As a deputy public defender for the County of Humboldt, Casey Russo has an insider’s perspective on our criminal justice system, and when it comes to the treatment of people with mental health issues, Russo says we’re doing it wrong.

Too often, he said, people are getting cycled through the revolving doors of crime and incarceration because of untreated mental health diagnoses, including substance use disorders.

A new state law is aimed at breaking that cycle. AB 1810, California’s mental health diversion bill, which was signed into law last summer by then-Gov. Jerry Brown, allows judges to reroute defendants from incarceration to customized mental health treatment programs.

The idea is to treat the underlying causes of criminal behavior while alleviating overcrowding at state mental hospitals. But Russo and others say Humboldt County isn’t taking adequate advantage of the new law.

Earlier this year, the Department of Health and Human Services (DHHS) chose not to apply for a state grant that could have netted the county close to $1 million to help implement mental health diversion and increase collaboration among judges, law enforcement, the Public Defender’s Office and DHHS. 

The county’s deputy mental health director, Paul Bugnacki, told the Outpost there was a variety of reasons for not pursuing the grant, including persistent staffing challenges, his department’s capacity limitations and our region’s lack of in-patient mental health facilities. 

But Russo and others say the county missed a key opportunity, and that everyone involved needs to get onboard with the paradigm shift taking place at the nexus between mental health and criminal justice. 

“It’s part of a broader effort to become more holistic and humane with the treatment of people whose criminal behaviors stem from mental health and/or substance abuse,” Russo said. “This is a huge, huge problem in Humboldt County.”

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In a recent phone interview, Russo said the scope of that problem should be obvious to everyone, not just professionals in the courts and county mental health. “Walk the streets of Eureka,” he said. “It appears to be a good percentage of the homeless population has mental health issues that seem to be going unaddressed.”

When these people engage in criminal behavior — often an expression of their mental health and/or substance use disorders — they lack the means to hire private attorneys, so they wind up clients of the Public Defender’s office.

“I would guess that 40 to 50 percent of my clients have some form of mental health issue going undiagnosed or untreated,” Russo said. And with an ongoing capacity crisis at the state’s mental hospitals, such defendants typically wind up spending weeks, months or years in jail or prison. Indeed, in California, jails and prisons have become de facto mental institutions.

While just four percent of the general public has a serious mental health disorder, 20 percent of California’s jail inmates are on psychiatric medications, a figure that doesn’t account for inmates whose conditions have gone undiagnosed. And in the state’s prisons, 30 percent of inmates are in the mental health system. 

After 1967, when then-Gov. Ronald Reagan signed the Lanterman-Petris-Short Act, ending the practice of institutionalizing patients against their will for any more than 72 hours, the number of mentally ill people in state hospitals plummeted while the number entering the criminal justice system increased significantly. All told, there are now ten times as many mentally ill people in jails and state prisons than in state mental hospitals. 

Needless to say, the prison and jail environments are hardly ideal locations to get well. Not only do mentally ill inmates spend longer in jail or prison and cost more to keep there than the average inmate, they also emerge with a criminal record and, often, little or no social support. They’re less employable, less able to secure housing, and if their mental health disorders go untreated they’re highly likely to reoffend.

“The cycle drives itself,” Russo said.

One man, Santa Clara County Judge Stephen Manley, tried a radical new approach: Working in collaboration with probation officers, mental health professionals, social workers and attorneys, Manley began diverting mentally ill and drug-addicted defendants into customized treatment programs in lieu of jail time.

Manly oversees Santa Clara County’s dedicated drug and mental health courts, which focus on rehabilitation rather than punishment. As reported on Medium last year:

Clients coming through Manley’s court leave with thorough and highly personalized treatment plans. These are designed to make it as easy as possible for the client to stay on track. The plan always includes housing (the majority of his clients are homeless) and usually more than one kind of mental health or rehabilitation treatment.

If Manly’s “clients,” as he calls criminal offenders, fail to adhere to the terms of their treatment plans, they’re sent to jail. And many of them do fail. But the intent is to address the underlying causes of criminal behavior, and Manly says it has been incredibly successful.

More than 70 percent of clients complete their treatment programs, and the county jail population was reduced by 25 percent in just a year and a half, according to Manly. “And no,” the Medium story notes, “there has not been an increase in other crimes as a result.”

This is pretty much the same model mapped out with AB 1810, which created a pair of “diversion statutes” in the California Penal Code. Under the new law, defendants must meet six criteria in order to qualify for a mental health treatment program of up to two years, rather than jail time:

1. The defendant must have a diagnosed mental health disorder identified in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5 currently). 
2. His or her mental disorder must have played a significant role in the commission of the charged offense.
3. A mental health expert must find that the defendant’s condition would respond to treatment.
4. The defendant must waive his or her right to a speedy trial and agree to diversion.
5. The defendant must agree to comply with treatment.
6. The judge must find that the defendant doesn’t present an unreasonable danger to public safety if treated in the community.

Clients are supervised during the course of their treatment, either by the court, probation or case managers. Some are sent to in-patient psychiatric facilities while others move into residential treatment centers or simply attend individual and/or group therapy in conjunction with medication management.

Certain crimes, including murder, voluntary manslaughter and rape, are not eligible for diversion. And if the client fails to follow the treatment program or engages in further criminal activity, he or she will go back before a judge and criminal proceedings could be reinstated.

California judges have been granting diversions since the beginning of the year, including here in Humboldt. However, most counties in the state, including our neighbors in Del Norte and Mendocino, have separate mental (or “behavioral”) health courts. Humboldt County Superior Court does not. 

Del Norte County implemented what they call their Integrated Treatment Court in November 2017, before passage of AB 1810. 

“It has definitely improved the relationships and collaboration between the courts, our district attorney, probation, the police department and ourselves,” said Ranell Brown, assistant director of Del Norte County’s Department of Health and Human Services. “We meet before court to discuss the client situation and next steps. It has helped us provide the best service.”

Russo and others believe this is what Humboldt County needs: a dedicated, separate mental health court — much like the county’s Adult Drug Court program — where an assigned judge works with other agencies to develop treatment plans for diversion cases.

“They really do need a mental health court,” said Stephen Infantino, who worked as a patient rights advocate for DHHS from 2009 to 2016. “It’s absolutely needed. We have a big drug addiction problem, a poverty problem, a mental health problem. Anybody who walks down the street can see it. Between Sempervirens [the county’s acute psychiatric inpatient facility] and the county jail, there’s got to be something else.”

Humboldt County has actually had a dedicated mental health court before — twice in the past two decades, according to Humboldt County Superior Court Judge Timothy Canning. 

“Unfortunately we were unable to sustain those courts due to lack of funding or limitations in resources,” he said in an emailed response to questions from the Outpost. 

An effective mental health court requires quite a team of people, Canning pointed out. This includes “a supervising judge with proper training and knowledge in the field, trained court staff, case worker(s), attorneys and participation by the involved agencies.” 

The lack of adequate resources is the biggest obstacle to reestablishing a mental health court in Humboldt County. “It is my understanding [that] neither Probation nor DHHS has been afforded any funding to accommodate additional programs for Mental Health Diversion,” Canning said.

As a result, defendants and their attorneys have to cobble together a treatment program from existing community resources, “which are often already overtaxed,” Canning said. 

Without going into case specifics, Canning said he has granted “a few” diversion petitions. Regarding the prospect of reinstituting a dedicated mental health court he said, “From the court’s perspective there is certainly a will to provide such a service to the community, but we also want to insure its sustainability and success. … Until adequate resources are provided we are handicapped in providing successful outcomes for otherwise eligible mentally ill defendants.”

All the more reason to go after that state grant, Russo said. 

“[N]ot having cooperation from DHHS and not having them pursuing the funds necessary to facilitate the diversion program really cripples our ability to get our clients approved for diversion,” he said.

Without full cooperation from DHHS, probation and the other involved agencies, Russo said, “we’re looking at a dead end when it comes to our ability to devise an appropriate treatment plan for the court. The result will be that we’ll continue to see folks whose criminal behavior is clearly tied to untreated mental health issues be swept into the punitive web of standard criminal prosecution, where their mental health won’t be properly addressed, and they will be statistically likely to re-offend.”

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Bugnacki said DHHS has actually been doing a lot of collaboration with law enforcement and the court in an effort to take a more holistic approach toward people with mental illness who’ve been charged with crimes. 

This includes the Community Corrections Resource Center, a facility on the corner of H and Fourth streets that offers employment training, alcohol and drug treatment programs, plus mental health and social services. It also includes more services inside the Humboldt County Correctional Facility.

But with the myriad challenges inherent in staffing and operating existing DHHS programs, DHHS officials chose not to pursue the diversion grant on offer from the California Department of State Hospitals. The potential financial award to Humboldt County would have been in the range of $653,200 to $979,800.

“When we looked at everything we have going on, and the really the small dollar amount of the grant offering, it didn’t make sense for us to go ahead and bite off more than we could chew,” Bugnacki said.

The grant would have required 10 percent matching funds from the county, but staffing presents an even larger challenge. With the Affordable Care Act’s Medicaid expansion in California, it has become increasingly difficult for employers across the state — not just here in Humboldt — to fill vacancies for psychiatrists, nurses, clinicians and case managers.

Bugnacki said DHHS is currently running a 30- to 60-percent vacancy rate in community corrections-related programs, which involve obligations to other agencies such as Probation and the Humboldt County Sheriff’s Office. And the department is administering three separate grants in other areas — for expanded mobile response teams, school-based collaboratives and providing counselors and clinicians for crisis assessments. They’ve been unable to fully staff those positions, putting DHHS at risk of losing those grant monies.

The county has recently turned to a staffing agency that provides travel nurses and doctors. DHHS, meanwhile, is engaging in a variety of employee recruitment and retention measures, including an increased advertising budget and expanded loan repayment program through the Health Resources and Services Administration.

Bugnacki said he agrees that people with mental health disorders need to be treated more holistically, with focus on the underlying conditions that lead some to engage in criminal behavior. 

“That’s why we’re really focused on the CCRC program and services in our jail, helping to link those individuals to ongoing support services [including] substance counseling,” he said.

Last month, DHHS collaborated with the California Department of Health Care Services, consulting firm Health Management Associates and various community stakeholders to facilitate a two-day event at the Sequoia Conference Center called “Building Sustainable Transitions of Care for People With Addiction in Humboldt County.” 

The department also participates in quarterly meetings with mental health program providers, law enforcement, court personnel and county supervisors for a project called Sequential Intercept Mapping, which has the same goal as mental health diversions: namely, developing community-based solutions for people with mental and substance use disorders.

“We are at the table. We’re discussing this stuff, trying to find solutions that are workable and attainable,” Bugnacki said. “We’re really active. We agree it’s a need.”

But Russo still believes the county missed an opportunity by not pursuing the diversion grant. “How do you justify not asking for more resources by saying we don’t have enough resources?” he said. “As I see it this could have been seed money for the creation of a true mental health court, which this county desperately needs.”

The one thing everybody seems to agree on is this: If we want to address the root issues that lead people with mental illness to commit crimes, it will mean spending more on treatment and less on incarceration.

Russo said the advantages would be far-reaching: money saved in law enforcement and health care, reductions in crime and a cleaner community, one where tourists are more inclined so spend money and medical professionals (among others) are more inclined to put down roots. 

“It benefits the community significantly to address this issue,” Russo said.