drugs and alcoholand with law enforcement, probation and correctional officers attempting to do the work of social workers. Currently, four overlapping populations with mental health disorders are being especially neglected: (a) those with addictive illness (b) those involved with the criminal justice system (c) those who are homeless (d) those who do not qualify for disability benefits. Among people with mental health disorders, people with co-occurring substance use disorders are more likely to be involved with criminal justice due to their use of alcohol and drugs. If their primary disorder is considered a substance use disorder they are more likely not to qualify for disability benefits and will not qualify for a full menu of mental health services. For example, currently, they do not qualify for hospitalization in a crisis, nor do they qualify for conservatorship. They are at TREMENDOUS risk for homelessness, suicide and accidental overdose death. This population (including the homeless and not-yet-homeless) needs integrated treatment designed for dual disorders, job training, job coaching and meaningful work. For those with severe and persistent mental illness who qualify for disability benefits, there is an acute shortage of adequate local residential treatment. People with a variety of behavioral health issues are being denied treatment at county ADMHS based on a somewhat arbitrary judgment of their primary problem. This needs to change. The whole person needs to be addressed. If 64.5 percent of all inmates in the U.S. in 2006 had a substance use disorder, why hasnt alcohol and drug treatment and rehabilitation been a higher priority at the federal, state and local levels? If over 70% of SB County Jail inmates have a substance use disorder and over 80% of ADMHS mental health clients have one too; if most of the AB-109 realigned non-serious, non-violent population and much our homeless population does as well, why isnt substance abuse treatment higher on our countys priority list? Why dont we do more to help people with addictive disorders recover and break out of the costly revolving door cycle? If we did, what would be most effective approach? The first obstacle is the unwillingness of many people with mental illness or addictive illness to undergo treatment. The second obstacle is the cost of rehabilitating those who are willing. Common Grounds experience across the nations has proven that even the most treatment resistant homeless persons can usually be persuaded to come inside and in many cases, to find stability and recovery from untreated mental illness and substance misuse. If our trained volunteers and case managers take the time to build
January 2012 55
bridges of trust with these individuals, if we redesign our service delivery system to be more effective, if we made use of our restorative and treatment courts and begin redirecting our funds from punishment to rehabilitation, providing crisis, transitional and long-term residential treatment, case management, meaningful work, and affordable housing to this population, we could see impressive results. A key to breaking the revolving cycle for those who do not qualify for disability benefits is to offer them a transitional period of residential treatment concurrent with case management, job skills training, job coaching and placement in an actual job. With meaningful work they are more likely to maintain sobriety, maintain housing and recover. An initiative to create new jobs in cooperative businessesand in cooperative living centers-- will strengthen our community as a whole in times of economic downturn and high unemployment. We have successful models to guide us in this endeavor. Incarceration has an important role to play--but is greatly overused. The violation of patients rights was used to justify deinstitutionalization. We need to start all over again with a movement to protect the even more egregious violation of the rights of persons with mental health and substance use disorders as they sit behind the bars of a jail or a prison, and as they live and die on our streets. ADMHS has a recommended 2011-12 budget of $79.7M (2.3M from General Fund). We spend $108.9M (68M from General Fund) on Sheriffs Department; $44M on our courts (run by the State of California); over $18.1M on district attorneys ($12M from General Fund); over $9.8M on public defenders ($6.95M from General Fund), and $41.8M ($24.7 from General Fund) on Probation every year and still our recidivism rate is upwards of 70%. These figures include the General Fund share. Santa Barbara County spends almost $844 million dollars annually for FY 2011-12on a system that doesnt begin to adequately address the tremendous challenges posed by the Revolving Door syndrome. Is this our best shot? Public safety is often used as a reason to strengthen law enforcement, jails and the courts while the safety net is fraying. This is part of a national trend which can and must be resisted at the local level. In truth, public safety requires a robust social safety net. We will not have public safety without repairing our safety net. We will not begin to counter the wasteful, futile spin of the Revolving Door without reordering our priorities. A portion of AB-109 Public Safety Realignment funding must be applied to cost-effective, high impact rehabilitation programs. Our service delivery system needs to be revamped and linkages created from one agency or program to another. Successful models from other communities can guide us, and Santa Barbara may be able to devise its own innovative models to address specific needs As this report has recommended, a whole continuum of viable options needs to be put into place to direct our target population away from incarceration and homelessness and towards recovery, meaningful work and stable housing. The savings to taxpayers, in the long run will be formidable. The gains in term of quality of life in our community should be appreciable.
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Appendix A: Case Stories

The following are additional examples of real-life scenarios occurring daily in Santa Barbara:
Falling Through the Cracks

A court commissioner forgot to sign a document. As a result of this error, a young duallydiagnosed patient is surprise-arrested at the ER immediately after surgery for a deep self-inflicted wound, booked into county jail without medication and released at 2 a.m. several days later. Commissioner apologizes. A young dually- diagnosed Latino male finally agrees with his parents that he should apply for disability benefits. He is rearrested for not reporting to Probation where he was afraid to go since he could not afford the $91 monthly fees. He misses his disability medical appointment and has to start back at square one when he is released from prison. A father calls 911 when he finds his bipolar 19 year- old son in the process of overdosing on opiates. Police take him to Cottage Hospital, then book him into the jail. He is released at 2 a.m. in his undershorts. Now he is a felon and still not connected to any treatment. An upstanding community member who is a Santa Barbara native, suffers from schizophrenia but does not choose to take medication. He has an acute anxiety attack and is advised to get a prescription for anti-anxiety meds. The neighborhood clinic wants to check his medical records to make sure he has no history of abusing prescription drugs before they prescribe. They ask that he return the next day. The next morning, he drives up to the pass and jumps off the Cold Springs Bridge to his death. A Santa Barbara citizen with no criminal record is stopped by a police officer for a traffic stop and asked immediately: Who is your probation officer? A young Latino dually-diagnosed client of the ADMHS is facing a prison sentence for a series of minor drug violations. The prosecutor uses a letter from his psychiatrist at ADMHS stating that he missed many appointments, opining that he was malingering. The judge sentences him to state prison for two years. CASE #3 Part II. After serving several months in a state prison program for substance users, he is placed in a poorly-supervised group home near Bakersfield run by California Department of Corrections and Rehabilitation (CDCR). When fellow residents take him on a joy ride back to Santa Barbara to try to take advantage of his SSI check, his parole officer warns his mother how dangerous the ex-cons are who are using her son and tries to get her mother to set up a sting all by herself, declining to show up and assist. Part III. When the client returns to Santa Barbara, his case manager at C.A.R.E.S. will not see him and he is told to go to the Parole psychiatrist in Oxnard, where, on the recommendation of the clients family member the psychiatrist prescribes a medication that some have described as being from the Jurassic Era. Part IV. When intense advocacy helps him become a resident at a local treatment center, his county doctor orders a med change, which causes a dramatic regression in cognitive functioning. The physician is out of town for weeks on a family emergency. The client feels lost and rejected by fellow residents at the treatment center and begins to talk about suicide. The residential treatment center staff fiercely advocates that he be hospitalized, but his county case manager insists he is fine.
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Part V. The staff at the residential treatment center, family and local advocates advocate intensively on this behalf and weeks later the other county psychiatrist at the Calle Real clinic agrees to hospitalize him. He spends 15 hours at Cottage Hospital and is finally transferred to a crisis residential facility in Ventura County without his med list. The doctors there are beginning to get a handle on the medications and see some progress in the patients condition. They recommend that he stay another few days. The case manager in Santa Barbara disagrees and wants him discharged immediately, even if it means putting him on the streets of Ventura with a bus token. After intensive advocacy he is eventually returned to Santa Barbara.
HIPAA Regulations
A close relative calls the homeless shelter from outside the U.S. concerned about a cognitively impaired residents welfare. Staff is reprimanded for telling her that yes, her relative is alive. A young man with Aspergers Syndrome engages in self-mutilation and attempts suicide twice in the county jail and stops eating and drinking. He is placed in a safety cell where he is seeing in fetal position on the cement floor. After intense advocacy efforts he is moved to the PHF Unit for one day on two different occasions but, due to HIPAA regulations, the staff there cannot inform his mother that he has lost a substantial amount of weight and is covered with abrasions and a recently sutured gash in his arm.
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Appendix B:
Santa Barbara County Substance Abuse Treatment Court
anta Barbara County Substance Abuse Treatment Court (SATC) serves over 200 non-violent, drug abusing offenders each year, offering court-supervised, community-based treatment in lieu of criminal processing and incarceration. The program is 18 months in length, with group and individual therapy, educational and vocational training and assessment, as well as frequent drug testing and judicial hearings.
While the program has been effective, obtaining a 48% graduation rate among a population of long-term drug abusers with criminal backgrounds, some clients need additional interventions to reach their goals. Methamphetamine is the drug of choice among this population, and newer evidence-based practices involving cognitive behavioral therapy (CBT) may be useful for this population. In addition, many of the offenders have a dual diagnosis (i.e., a psychiatric disorder as well as substance abuse problem) and need special assistance with these problems. Finally, a number of the women in the program have a history of trauma, and would benefit from integrated substance abuse and trauma-related treatments. This project will augment the usual drug treatment offered by the SATC with specialized interventions in each of these areas: a curriculum called the Matrix for amphetamine treatment; a psychiatrist to assist with clients who have a dual diagnosis; and a program entitled Seeking Safety for clients with a history of trauma. UCSB, with Meredith Cosden, Ph.D. serving as the Principal Investigator, will be responsible for the evaluation of the project.
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Appendix C:
The Story of Rick and Gibby
he story of Rick and Gibby, who recently moved into The Village Apartments owned by the Turner Foundation, is a heart-warming illustration of the multiplier effect of reaching out a helping hand.
Rick, who was homeless for most of the last 15 years in Santa Barbara, tells how he was motivated to go through the Project Recovery after his son asked him, why dont you become the man you used to be? and a street outreach guy bugged him about going to detox. After a couple of weeks at the detox center, he moved into the Casa Esperanza shelter next door and met Gibby, who suffers from dramatic short-term memory loss and was having great difficulty dealing with the noise and crowded conditions at the shelter. Rick started helping Gibby, making sure he got regular showers and a change of clothes and then began working through a series of obstacles to get Gibby on social security disability benefits. One of the biggest things about the whole deal is learning to ask questions, Rick recalls. Gibby was identified as among those most at-risk by the Common Ground homeless survey conducted on the streets of Santa Barbara in January of 2011. Rick became Gibbys in-home caregiver. Everyone who knows Gibby agrees he would not have made it through last winter without Rick. The folks at The Village Apartments often tell them how glad they are to have them there. I havent been told that a whole lot in my life, Rick says.
January 2012
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Families ACT! Report - in Search of Solutions To Santa Barbara's Revolving Door Final Edit

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In Search of Solutions to Santa Barbaras Revolving Door

A Report and Recommendations by Families ACT!

In Search of Solutions to Santa Barbaras Revolving Door

2. Co-Occurring Disorders ......................................................................................................................................................2

4. The Santa Barbara Task Force on Co-Occurring Disorders ..........................................................................................14

5. Mapping the Gaps ..............................................................................................................................................................18

6. 2011 Grand Jury Report on Homeless Mentally Ill .........................................................................................................25

7. Emergency, Transitional and Treatment Beds in Santa Barbara ..................................................................................27

8. Alcohol Drug and Mental Health Services (ADMHS) ......................................................................................................30

In Search of Solutions to Santa Barbaras Revolving Door

12. What is Needed? ..............................................................................................................................................................41

13. Funding for Alternatives .................................................................................................................................................46

In Search of Solutions to Santa Barbaras Revolving Door

In Search of Solutions to Santa Barbaras Revolving Door

Innovative and costeffective solutions proposed include:

Deposit Fund to help facilitate people moving into shared rentals

In Search of Solutions to Santa Barbaras Revolving Door

B. About Families ACT!

In Search of Solutions to Santa Barbaras Revolving Door

B. Prevalence and Risk Factors

In Search of Solutions to Santa Barbaras Revolving Door

Op. Cit. NIDA Research Reports Series: Comorbidity p. 9

In Search of Solutions to Santa Barbaras Revolving Door

C. Integrated Treatment and the No Wrong Door Approach

D. Patients, Street People or Criminals?

In Search of Solutions to Santa Barbaras Revolving Door

A. Cycles of De-institutionalization and Re-institutionalization:

In Search of Solutions to Santa Barbaras Revolving Door

B. Defunding Mental Health Care

In Search of Solutions to Santa Barbaras Revolving Door

C. The Criminalization of Drug Use:

In Search of Solutions to Santa Barbaras Revolving Door

D. The School-to-Prison Pipeline

E. U. S. Incarceration Rate Highest in the World

In Search of Solutions to Santa Barbaras Revolving Door

F. Californias High Recidivism Rate

In Search of Solutions to Santa Barbaras Revolving Door

G. Co-occurring Disorders as a Factor in Recidivism

H. Paths to Public Safety: Retribution or Rehabilitation?

Corrections as the New Goldmine

In Search of Solutions to Santa Barbaras Revolving Door

4. The Santa Barbara Task Force on Co-Occurring Disorders

In Search of Solutions to Santa Barbaras Revolving Door

B. An Opportunity for Collaboration

C. Drug -and Alcohol- Related Deaths

In Search of Solutions to Santa Barbaras Revolving Door

D. Critically Important Data

In Search of Solutions to Santa Barbaras Revolving Door

5. Mapping the Gaps

In Search of Solutions to Santa Barbaras Revolving Door

A. Safety Net or Labyrinth?

B. Falling Through the Cracks

In Search of Solutions to Santa Barbaras Revolving Door

C. A Series of Catch 22s

In Search of Solutions to Santa Barbaras Revolving Door

Treatment Advocacy Center: http://www.treatmentadvocacycenter.org/problem/anosognosia

In Search of Solutions to Santa Barbaras Revolving Door

In Search of Solutions to Santa Barbaras Revolving Door

6. 2011 Grand Jury Report on Homeless Mentally Ill

In Search of Solutions to Santa Barbaras Revolving Door

B. Voluntary Treatment, Involuntary Treatment or Court-Ordered Treatment

In Search of Solutions to Santa Barbaras Revolving Door

7. Emergency, Transitional and Treatment Beds in Santa Barbara