72 Hours: Inside the mental health crisis in San Diego County

SUNDAY • APRIL 16, 2023

72 HOURS INSIDE THE MENTAL HEALTH CRISIS IN SAN DIEGO COUNTY

2

THE SAN DIEGO UNION-TRIBUNE

SUNDAY • APRIL 16, 2023

THE SAN DIEGO UNION-TRIBUNE

SUNDAY • APRIL 16, 2023

72 HOURS

INSIDE THE MENTAL HEALTH CRISIS IN SAN DIEGO COUNTY

S

SAM HODGSON U-T

CONTENTS INTRODUCTION ..................................................................3 MONDAY ...........................................................................4-9 How did we get here and where are we headed? ..........................5 County jail is placed in tough role as provider .............................7 Schools ramping up mental health support for youth ...................8

TUESDAY.........................................................................9-14 How does behavioral health court work? ...................................10 Shifting to chronic care instead of crisis care .............. ..............11 Care court designed to expand treatment .................................14

WEDNESDAY ................................................................15-19 County to unwind law enforcement from mental health cases ......15 Vets have high rate of mental health issues ..............................16 Homeless people are focus of programs ...................................17

an Diego County has a mental health crisis.

It’s on the streets and in the jails, in classrooms and suburban homes.

The problem isn’t new, but only in the past few years has it burst into the public consciousness in a way that’s forced elected leaders to pledge more and more time and money toward a fix.

Yet, by any metric, the situation is worsening.

Over the last three decades, the rate at which adults were placed on 72-hour mental health holds has nearly doubled. For kids, the number has increased almost tenfold.

Mental health calls for service to law enforcement have spiked by more than 120 percent since 2009, creating backlogs at all levels.

During a three-day period last year — April 25-27 — people sometimes stayed in crisis stabilization centers beyond a 24-hour limit set by the state because there were no hospital beds available.

The same went for emergency rooms. At one point, there were more than 40 psychiatric patients waiting in ERs for a mental health facility to take them. Rady Children’s Hospital always had at least 10 kids in a similar situation.

Things were hardly better in hospitals. During the three-day period, there were 742 psychiatric beds available in the county, and during this time many facilities reported few, if any, empty beds.

And an empty bed wasn’t always an available bed. More than a quarter of the 60 spaces at the county’s psychiatric hospital stayed open during the period because the facility lacked enough employees to take more people, especially as some patients needed oneon-one attention every hour of the day, county officials said.

Yet the region has no comprehensive real-time system for tracking when behavioral health beds are available, making it nearly impossible to know when the county teeters at capacity.

Some patients ready to leave the hospital may not be able to live on their own, but residential care facilities that provide meals and dispense medication have been disappearing. Over the past decade, the county has effectively lost 68 places that had supplied more than 500 beds, state data show.

That sometimes leaves people stranded. About half the beds at the county hospital as well as Scripps Mercy in Hillcrest were occupied by people ready but unable to leave because there was nowhere for them to go for further treatment.

At the end of last April, one person in Sharp Mesa Vista had been there 242 days. Scripps had a patient for 530 days. Another patient at the Psychiatric Hospital of San Diego County hit 711 days.

Those who do get out sometimes enter a seemingly endless cycle of confrontations with law enforcement. There are clinicians who help officers field some of the tens of thousands of mental health calls that come in each year, but they’re often not available and the county doesn’t track how often those psychiatric teams can’t respond.

Unsurprisingly, the largest provider of mental health care in the county isn’t a hospital system or a nonprofit or a crisis center. It’s jails.

More than a third of people jailed last April were on psychotropic medication for a mental health disorder.

But what all this looks like on an individual level — between the people struggling every day to give and get help — is often hidden, which is why The San Diego Union-Tribune spent much of the past two years working to pull back the curtain.

EPILOGUE ..........................................................................20 PERSONAL ESSAYS....................................................21-24 BACKSTORY .......................................................................25

72 HOURS STAFF

EDITORIAL..........................................................................25

Project editors........................................................... Tarcy Connors, Dana Littlefield Lead writers ................................... Blake Nelson, Teri Figueroa, Lyndsay Winkley Reporters ... Emily Alvarenga, Andrew Dyer, Teri Figueroa, David Hernandez, Dana Littlefied, Jeff McDonald, Tammy Murga, Blake Nelson, Alex Riggins, Paul Sisson, Deborah Sullivan Brennan, Gary Warth, Lyndsay Winkley Photojournalists........................................................... K.C. Alfred, Nelvin C. Cepeda, Eduardo Contreras, Adriana Heldiz, Sam Hodgson, Meg McLaughlin, Denis Poroy, Ana Ramirez, Alejandro Tamayo Photo editor .................................................................................................... Roger Wilson Video editor......................................................................................................... John Kelley Photography director ............................................................................... Sam Hodgson Graphics artist...................................................................................... Michelle Gilchrist Graphics director ...................................................................................... Cristina Byvik Personal commentary editors .................................. Laura Castañeda, Matt Hall, Tania Navarro, Chris Reed Copy editors .............................................................................. David Clary, Lora Cicalo Online design art director .................................................................. Gloria Orbegozo Digital creative director ........................................................... Michael James Rocha Print design art director ........................................................................... Michael Price Logo designer......................................................................................... Gregory Schmidt

To view this coverage online and watch its related videos, go to sandiegouniontribune.com/72hours or scan this code with your phone.

ON THE COVER: Mental health associate Jose Romo stands guard at a door broken the day before by a patient at Sharp Mesa Vista Hospital in San Diego on Monday. K.C. ALFRED U-T TOP: Emergency Services dispatcher John Buie fields calls on Monday at the Sheriff ’s Department Communications Center in San Diego. Dispatchers can be flooded with requests for help, and it’s not always clear if mental health is a factor.

RIGHT: Ketema Ross rests while waiting for lunch to be served on Monday at San Diego’s Connection 2 Community Clubhouse, which offers services for people with mental health concerns.

NELVIN C. CEPEDA U-T

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2

THE SAN DIEGO UNION-TRIBUNE

SUNDAY • APRIL 16, 2023

THE SAN DIEGO UNION-TRIBUNE

SUNDAY • APRIL 16, 2023

72 HOURS

INSIDE THE MENTAL HEALTH CRISIS IN SAN DIEGO COUNTY

S

SAM HODGSON U-T

CONTENTS INTRODUCTION ..................................................................3 MONDAY ...........................................................................4-9 How did we get here and where are we headed? ..........................5 County jail is placed in tough role as provider .............................7 Schools ramping up mental health support for youth ...................8

TUESDAY.........................................................................9-14 How does behavioral health court work? ...................................10 Shifting to chronic care instead of crisis care .............. ..............11 Care court designed to expand treatment .................................14

WEDNESDAY ................................................................15-19 County to unwind law enforcement from mental health cases ......15 Vets have high rate of mental health issues ..............................16 Homeless people are focus of programs ...................................17

an Diego County has a mental health crisis.

It’s on the streets and in the jails, in classrooms and suburban homes.

The problem isn’t new, but only in the past few years has it burst into the public consciousness in a way that’s forced elected leaders to pledge more and more time and money toward a fix.

Yet, by any metric, the situation is worsening.

Over the last three decades, the rate at which adults were placed on 72-hour mental health holds has nearly doubled. For kids, the number has increased almost tenfold.

Mental health calls for service to law enforcement have spiked by more than 120 percent since 2009, creating backlogs at all levels.

During a three-day period last year — April 25-27 — people sometimes stayed in crisis stabilization centers beyond a 24-hour limit set by the state because there were no hospital beds available.

The same went for emergency rooms. At one point, there were more than 40 psychiatric patients waiting in ERs for a mental health facility to take them. Rady Children’s Hospital always had at least 10 kids in a similar situation.

Things were hardly better in hospitals. During the three-day period, there were 742 psychiatric beds available in the county, and during this time many facilities reported few, if any, empty beds.

And an empty bed wasn’t always an available bed. More than a quarter of the 60 spaces at the county’s psychiatric hospital stayed open during the period because the facility lacked enough employees to take more people, especially as some patients needed oneon-one attention every hour of the day, county officials said.

Yet the region has no comprehensive real-time system for tracking when behavioral health beds are available, making it nearly impossible to know when the county teeters at capacity.

Some patients ready to leave the hospital may not be able to live on their own, but residential care facilities that provide meals and dispense medication have been disappearing. Over the past decade, the county has effectively lost 68 places that had supplied more than 500 beds, state data show.

That sometimes leaves people stranded. About half the beds at the county hospital as well as Scripps Mercy in Hillcrest were occupied by people ready but unable to leave because there was nowhere for them to go for further treatment.

At the end of last April, one person in Sharp Mesa Vista had been there 242 days. Scripps had a patient for 530 days. Another patient at the Psychiatric Hospital of San Diego County hit 711 days.

Those who do get out sometimes enter a seemingly endless cycle of confrontations with law enforcement. There are clinicians who help officers field some of the tens of thousands of mental health calls that come in each year, but they’re often not available and the county doesn’t track how often those psychiatric teams can’t respond.

Unsurprisingly, the largest provider of mental health care in the county isn’t a hospital system or a nonprofit or a crisis center. It’s jails.

More than a third of people jailed last April were on psychotropic medication for a mental health disorder.

But what all this looks like on an individual level — between the people struggling every day to give and get help — is often hidden, which is why The San Diego Union-Tribune spent much of the past two years working to pull back the curtain.

EPILOGUE ..........................................................................20 PERSONAL ESSAYS....................................................21-24 BACKSTORY .......................................................................25

72 HOURS STAFF

EDITORIAL..........................................................................25

Project editors........................................................... Tarcy Connors, Dana Littlefield Lead writers ................................... Blake Nelson, Teri Figueroa, Lyndsay Winkley Reporters ... Emily Alvarenga, Andrew Dyer, Teri Figueroa, David Hernandez, Dana Littlefied, Jeff McDonald, Tammy Murga, Blake Nelson, Alex Riggins, Paul Sisson, Deborah Sullivan Brennan, Gary Warth, Lyndsay Winkley Photojournalists........................................................... K.C. Alfred, Nelvin C. Cepeda, Eduardo Contreras, Adriana Heldiz, Sam Hodgson, Meg McLaughlin, Denis Poroy, Ana Ramirez, Alejandro Tamayo Photo editor .................................................................................................... Roger Wilson Video editor......................................................................................................... John Kelley Photography director ............................................................................... Sam Hodgson Graphics artist...................................................................................... Michelle Gilchrist Graphics director ...................................................................................... Cristina Byvik Personal commentary editors .................................. Laura Castañeda, Matt Hall, Tania Navarro, Chris Reed Copy editors .............................................................................. David Clary, Lora Cicalo Online design art director .................................................................. Gloria Orbegozo Digital creative director ........................................................... Michael James Rocha Print design art director ........................................................................... Michael Price Logo designer......................................................................................... Gregory Schmidt

To view this coverage online and watch its related videos, go to sandiegouniontribune.com/72hours or scan this code with your phone.

ON THE COVER: Mental health associate Jose Romo stands guard at a door broken the day before by a patient at Sharp Mesa Vista Hospital in San Diego on Monday. K.C. ALFRED U-T TOP: Emergency Services dispatcher John Buie fields calls on Monday at the Sheriff ’s Department Communications Center in San Diego. Dispatchers can be flooded with requests for help, and it’s not always clear if mental health is a factor.

RIGHT: Ketema Ross rests while waiting for lunch to be served on Monday at San Diego’s Connection 2 Community Clubhouse, which offers services for people with mental health concerns.

NELVIN C. CEPEDA U-T

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THE SAN DIEGO UNION-TRIBUNE

SUNDAY • APRIL 16, 2023

72 _

HOURS

‘She has knives in her hands. I thought she was going to kill me.’

O

MONDAY

n anMonday afternoon in Spring Valley, a man called 911.911. a Monday afternoon in Spring Valley, a man called He’d been out driving when he spotted a homeless woman by a bus stop. He pulled over, hazard lights flashing, to protect her from traffic.

“She’s out of her mind,” he told the dispatcher. The woman could be heard yelling in the background, her words unintelligible.

“Please hurry,” the man said. He gave the woman’s age, race and clothing.

“What color is her hair?” the dispatcher asked.

“It’s full of dirt.”

He asked if any mental health clinicians were available. None were.

“Do you know her name, sir?” the dispatcher asked.

“She’s my daughter.”

San Diego County, like many places nationwide, faces a mental health crisis.

But what that crisis looks like minute by minute is rarely seen.

For 72 hours in April 2022, nearly two dozen journalists with The San Diego

Union-Tribune spread across the county to follow clinicians and police, patients and relatives, jail guards and 911 dispatchers.

The three-day period mirrors one of the mental health care system’s main

ANA RAMIREZ U-T

After she was arrested, Crystal Jenkins was given the option of joining a program for people with serious mental illnesses. If she committed to therapy, living in a group home, curfews and taking medication, she could stay out of jail.

tools: The 72-hour hold, which is when police or mental health professionals hospitalize someone against their will if they’re believed to be a threat to themselves, a risk to others or “gravely disabled.”

The reporting found a system overwhelmed at every step. While reforms are under way, some will likely take years to fully implement, and it’s not clear how they will be paid for.

Reporters received unprecedented access to psychiatric facilities and conducted a first-of-its-kind analysis of years-worth of data. Many of the following

TOP: In the earlymorning hours on Monday, wails can be heard near the corner of F Street and Seventh Avenue downtown. Nobody’s visible. Just a howl, then silence.

scenes were witnessed firsthand. Others are based on interviews with participants and from court, health care and law enforcement records.

At the start of this 72-hour period, there was no way to predict that a woman hearing voices would repeatedly thrust knives into her own neck as her brother tried to pull her from a second-story window. Or that another woman’s recovery would go so well that a courtroom full of people would burst into applause. Or that a young graduate student would be released from a mental health facility Monday only to find himself in handcuffs by Wednesday, charged with attempted murder of a police officer.

Some stories don’t have a clear resolution, such as the woman at the Spring Valley bus stop: While her father knew she wasn’t taking her schizophrenia medication, it’s unclear if she ever got help.

But any three days could have been picked, because these days are every day.

WARNING This story includes descriptions of suicide. If you’re struggling with thoughts of hurting yourself, call the national crisis hotline at 988.

7:15 A.M.: Crystal Jenkins bows her head. Heavenly Father, thank you for waking me up today.

I ask for your protection around my family.

The 51-year-old doesn’t live with her 11-year-old daughter. Maybe someday.

In her National City group home, she spreads cream cheese and jelly on a bagel. Jenkins takes a bite. Then she pops a single white tablet into her mouth.

Around her, roommates pour cereal. The place can get crowded.

Yet it beats jail.

Two years earlier, around the time the pandemic shutdown began, Jenkins heard voices. You’re going to be murdered, they said. Your daughter will be molested.

She grabbed a knife, left her apartment and confronted a neighbor. The neighbor called police.

Jenkins was arrested and charged with brandishing a knife, a misdemeanor, and making a criminal threat, a felony.

Before the case was resolved, her public defender told her about Behavioral Health Court.

If she was willing to commit to therapy, living in a group home, curfews and taking medication, she could stay out of jail.

The program is only offered to people with serious mental illnesses, like bipolar disorder or schizophrenia, which Jenkins has. Since the court launched in 2009, more than 300 have participated.

Nearly half didn’t make it through.

Jenkins is now at the halfway point, and tomorrow a judge will decide if she can move to the next level.

If Jenkins advances, she’ll be one step closer to her daughter.

8:30 A.M.: Eugene Wheeldon drives to the airport. In some ways, Wheeldon is an old-school beat cop.

He makes daily rounds and greets people by name. The difference is, Wheeldon is the Harbor Police Department’s homeless outreach officer, and his residents live on the street.

Inside Terminal 1, by the baggage claim, Wheeldon spots the man he’s

THE SAN DIEGO UNION-TRIBUNE

2,693

The number of mental health holds placed on children in the county in fi scal 2021

5

SUNDAY • APRIL 16, 2023

3.4

The rate of holds placed on children for every 1,000 residents in the county in fi scal 2021

ADRIANA HELDIZ U-T

looking for: A big guy in sweatpants.

The officer approaches.

“I’m tired of being homeless,” the man says.

This is progress. Wheeldon asks if he has thought about hurting anybody.

“I feel like I’m going to kill myself,” the man says.

That answer changes things.

Section 5150 of California law details when people can legally be held against their will without committing a crime. Because of that statute, a 72hour hold is known as a 5150, and it can be used for suicide threats.

Wheeldon places the man in handcuffs, needing two pairs to hold his large arms. He’s not under arrest, but handcuffs are standard.

The rate that people are placed on 72-hour holds locally has increased sharply over the past two decades.

More than 10,200 holds were placed on adults in San Diego County in fiscal 2021, according to state data.

The program launched in 1995 to help officers handle mental health calls, and the county funds 72 clinician positions. Depending on the day, nearly all clinicians might be working.

At times, the number could be as low as 25.

Wheeldon drives the man to the Midway District and parks outside the Psychiatric Hospital of San Diego County. A staff member is waiting to open the door.

9 A.M.: Brian Cardoza heads to work. Cardoza has been a nurse for decades, and most of that time has been spent partnered with police as a member of a Psychiatric Emergency Response Team, which most people know as PERT. The program launched in 1995 to help officers handle mental health calls. While the county funds 72 clinician positions, only about half that number may be on duty on any given day. Cardoza never knows if there will be enough.

MID-MORNING : Elvie Del Rosario feels a squeeze on her shoulder.

It’s her 33-year-old son, Steven. He says he’s going to the store.

The Del Rosario family lives in a two-story home in Chula Vista.

Steven just moved back this month, after working as a software engineer and web developer in Riverside County. He’s been having trouble concentrating. Elvie doesn’t know what’s wrong.

Steven recently woke her in the middle of the night and asked to go to the hospital, but the trip didn’t happened.

Her son leaves the house.

9:50 A.M.: At the San Diego County Sheriff’s Department dispatch center, in Kearny Mesa, a school principal calls 911 to report a suicidal student.

PERT responds to the North County facility. The teen is taken to a hospital.

BLAKE NELSON U-T

Brian Cardoza has spent most of his nursing career as part of a Psychiatric Emergency Response Team. As a PERT clinician, he works with law enforcement on mental health calls.

Adults placed on 72-hour holds Adults were placed on more than 10,000 72-hour psychiatric holds across San Diego County in fiscal year 2020-21. The rate has nearly doubled over the last three decades.

60 per 10,000

FY 2020-21

39.9

50

40

30

20

10

0 ’90’91

’95’96

’00’01

’05’06

’10’11

’15’16

’20’21

Rate per 10,000 residents for fiscal years 1990-91 through 2020-21.

Source: California Department of Health Care Services

MICHELLE GILCHRIST U-T

10 A.M.: Inside a Vista strip mall, Kathy Shoemaker looks through a window. She sees a large room filled with recliners. Men and women huddle under blankets, and some watch a television on the wall.

The space is a crisis stabilization center, which is like an urgent care for people having a breakdown. Anyone can come any day. Many were brought in by law enforcement on 5150s, and nurses will evaluate who needs to go to a locked hospital unit.

Drawings from patients line the walls. One person wrote, “My family thinking I’m crazy is the biggest barrier.”

Shoemaker is the chief clinical officer for Exodus Recovery Inc., which runs the facility on behalf of the county.

They currently have a dozen people. State rules say nobody is supposed to stay in the stabilization center for more than 24 hours.

Shoemaker knows four who have already stayed past the legal limit.

There are just not enough hospital beds to take them.

MID-MORNING: In a Del Mar hotel, Yuhao Du calls his mother. “I don’t want to study in the States anymore,” Du says. “I want to go home.”

This would be a major change.

Du grew up in China, where he fell in love with physics. He applied for a student visa and moved to the United States in 2015. Four years later, he graduated from the University of Cali-

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THE SAN DIEGO UNION-TRIBUNE

SUNDAY • APRIL 16, 2023

72 _

HOURS

Patients recline in chairs at Exodus Recovery in Vista. The facility is like an urgent care for people in a mental health crisis.

Many were brought in by law enforcement on 5150s, and nurses will evaluate who needs to go to a locked hospital unit.

HOW DID WE GET HERE AND WHERE ARE WE HEADED?

Yuhao Du, who left China years ago to study at UC San Diego, had spent time at various mental health facilities.

SANDY HUFFAKER U-T

fornia San Diego with two bachelor’s degrees. He’s now 25 and in a physics graduate program at the same university. But on the Chinese app WeChat, he tells his mother he doesn’t feel safe.

He doesn’t say he was released earlier today from a mental health facility.

Du has checked into several of them since March, according to his attorney. One month Du was in and out at least four times, and he was diagnosed with schizophrenia. He recently called 911 and asked to return to China.

Friends have been trying to contact Du’s mom. They want to tell her something’s wrong.

10:12 A.M.: San Diego Police Department dispatchers work on the fourth floor of the downtown headquarters.

A 911 caller reports a potentially suicidal woman downtown.

PERT heads out.

RUNNING TALLY:

8

5150 calls have been logged by this time.*

10:30 A.M.: Cyra Mabalot learns she has an empty bed.

This can be a good thing.

Mabalot runs the Fancor Guest Home in El Cajon, an adult residential care facility. People come to her when they’re well enough to leave a hospital but not stable enough to, say, cook their own food. If someone leaves, it can be because they’re ready for independent living.

The man who left Monday was not ready.

During the night, residents heard screaming. Later, glass shattered in a bathroom. The man ran off, then came back. Police took him away.

Mabalot’s surprised officers took him at all. Sometimes it feels like officers look for every excuse not to take somebody.

Among first responders, a call that doesn’t quite qualify for a hold is dubbed a 5149½.

Regardless, an open bed is a precious commodity.

In Mabalot’s office is a stack of names, and every one needs a place to stay. Once she lets the world know there’s a vacancy, she says she can get 20 to 30 calls a day from caseworkers, begging for the spot.

She needs to make a decision soon.

11:16 A.M.: Callers say someone’s about to jump off the San Diego-Coronado Bridge. Four units are en route, but PERT isn’t available. One team is still downtown.

11:17 A.M.: A 14-year-old at a San Diego middle school threatens to gouge out her classmates’ eyes. Staff take tacks and nails from the girl.

11:19 A.M.: Eight officers are now at the bridge. Three people report a man has already jumped.

11:34 A.M.: A student in San Diego’s Grant Hill neighborhood has a history of depression and anxiety, a caller says. She just used a piece of glass to cut herself 16 times. Officers are still busy where the man jumped from the bridge.

K.C. ALFRED U-T

San Diego County reached an inflection point around mental health care in 2018, when Tri-City Medical Center closed its 18-bed psychiatric unit at the Oceanside hospital.

SANDY HUFFAKER FOR THE U-T

Yuhao Du’s mother, Xiuqin Li (right), received a message from her son saying he did not feel safe. She didn’t know that he had recently been released from a mental health facility.

“I don’t want to study in the States anymore. I want to go home.”

Yuhao Du

Directors said the closure was necessary because of expensive federal upgrade requirements and staffing difficulties.

The decision surfaced a broad community conversation already under way among advocates, health providers and the county government, which is legally responsible for providing behavioral health care services to the region’s 1 million Medi-Cal recipients.

It also put a spotlight on the fragility of the region’s system of care for people with urgent mental health needs. Many people picked up on temporary, involuntary holds in North County had to be transported to other already-full facilities, taking law enforcement officers off their beats for hours.

Since then, the public has acted at the ballot box, electing leaders who have increased funding and engaged in a longterm rethinking of how mental health care is provided.

Though there has been some investment in increasing bed space in locked hospital units, there is an even-greater focus on creating more places for people to live and pursue long-term recovery after intensive treatment.

SAM HODGSON U-T

A woman in Vista dials 911 and tells a dispatcher at the sheriff ’s communications center in San Diego that she’s suicidal. But when deputies get to her apartment, the woman says she’s OK.

Children placed on 72-hour holds Children up to age 17 were placed on nearly 2,700 72-hour psychiatric holds across San Diego County in fiscal year 2020-21, a rate more than 1.5 times that of the California.

FY 2020-21

50 per 10,000

34.4 San Diego 40

30

20

21.5

California

10

0 ’90’91

’95’96

’00’01

’05’06

’10’11

’15’16

’20’21

Rate per 10,000 residents for fiscal years 1990-91 through 2020-21.

Source: California Department of Health Care Services

MICHELLE GILCHRIST U-T

* Totals for 5150 calls were compiled from data collected by the Union-Tribune from all law enforcement agencies across San Diego County.

It is a far cry from where the region was in 1995 when the county Board of Supervisors outsourced mental health care services in the hopes of saving money.

That situation led the county to spend millions purchasing and renovating its current mental health hospital on Rosecrans Street in San Diego.

About 37,000 Californians lived in staterun facilities in 1955, but that number dropped to 8,531 individuals in just five facilities as of 2020, according to the California Department of State Hospitals.

Though it was never home to a state hospital, San Diego built its first mental health care facility in Hillcrest in the late 1950s after the closures.

In 1963, the Mental Health Services Act called for 1,500 community mental health centers to provide a wide range of services that could pick up the slack. However, according to a 2021 study in the American Journal of Psychiatry, “states built approximately half” of the centers that the act envisioned.

Without enough facilities to meet the demand, the report concludes, “care often fell to families, friends and associates,” and “those without homes often ended up on the streets, with many entering an institutional circuit of acute care hospitals, jails, prisons, and forensic facilities.”

PAUL SISSON U-T

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SUNDAY • APRIL 16, 2023

THE SAN DIEGO UNION-TRIBUNE

72 _

HOURS

EDUARDO CONTRERAS U-T

Therapist Victoria Sahagun (center) and community outreach worker Shawn Keating (right) offer assistance to people near the Carlsbad Village Station on Wednesday. Both are members of a Mobile Crisis Response Team.

COUNTY JAIL IS PLACED IN TOUGH ROLE AS PROVIDER

NOON: Two 5150 calls in San Diego are waiting for somebody to arrive.

AFTERNOON : For months, Angelina Juarez has been hearing voices.

The 33-year-old believes people are coming to hurt her.

Juarez lives in a Lincoln Park condominium with her mother, sister and brother. Her family says she was raped as a teenager, which pushed her to drink.

She recently went through rehab.

In a journal Juarez wrote, “Why can’t I seem to get a break? Every time I try, my demons awake.”

Juarez tells her family: If someone is going to take my life, it’s going to be me.

17 5150 calls have been logged by this time.

12:30 P.M.: Elvie Del Rosario opens her front door in Chula Vista.

Police are on her porch.

Del Rosario thinks she knows why they’ve come. She asks if they’re following up on an identity theft report she’d filed.

Officers say it’s about her son.

Steven had told her he was going to the store. But as soon as Del Rosario hears his name, she starts to cry.

The police say Steven just jumped from the Coronado Bridge.

In San Diego County, about one in every three people in Sheriff’s Department custody is on prescribed medication to treat a mental illness, making the county jail the largest mental health provider in the region.

DENIS POROY FOR THE U-T

An external view of the San Diego Central Jail downtown. More than a third of people locked up in April were on psychotropic medication for a mental health disorder, officials said.

The result has been a stunning growth in both the jail population and the number of suicide attempts, overdoses and deaths in sheriff’s facilities.

In 2021, a record 18 people died in San Diego County jails, many of whom had a history of mental illness. In 2022, 19 people died in sheriff’s custody, and one man died hours after he was released from county custody.

1:30 P.M.: A principal reports a high school student in San Ysidro who says he wants to die.

25 5150 calls have been logged by this time.

2 P.M.: Six 5150s are holding in San Diego.

2 P.M.: Fadi Nicolas isn’t nervous when the interview begins.

The doctor is behind his desk at Sharp Mesa Vista, San Diego’s largest private psychiatric hospital. Framed diplomas hang on his wall, charting his rise to chief medical officer at Sharp Behavioral Health.

Sitting across from him is a woman in her 30s.

Have you seen a psychiatrist recently? Nicolas asks.

You cannot ask these questions, the woman says.

What does your husband do? Nicolas asks.

This is top secret, she says.

The woman was brought in by worried relatives. The husband says she’s delusional and won’t take her medication, even after stays at two psychiatric units.

In the next room, Nicolas’ assistant hears the conversation going nowhere. She walks into the office and tells Nicolas he has a phone call.

This isn’t true. But it gives the doctor an excuse to leave the room.

Out of earshot, Nicolas picks up a phone.

I need a silent code, he says. Word is quietly passed: A team is needed at Nicolas’ office.

The doctor walks back in.

I’m going to keep you here a few days, he tells the woman. He opens a door, revealing more than a dozen people.

The woman dives for her bag.

Nicolas swears to himself. She’s got a gun, he thinks.

Staffers grab the woman’s arms.

She starts yelling.

You can’t do this, she says. I need a lawyer.

Nicolas can hear her voice fade as they walk away.

He checks her bag.

No gun. Just diapers.

2 P.M.: In Rancho San Diego, Melinda Wollitz waits to hear from her son.

It is a responsibility ill-suited to department officials — and rank-and-file deputies — who are expert law enforcers but not so skilled in recognizing mental illness or differentiating between criminality and psychosis.

The problem of incarcerating rather than treating mentally ill people has been recognized for years, but policymakers have been slow to implement meaningful changes to the criminal justice system.

BLAKE NELSON U-T

Fadi Nicolas is chief medical officer at Sharp Mesa Vista, San Diego’s largest private psychiatric hospital. He sometimes must decide whether to hold somebody against their will.

Mental health in San Diego County jails About a third of prisoners were on some kind of psychiatric medication in 2022, up from about 15 percent in 2006. An even greater proportion — more than half — of people in jail were receiving mental health services in 2022. That's up from about 20 percent two decades ago.

September 2022

100% 90

53.4% Population receiving mental health services Population taking psych medications

80

60 50 40 30

33.7% 20 10

’09

’10

’11

’12

’13

’14

’15

’16

’17

“We have created conditions that make criminal behavior all but inevitable for many of our brothers and sisters who are mentally ill,” the study concluded. “Instead of treating them, we are imprisoning them.”

Local policymakers are trying to address the medical and mental health needs inside San Diego County jails. The correctional health budget has climbed past $100 million a year, roughly 10 percent of the Sheriff’s Department spending.

But institutionally, the department has been slow to improve. Officials have long considered the people they incarcerate to be the problem — not so much the policies and practices inside county jails.

70

0

In 2013, for example, the Three Strikes Project at Stanford Law School concluded that government practices were wrongly directing sick people into jails and prisons.

’18

’19

’20

’21

’22

Data unavailable for October through December 2022.

Source: The California Jail Profile Survey LYNDSAY WINKLEY & MICHELLE GILCHRIST U-T

“The largest contributor to jail deaths is not the actions or inactions of the sheriff, but rather a jail population in which a high percentage of inmates have serious mental illness, and a jail population that engages in extremely self-destructive behavior,” then-Sheriff Bill Gore said in 2019, in response to a Union-Tribune investigation that disclosed the high number of deaths in custody.

Gore retired early in 2022 — on the same day state auditors reported that conditions in San Diego County jails were so dangerous that legislation was needed to force reforms on the department.

JEFF MCDONALD U-T

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NELVIN C. CEPEDA U-T

At their El Cajon home on Monday, Bruce and Melinda Wollitz sit next to photos of their son, Marshall, from when he was a boy. He’s long struggled with mental illness, and his parents haven’t heard from him since he got out of jail months ago.

She doesn’t have much hope he’ll call.

“The last time I saw Marshall was Oct. 9, after he was released from jail,” she says. That was more than six months ago.

As a kid, Marshall excelled in school, but he was diagnosed with bipolar disorder and severe depression, his parents say. They repeatedly called the police, and Marshall was placed on multiple 5150s.

Three days would pass, he’d get out and the cycle would repeat.

He’s now 27. As part of his parole, he was supposed to call his parents once a week. He hasn’t called once.

Wollitz has no idea where he is.

She wonders if the system can do anything for her son.

“You can’t cure somebody in 72 hours,” she says.

34 5150 calls have been logged by this time.

3:30 P.M.: Max Disposti often doesn’t want to call the police.

When somebody has a breakdown at the North County LGBTQ Resource Center, where Disposti is the executive director, just the presence of a gun might push somebody over the edge.

The county’s new Mobile Crisis Response Teams, however, feel like an improvement.

MCRT was pioneered in 2021 by county officials and Exodus Recovery, the group overseeing the crisis center.

Anyone can call MCRT directly and get a team of mental health professionals, although they let police deal with the armed and dangerous.

There are now 35 teams, with more on the way, and they’ve already shown up more than a dozen times to the LGBTQ center.

“It was so refreshing,” Disposti says.

3:41 P.M.: A man in El Cajon says his girlfriend’s daughter is slamming items around the house.

The teenager is manic and on medication, he says. The call is coded 5150.

When deputies arrive, they decide the situation is actually a 415F, a “family disturbance.” Deputies tell the family about Mobile Crisis Response Teams and leave.

4:08 P.M.: Laura Thill catches her breath. In just the last hour at Sharp Mesa Vista, Thill rushed to four “code greens,” which occur whenever somebody in the psychiatric hospital needs to be restrained.

As administrative liaison, Thill is a “safety observer.” When a woman arrived, took off her clothes and began

“You can’t cure somebody in 72 hours.”

Melinda Wollitz

throwing things, or a man became combative at discharge, Thill watched carefully as hospital staff stepped in.

She made sure nurses had space to run away. She monitored flailing limbs. And she kept especially close watch on patients’ mouths and noses.

Nothing should cover the face.

A little later, Thill checks her smartwatch. She’s walked almost 10 miles today.

4:44 P.M.: A man says his homeless brother is at their mother’s home in Encinitas.

“He is dangerous.” The caller says his brother drinks, has schizophrenia and a violent history.

The 911 dispatcher reaches out to a counterpart at a Mobile Crisis Response Team, and the two talk through what the teams can and can’t do.

We need a “long-term solution,” the 911 dispatcher says.

“We’re not really long term,” the MCRT dispatcher responds.

ANA RAMIREZ U-T

Max Disposti is founder and executive director of the North County LGBTQ Resource Center in Oceanside.

Mental health calls for service From 2009 to 2021, mental health calls for service have more than doubled. In 2009, the county was seeing nearly 17,300 calls. In 2021, the total had topped 38,000.

2021

38,380 40,000

30,000

20,000

10,000

0

’09

’10

’11

’12

’13

’14

Source: SANDAG

’15

’16

’17

’18

’19

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’21

MICHELLE GILCHRIST U-T

4:45 P.M.: The woman is easy to spot.

Early 30s. Yellow dress. Teetering on heels.

Brian Cardoza, the PERT clinician, approaches with Harbor Police officers.

Someone had reported a woman trying to open car doors on Shelter Island, and while Cardoza doesn’t see her grabbing any vehicles, the woman is clearly confused.

She speaks in monotone, her words soft and slightly slurred. Sometimes she stares at the ground, hair over her face.

While they talk, a man in a flannel shirt walks out of a nearby bathroom.

He says the woman is his girlfriend.

They’re visiting from Las Vegas and he’s worried about her.

The woman’s been hearing voices and she keeps calling her boyfriend the wrong name.

Cardoza must assess if the woman can safely be left alone. The law says someone can be detained if they’re “gravely disabled,” meaning they can’t care for themselves, but this woman is well-dressed and clean and the boyfriend says she’s not a danger.

Then two things change.

First, an officer running a background check finds a felony warrant for the woman. She must be arrested.

Second, some officers wonder if she’s being trafficked.

The woman is in a nice dress, staying at a hotel, bouncing back and forth from Vegas. Taken individually, those facts don’t mean much. But together?

SCHOOLS RAMPING UP MENTAL HEALTH SUPPORT FOR YOUTH A 15-year-old student with a history of psychosis is “confused” and not recognizing the school staffers he sees almost every day.

A 14-year-old diagnosed with depression threatens to stab and gouge the eyes of other students in her middle school classes.

A high school student reports to a school therapist that he has made a plan to take his own life.

Each scenario — reported in 911 calls made to local law enforcement last April — demonstrate that young people across San Diego County grapple with mental health crises much like their older

counterparts, and that teachers, counselors and school administrators are often in key positions to respond.

What that response looks like varies by the severity of the behavior and whether there is a threat to the safety of the student and/or others on campus.

In 2021, about 44 percent of high school students nationwide reported in a survey that they felt persistently sad or hopeless, up from 37 percent in 2019, according to the Centers for Disease Control and Prevention.

School administrators said authorities should approach student mental health in a trauma-informed manner that

explores how adverse events can trigger problem behavior.

“You don’t always know the source of why a person is acting or behaving a certain way,” particularly since the pandemic, said Sandra Ceja, director of student support services for the Vista Unified School District.

Vista Unified created a three-tier system for addressing mental health services, with tier one consisting of preventative measures, tier two where school counselors provide individual or group counseling and tier three involving additional interventions, such as lessons on emotional intelligence and decisionmaking, Ceja said.

Escondido Union School District employs a full-time clinical social worker at each of its 24 schools, along with other social workers assigned to specific groups including homeless students, foster children and those from military families, according to district spokesperson Michelle Breier.

The San Diego County Office of Education convened a Student Wellness and School Culture team that helps schools adopt suicide-risk screening protocols, prepares teachers and staff to address suicide risks and trains parents on suicide prevention, according to chief of staff Music Watson.

DEBORAH SULLIVAN BRENNAN U-T

36 5150 calls have been logged by this time.

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ANA RAMIREZ U-T

Judge Cindy Davis speaks to a participant during Behavioral Health Court at the Superior Court in San Diego. Davis has been a Superior Court judge for almost a decade and believes this program can heal people with serious mental illnesses.

TUESDAY

Cardoza sets his laptop on the hood of an SUV to research her mental health history.

Officers will have the woman sit down with a trafficking expert.

While Cardoza’s working, another request comes in from dispatch. A man is chasing somebody on the boardwalk. Is PERT free?

Cardoza can’t leave the call he’s on.

7:41 P.M.: A San Diego woman comes home to find her sister hanged herself.

7:50 P.M.: A naked man is seen on Seventh Avenue and Robinson Street yelling “child molester!”

Earlier, a naked man was reported on state Route 163 at Balboa Avenue.

That followed several callers who said a naked man was in the street near Hillcrest’s DMV office. They are three different men.

8 P.M.: After the woman in a yellow dress is interviewed by a trafficking expert, she’s driven to Santee and booked at the Las Colinas Detention and Reentry Facility.

Brian Cardoza helps check her in.

Through plexiglass, he tells a nurse everything he knows.

The woman’s history does not make her an outlier.

More than hospitals or crisis centers or nonprofits, San Diego jails are the region’s largest provider of mental health care.

More than a third of people jailed in April were on psychotropic medication for a mental health disorder, according to the Sheriff ’s Department.

46 5150 calls have been logged by this time.

49 5150 calls have been logged by this time.

9 P.M.: Sitting on a bed, not far from a bulletin board with pictures of her daughter, Crystal Jenkins stares at her homework.

She recently began an online program through Eastern Gateway Community College, in Ohio, to earn an associate’s degree in social work. After everything she’s been through, Jenkins wants to help people navigate the same road.

Her program asked her to talk to someone in crisis, so she interviewed a roommate to write up a personalized care plan.

Jenkins finds the assignment thrilling.

The care plan is also similar to the one she’s following.

Behavioral Health Court has four steps, and each one gives you a little more freedom. Jenkins is at the second phase.

Her next court date is now hours away.

10:57 P.M.: A woman calls 911.

“My daughter is losing her mind,” she says, adding expletives. “She has knives in her hands. I can’t even go downstairs to open the door for you guys.”

“Is she threatening you with a knife?” the dispatcher asks.

“I thought she was going to kill me,” the mother replies.

An officer is at the Lincoln Park condominium within minutes.

Angelina Juarez, the 33-year-old who’d told her family that people were coming to hurt her, is partially outside a second-story window.

She has a knife in each hand and threatens to jump.

“Definitely going to need an ambulance,” an officer says. “She’s actively trying to stab her neck.”

In the background, a woman can be heard screaming.

MEG MCLAUGHLIN U-T

An entry from Angelina Juarez’s journal as seen at her mother’s house in National City. The 33-year-old woman had told her family that people were coming to hurt her.

The process for initiating a 72-hour hold There are three scenarios in which you can lose your freedom without breaking the law.

The first is if you’re suicidal. The second occurs if you’re deemed a danger to others. The third is when you’re so disabled you can’t care for yourself.

If police or mental health professionals find one to be true, you could be involuntarily held for three days.

INTAKE PROCEDURES FOR A 5150

1

You'll likely first be placed in handcuffs. You’re not under arrest, but it’s common to be restrained until you can be evaluated.

2

You might then be taken to a crisis stabilization unit or an emergency room. During this three-day period, Rady Children’s Hospital always had at least 10 mental health patients in the ER because there was no space at a psychiatric unit. Their average emergency room stay is three days, according to Sandy Mueller, Rady’s senior director of behavioral health services. She said the hospital typically gets more than 20 suicidal children every day.

3

If a psychiatrist decides you’re unstable, you’ll be taken to a psychiatric ward or hospital. You generally cannot appeal your stay during the first 72 hours.

There were 742 psychiatric beds available in the county during this period. Many facilities reported few, if any, empty beds, including Rady, Scripps Health, Alvarado Parkway Institute, Aurora San Diego and UC San Diego Health.

Others, including the VA, didn’t say how full they were.

At the same time, even empty beds weren’t necessarily available.

More than a quarter of the Psychiatric Hospital of San Diego County’s 60 beds were always open, even as emergency rooms backed up, because the facility lacked the staff to take more people, according to Luke Bergmann, the county’s behavioral health director.

4

If clinicians believe you need to stay longer than three days, they must file additional paperwork and receive approval from a San Diego Superior Court official.

5

Even when you get the green light to leave, you might not have a home to go back to. Furthermore, if you're so disabled you need an assisted living facility, you could be stuck waiting for months. During these three days, about half of all beds at the county hospital were occupied by people who were ready but unable to leave. The same went for nearly half of the 36 beds at Scripps Mercy in Hillcrest.

12:01 A.M.: The clock ticks past midnight.

In Lincoln Park, Angelina Juarez drops both knives, disappears inside, then reappears at the window.

“And, she has another knife,” a cop says.

Another reports, “She’s trying to get the knife deeper into her neck.”

Juarez teeters, almost falls. An officer sees her cough up blood.

Her brother appears.

He holds her up and reaches for the knife, wrestling his sister from the window.

Officers move in. One sees that Juarez has stabbed herself in the neck more than 30 times.

She’s taken to Scripps Mercy Hospital in Hillcrest.

2:38 A.M.: Craig Tenma is asleep when his iPhone lights up, signaling an incoming call. He already missed one hours earlier.

He sees the third attempt after sunrise. Tenma picks up.

The man calling has schizophrenia and bipolar disorder. “He just wants someone to talk to,” Tenma says later.

The 59-year-old paramedic is with San Diego’s Resource Access Program, which works with people who repeatedly dial 911.

The man on the phone has reached out to Tenma directly up to five times a day, for months.

That’s the goal.

Staffers sometimes spend up to a year guiding chronic callers, some of whom have mental illnesses, through the health care system.

The effort is partially to reduce pressure on 911 dispatchers and emergency rooms, but proponents also argue that people are more likely to accept long-term solutions if they build relationships with caretakers.

Tenma plans to visit the man in the afternoon.

8:30 A.M.: On the 12th floor of the downtown San Diego Central Courthouse, Judge Cindy Davis looks around.

About a dozen people are spread throughout her courtroom. A public defender is at one table, a deputy city attorney at another.

Two probation officers are in the jury box, while a doctor appears virtually on a monitor.

The group forms the backbone of Behavioral Health Court. Later today, they plan to hear from participants like Crystal Jenkins. But first, they need to decide whether to accept someone new.

“Welcome back, team,” Davis says.

Davis has been a Superior Court judge for almost a decade and believes this program can heal people with serious mental illnesses. As long as participants commit to changing their lives, Davis is committed to keeping them free.

The man in question has an illness that causes him to hallucinate, and he recently pleaded guilty to serious assault.

He appears to want help, but he lacks a support system.

The team believes they can provide that support.

A clear consensus emerges: He’s accepted.

9:49 A.M.: A woman in her 70s tries to hit people with her walker. PERT arrives. She is deemed 5150.

52 5150 calls have been logged by this time.

57 5150 calls have been logged by this time.

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ANA RAMIREZ U-T

Crystal Jenkins steps before Judge Cindy Davis at Behavioral Health Court in San Diego on Tuesday. Today she’ll learn whether she can advance to the next phase of the program, which would bring her one step closer to living with her daughter.

HOW DOES BEHAVIORAL HEALTH COURT WORK?

10 A.M.: In the recliner room at the Vista Crisis Stabilization Center, five clients have stayed past the 24-hour limit.

Behavioral Health Court is a program in San Diego Superior Court offered to a small number of defendants in criminal cases who suffer from serious mental illness. It’s an intense program designed for the most serious cases.

The most common path for entry is through a track called BHC Probation, and it offers 75 spots for San Diego County adults who meet specific criteria.

To qualify, candidates — most of whom are facing felony charges, although some are facing misdemeanors — must have a serious mental illness as defined by Title IX of the California Code of Regulations, like schizophrenia, schizoaffective disorder or bipolar disorder.

ANA RAMIREZ U-T

Judge Cindy Davis becomes emotional speaking about Behavioral Health Court, which she oversees, while at the downtown San Diego Central Courthouse.

A guilty plea to a gun charge would bar admission to the program. Registered sex offenders and registered arsonists are not eligible.

Candidates must have tried and failed at lower-intensity, court-ordered programs or solutions. They must be mentally competent to stand trial and agree to plead guilty and to follow the strict requirements of the program.

Applicants are screened by mental health professionals, then the applications are reviewed by the judge, prosecutors, defense attorneys and others, including probation and treatment professionals.

They decide as a team whether to accept someone into the program.

Once accepted, participants can leave jail — most of them are in custody— and move into group homes. They are provided with treatment, medication, group therapy and individual counseling. All participants are required to take their prescribed medication, and they must remain sober.

Behavioral Health Court has four phases.

The entire program lasts a minimum of 18 months.

As of October, 357 people had taken part in the program since it started in 2009, according to the county. Of that number, 150 people graduated — a completion rate of about 51 percent. Those who did not complete the program were sent to jail or prison to serve the sentence they’d faced before being accepted into the program.

The county pays about $100 a day per participant for Behavioral Health Court. By comparison, the county pays between $126 and $240 a day to house a person in jail.

TERI FIGUEROA U-T

71 5150 calls have been logged by this time.

1:22 P.M.: At San Diego police dispatch, a 28-year-old calls to say she’s considering shooting herself. She has bipolar disorder and a history of violence toward her mom; she asks for PERT.

Candidates are usually referred to the program during the plea-bargaining phase of a case.

Many defendants are referred by the Office of the Public Defender, which represents about 90 percent of all criminal defendants in the county. The office has a special unit focused on mental illness diagnosis and treatment for its clientele.

NOON: Hail Mary, full of grace Elvie Del Rosario and her siblings sit around a picture of her son.

The Lord is with thee They’ve gathered in Chula Vista to pray since Steven Del Rosario jumped from the San Diego-Coronado Bridge.

The rosary is a Catholic tradition meant to guide loved ones to heaven, and Elvie plans to pray it at noon for the next several weeks.

Blessed art thou among women And blessed is the fruit of thy womb, Jesus Elvie had always felt close to her son. They loved to hike together. She confided in him, and he called her “Elvs.”

Holy Mary Mother of God Steven had talked about seeing “darkness” but Elvie hadn’t known just how low Steven was.

Pray for us sinners Now and at the hour of our death Steven kept a journal on his computer. Many of the 140-plus pages were addressed to God. “If your plan is for my story to end, please let it happen sooner than later,” Steven once wrote. “I am not afraid.”

Amen

ANA RAMIREZ U-T

Another participant in Behavioral Health Court listens to Judge Cindy Davis on Tuesday. The program focuses on people with serious mental illnesses who’ve committed crimes.

“It helps me to notice my thoughts before I have a reaction.”

A Behavioral Health Court participant speaking about therapy

Suicides across San Diego County The number of suicides has held relatively steady since 2009.

500

2021

380 400

300

200

100

0 ’09

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Source: San Diego County Medical Examiner’s Office

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MICHELLE GILCHRIST U-T

1:46 P.M.: Behavioral Health Court is now in session.

Thirteen participants wait to be called. On a bench near the back, Crystal Jenkins sits in a white T-shirt and green shorts, a bobby pin holding her hair in place.

Judge Cindy Davis calls up the first participant, who says he just applied to the University of Phoenix.

“Keep up the good work,” Davis says.

The judge summons a second man.

He says he’s almost finished a treatment program, and Davis asks if therapy has helped.

“It helps me to notice my thoughts before I have a reaction,” he replies.

Before long the judge says, “Crystal Jenkins.”

She walks to a podium across the room.

Jenkins talks about her social work program and the desire to coach people with similar struggles. She says she wants more supervised visits with her daughter.

The judge looks Jenkins in the eye.

It’s time to move to Phase 3, the judge says. “You’re well on your way to graduating.”

The courtroom bursts into applause.

2:32 P.M.: A basketball swishes through a hoop.

Men and women shout for joy.

As peaceful as the courtyard is, nearby concrete walls and a heavy metal gate don’t let anyone forget they’re inside the Psychiatric Hospital of San Diego County.

The Midway facility is the region’s only safety-net hospital, meaning as long as space is available, nobody is turned away — regardless of whether they can pay or how many times they’ve checked in.

83 5150 calls have been logged by this time.

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K.C ALFRED U-T

This gate can be one of the first things people see when they’re admitted to the Psychiatric Hospital of San Diego County in the Midway District. The facility is the region’s only safety-net psychiatric hospital. If there is space available, no one is turned away.

SHIFTING TO CHRONIC CARE INSTEAD OF CRISIS CARE

Many people have been abandoned by their families and believe doctors will similarly walk out on them, says Michael Krelstein, the facility’s director. Sometimes a patient cycles through more than a dozen times “before they begin to believe that change is possible,” the doctor says.

Though courts can order patients to take medications, sometimes therapy isn’t complicated.

A silver box on a nearby wall holds a blanket warmer.

“You put a blanket on them and they’re asleep, you haven’t even talked about medication,” says administrator Angela Warneke.

85 5150 calls have been logged by this time.

5150 calls have been logged by this time.

Existing research supports that assertion.

3:03 P.M.: A middle school in south San Diego reports a 13-year-old who’s thinking about suicide.

3:30 P.M.: This case makes Fadi Nicolas mad.

The Sharp Mesa Vista doctor is in a meeting with colleagues, discussing a patient in his 60s.

The man has schizophrenia and dementia and had been living at a skilled nursing facility. A court oversees his care, and paperwork to renew his conservatorship needed to be filed the previous November.

But the facility forgot, Nicolas says.

Someone realized their mistake and dropped the man off at Sharp Memorial’s emergency room Friday, according to Nicolas.

“It just shows, once again, how fragmented and just disjointed this whole mental health system” is, Nicolas says later. “You have to be keeping a close eye on every insurance piece, every legal aspect.”

Sharp asked the facility to take the man back. They said no, he says.

The hospital threatened to report the facility. The nursing home backed down.

In the meantime, Nicolas did the conservatorship paperwork himself.

3:30 P.M.: Dennis puts on a pair of headphones. He hears a string of notes that sound like they’re going up.

In response, he clicks an “up arrow” on a computer screen.

Watching him is Gregory Light, vice chair of the University of California San Diego psychiatry department.

The two are in a small room for a clinical trial on schizophrenia.

Researchers have found the illness warps how the brain processes sound, leading people to hear voices that aren’t there.

“I think I shut out a lot of the world,” Dennis says. “People who have mental illness are shunned a lot, and I’m one of them.”

This therapy will hopefully retrain brains to process noises more accurately.

Dennis, who asked that his last name not be used, isn’t sure it’ll work.

But just participating gives him a boost.

92

Treatment of mental illness takes time.

Experts say many people struggling with their mental health need repeated help to stay on the path to success.

K.C. ALFRED U-T

San Diego County Psychiatric Hospital’s Michael Krelstein says patients sometimes require more than a dozen stays “before they begin to believe that change is possible.”

3:53 P.M.: A woman says her 35year-old son is having a mental break in Rancho Peñasquitos.

A similar examination from 2015 of cognitive behavioral therapy, commonly treating a wide range of disorders from anxiety to substance use, found that nearly 16 percent of people dropped out before starting a treatment program and about 26 percent stopped participating after getting started.

In light of such evidence, Luke Bergmann, San Diego County’s behavioral health director, has convinced his bosses to invest in a broad range of resources — from care coordinators to drug and alcohol treatment — instead of simply providing more treatment beds to accommodate growing numbers of patients.

NELVIN C. CEPEDA U-T

Larry Richer takes a break playing the guitar at San Diego’s Connection 2 Community Clubhouse, which helps homeless people who have mental health concerns.

“Currently, we have a system that is heavily weighted toward crisis; most resources spent on mental health services are meant to address crises like hospitalizations, emergency department visits, law enforcement interventions, jails and the like,” Bergmann said in an address to the county Board of Supervisors in 2019.

“What we need to do, in other words, is shift from a crisis system to a chronic system ... with better coordination on ongoing care, better links to housing and better integrated with primary care,” he said.

“I get asked all the time how many beds San Diego County needs,” Bergmann said. “And the answer is, we will only know as we begin to invest in chronic care management because good chronic care will reduce the need for in-patient beds.”

3:38 P.M.: San Diego police have five 5150 calls waiting for PERT. 3:43 P.M.: Staffers at the Jane Westin Center, a downtown clinic, say they have a client planning to kill himself.

He was released from a hospital nearly a week ago and hasn’t eaten in six days.

No PERT clinicians are available.

Officers are dispatched.

A scholarly paper published in 2020 that analyzed a broad set of medical studies found that, on average, 49 percent of people prescribed medication to treat severe mental illness stop taking the drugs or quit following dosing schedules.

ALEJANDRO TAMAYO U-T

Dennis, who asked that his last name not be used, participates in a UC San Diego study on schizophrenia Tuesday. The therapy tries to retrain brains to process noises more accurately.

“I think I shut out a lot of the world.

People who have mental illness are shunned a lot, and I’m one of them.”

Dennis

In September 2022, the county published a new “optimal care pathways” model that aims to prevent up to 40 percent of mental health care hospital admissions by funding a more holistic system that uses specially trained peer educators and provides “continuous care and housing” to those who need it.

Cost and workforce shortages are the main impediments to this vision. A recent study by the San Diego Workforce Partnership showed that local providers are underpaid and in short supply.

Advocates say the way to pay for a more comprehensive system is by reducing expensive hospital admissions. However, the county has not yet performed a full financial analysis.

PAUL SISSON U-T

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711

HOURS

13

SUNDAY • APRIL 16, 2023

The number of days, as of the 72-hour period, that one patient had remained hospitalized because no beds were available at an outpatient facility

K.C. ALFRED U-T

Nurse Vinna Litonjua talks with a patient at Exodus Recovery on Monday in Vista. It is a crisis stabilization center, which is like an urgent care for people experiencing a breakdown. There are a dozen recliners for patients.

ADRIANA HELDIZ U-T

San Diego police Officers Jeff Martinez, Michael Padgett and PERT clinician Jessica Aguirre speak with homeless residents downtown on Monday.

K.C. ALFRED U-T

Michael Krelstein walks through the San Diego County Psychiatric Hospital courtyard.

He is director of the Midway facility, which is the region’s only safety-net hospital.

K.C. ALFRED U-T

Security cameras show different areas of Exodus Recovery, a crisis stabilization center, in Vista on Monday. Some patients were brought in by law enforcement.

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711

HOURS

13

SUNDAY • APRIL 16, 2023

The number of days, as of the 72-hour period, that one patient had remained hospitalized because no beds were available at an outpatient facility

K.C. ALFRED U-T

Nurse Vinna Litonjua talks with a patient at Exodus Recovery on Monday in Vista. It is a crisis stabilization center, which is like an urgent care for people experiencing a breakdown. There are a dozen recliners for patients.

ADRIANA HELDIZ U-T

San Diego police Officers Jeff Martinez, Michael Padgett and PERT clinician Jessica Aguirre speak with homeless residents downtown on Monday.

K.C. ALFRED U-T

Michael Krelstein walks through the San Diego County Psychiatric Hospital courtyard.

He is director of the Midway facility, which is the region’s only safety-net hospital.

K.C. ALFRED U-T

Security cameras show different areas of Exodus Recovery, a crisis stabilization center, in Vista on Monday. Some patients were brought in by law enforcement.

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NELVIN C. CEPEDA U-T

On Tuesday, workers from Father Joe’s Villages check an area downtown well-known for encampments to see if anyone needs help. Similar outreach groups have popped up around the region in recent years as the number of homeless people rises.

CARE COURT DESIGNED TO EXPAND TREATMENT

He has a history of hearing voices and has been texting to say a police helicopter is hovering over his home.

There is no police helicopter. “He’s afraid they are going to take him away and he is not going to see me again,” she says.

The woman asks for PERT. None are available.

6:10 P.M.: San Diego police have six 5150 calls waiting for an officer.

In 2022, California launched an effort to address one of the state’s most frustrating issues: How to get mental health care to people who may not want it.

The new approach Gov. Gavin Newsom announced last March was the Community Assistance, Recovery and Empowerment Court, or CARE Court, which has been heralded as a way to expand the number of people who could be mandated treatment for mental health disorders.

Under the CARE Act, which legislators approved last year, courts could mandate people undergo up to 24 months of treatment that would be communitybased and individualized.

Treatment could include short-term stabilization medications and connection to housing and other support services.

The new approach is seen as an alternative to conservatorships, hospitalizations and incarcerations, and it revises what has been followed since the 1967 adoption of the Lanterman-Petris-Short Act, which created strict due-process protections for people with mental health issues who otherwise could be institutionalized.

Over the decades, the LPS Act often has been seen as too restrictive, leaving people with mental issues to languish in the streets.

Court-ordered treatment often came as part of the criminal justice system and only after a person had been arrested.

Under the new approach, family members, first responders, clinicians and community members could refer a person to CARE Court to be evaluated for eligibility to a treatment program.

To be eligible, a person must be either unlikely to survive safely without supervision or be a threat to themselves or others.

The state has set a timeline for San Diego, San Francisco, Orange, Riverside, Stanislaus, Tuolumne and Glenn counties to establish new CARE Courts by Oct. 1 of this year.

ADRIANA HELDIZ U-T

Downtown, Jessica Aguirre, a PERT clinician and member of the San Diego Police Department’s Homeless Outreach Team, speaks Monday with a person looking for a shelter bed.

Staffing on the rise at San Diego County Behavioral Health Services The county of San Diego has boosted staffing and spending in its Behavioral Health Services office, with the 2023-24 spending plan employing more than 1,200 people.

1,207.5 1,200

6:20 P.M.: A woman says her 28year-old son is not taking his schizophrenia meds and has not slept in three days.

He’s threatened to kill her. She’s hiding in the garage.

1,000

829.5 800

600

400

200

0 ’12’13

’13’14

Laura’s Law was adopted by the San Diego County Board of Supervisors in April 2015, but the results have been underwhelming.

Only 10 people have been ordered into treatment in San Diego since 2015.

GARY WARTH U-T

’14’15

’15’16

’16’17

’17’18

’18’19

’19’20

’20’21

’21’22

’22’23

’23’24

Spending history at San Diego County Behavioral Health Services The county of San Diego has been increasing the budget for Behavioral Health Services, the department that manages mental helath services. However, in the last decade, almost $250 million from the allocated budget has gone unspent.

$895.7

9:25 P.M.: Because she’s now in Phase 3 of Behavioral Health Court, Crystal Jenkins doesn’t have to be home until 10 p.m.

She makes it with about a half hour to spare.

Jenkins had been eating strawberry cheesecake sundaes with a friend. After today’s hearing, she can’t get over how much she’s changed since the start of the program.

Jenkins recently applied to be a peer support specialist at the National Alliance on Mental Illness. She’s already certified for that work through a two-week online course she took from Recovery International, an Illinoisbased nonprofit.

She finished the class impressed.

Whoever was working at Recovery seemed to know what they were doing.

$1,000 million

Actual spending Unspent money

800

Approved

This is not the first time the state has attempted to mandate treatment.

In 2002, California adopted Laura’s Law, which allows authorities to order an assisted-outpatient treatment plan to people who have a serious mental illness plus a recent history of psychiatric hospitalizations, incarcerations, or have threatened or committed serious violent behavior.

6:15 P.M.: Xiuqin Li is worried about her son.

Yuhao Du called yesterday from Del Mar, saying he felt unsafe. It had been unsettling.

It’s hard to know what to do. Li, a cardiologist, is still in China.

She had seen concerning behavior while raising her son. Around age 13, Du was sent home from school for drinking ink. He would repeatedly turn lights on and off, and his parents learned he has a compulsive disorder.

But Li knew of few psychiatric services available.

When Du moved across the world to study at UC San Diego, he seemed his normal, warm-hearted self. Then his demeanor changed. He told his parents he’d been seeing a doctor for mental health issues.

Li suspected it was pressure from school.

600

$431.1 400

200

ANA RAMIREZ U-T

0 ’12’13

99 5150 calls have been logged by this time.

’13’14

’14’15

’15’16

’16’17

’17’18

’18’19

’19’20

’20’21

’21’22

’22’23

’23’24

Source: County of San Diego MICHELLE GILCHRIST & KARTHIKA NAMBOOTHIRI U-T

Crystal Jenkins is now in Phase 3 of Behavioral Health Court. She applied to be a peer support specialist at the National Alliance on Mental Illness.

112 5150 calls have been logged by this time.

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ANA RAMIREZ U-T

Lisa Garcia puts on makeup at her El Cajon home on Monday before hosting a Zoom meeting for Recovery International. Garcia experienced a series of crises, was twice hospitalized and struggled to find the correct medication before she was finally diagnosed with bipolar disorder.

COUNTY TO UNWIND LAW ENFORCEMENT FROM MENTAL HEALTH CASES Out of nearly three dozen police shootings in the county from 2018 through June 2022, 40 percent involved someone with mental health issues, a review by The San Diego Union-Tribune found.

That’s nearly triple the percentage found during the previous 25 years.

O

ne of the most intractable problems in the mental health crisis is how to reduce confrontations with law enforcement.

About 14 percent of people shot by police in the county from 1993 through 2017 had documented mental health issues, according to the District Attorney’s Office.

An additional 16 percent showed “unstable behavior.”

The Union-Tribune analyzed 35 additional police shootings from 2018 through mid-June and found an even greater proportion. In 40 percent of cases, the person shot either had a documented diagnosis or mental health issues were suspected.

PERT and MCRT were partly created to lessen the bloodshed, and the county has more than tripled the number of law enforcement and mental health clinician teams since 2008.

It’s still not enough to handle the volume of calls.

And sometimes officers are the ones in danger.

It’s an increase that underscores how volatile interactions between law enforcement and those in crisis can be.

Every year, police officers and sheriff’s deputies respond to tens of thousands of calls about people in behavioral health crises, and the county has been working for decades to disentangle law enforcement from those kinds of emergencies.

Critics have long argued against law enforcement involvement in such situations, saying they are more likely to escalate mental health emergencies than provide the kind of help that is needed.

Sometimes those emergencies become violent.

About 14 percent of the 451 people shot by police or sheriff’s deputies in the county from 1993 through 2017 had documented mental health issues, according to a report from the San Diego County District Attorney’s Office.

An additional 16 percent showed “unstable behavior.”

The Union-Tribune reviewed documents from the District Attorney’s Office summarizing shootings from 2018 through June 15, 2022, and found an even greater proportion. In 35 incidents, five people had a documented mental health diagnosis and nine people had suspected mental health issues.

An additional 21 shootings occurred during this time frame but remain under review or were withheld because of a pending criminal case.

Shootings by law enforcement inspired county and mental health leaders to create the Psychiatric Emergency Response Teams in 1996, officials say. The program, often referred to as PERT, pairs licensed mental health clinicians with law enforcement officers.

During the pilot program, there was one PERT team working out of the San Diego Police Department’s Western Division.

Now, there are 72.

Two years ago, another alternative was created: Mobile Crisis Response Teams, which are made up of behavioral health clinicians, case managers and peer support specialists.

The teams respond to those in crisis, connect people with mental health resources and follow up to ensure they get any additional care they might need.

LYNDSAY WINKLEY U-T

K.C. ALFRED U-T

Members of Chula Vista’s Homeless Outreach Team talk with Gary Burke who was living in his motor home on Wednesday.

Burke was open to help, but he needed transportation.

Mental illness in police shootings A District Attorney's Office review of 439 police shootings found 30 percent of those shot either had a documented mental illness or exhibited unstable behavior. A Union-Tribune analysis of an additional 35 shootings found an even greater proportion: 40 percent of those shot had a mental illness or suspected mental health issues.

Documented mental illness Exhibited unstable behavior Suspected mental illness No mental illness

14%

14%

16%

Total shot: 451

69%

26%

1993 to 2017 DA analysis

Total shot: 35

60%

2018 to 2022 U-T analysis

In the DA's review, 12 subjects had a mental illness and exhibited unstable behavior.

In the Union-Tribune's review, another 21 police shootings occurred from 2018 through June 15, 2022, but remained under review or were withheld because of a pending criminal case at the time of this analysis.

Source: San Diego County District Attorney’s Office

MICHELLE GILCHRIST U-T

WEDNESDAY 6:30 A.M.: Stuck to the wall of Lisa Garcia’s bathroom is a small piece of paper.

The text, taken from a book, reads almost like a prayer.

A thing is valuable if it promotes inner peace.

The attainment of inner and outer peace is your supreme value.

Garcia opens her medicine cabinet and grabs five bottles. Three have the letter “M” scrawled in Sharpie, for “morning.” The other two have a “B” for “both,” meaning they’re for both morning and night.

In her El Cajon home, she pours eight pills into her hand and pops them all into her mouth.

It sure beats the hospital.

In 1989, Garcia’s mom died. She broke up with her boyfriend. She stopped going to her catering job and stopped taking her 8-year-old to school.

She was hospitalized after her family staged an intervention. But it wasn’t clear what was wrong. Medications were tried and abandoned. Garcia crashed her car into the back of a semi-truck. Another time she disappeared for days in a casino.

After another hospitalization, she got the correct diagnosis: She has bipolar disorder.

Garcia found the right pills and a therapist told her about Recovery International, the same organization from which Crystal Jenkins took a course.

Garcia has now worked at Recovery for nearly 25 years.

She credits the nonprofit’s approach with helping keep her well.

8:26 A.M.: Gary Burke needs a ride.

His home is a beige and orange RV parked on C Street by downtown Chula Vista. A small crowd of police, nurses, PERT clinicians and nonprofit staffers gather around, part of the Chula Vista Police Department’s Homeless Outreach Team.

Similar groups have popped up around the region in recent years.

There were more than 8,500 homeless people in the county near the start of last year, a 10 percent increase from the previous tally, according to the San Diego Regional Task Force on Homelessness. That’s almost certainly an undercount.

More than a third of those surveyed on the street said they had a mental health disorder.

From the RV, Burke says he’s a homeless veteran with brain trauma and post-traumatic stress disorder, and he’s willing to go to the San Diego Veterans Affairs Medical Center.

But the facility’s in La Jolla, about 20 miles away. RV parking is hard to find, and gas is expensive.

“He can go on the trolley,” one person says.

“He’ll need a bus pass,” says another.

“We have the numbers to give him a ride,” Lt. Ernie Pinedo says. “Maybe he decides in the trolley, ‘You know what, I’m not gonna go.’ So, let’s just take him straight there.”

Someone tells Burke that a cop will drive. Burke begins to cry.

“First time ever — and I’m surprised — that somebody even knows that I’m this bad,” he says.

9:30 A.M.: Josh Barder enters a consultation room.

Barder normally supervises social

128 5150 calls have been logged by this time.

130 5150 calls have been logged by this time.

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EDUARDO CONTRERAS U-T

Dispatcher Jayda Meza works at the San Diego County Sheriff ’s Emergency Communication Center on Wednesday. Callers sometimes ask for PERT, but clinicians aren’t always available to help with situations ranging from suicidal students to violent relatives.

He wanted to come back to Fancor Guest Home in El Cajon.

The man doesn’t have a lot of options. Over the past decade, San Diego County has effectively lost 68 similar facilities that had supplied more than 500 beds, state data show.

The reasons are legion: Costs have increased and licensing requirements have tightened. Residents pay their way with Social Security payments, which inch up incrementally, if at all, administrators say.

Mabalot told the man no. She doesn’t feel he’s safe anymore.

This leaves her with a choice.

She can pick a random name from her list, call their case worker and set up an interview. She’ll do her best to choose somebody who appears stable, but a new person is a new person.

Or she can call someone she knows.

She remembers meeting one guy at a sister facility. He’d been evicted years ago after he stopped taking medication, took methamphetamine and attacked somebody. But he never made Mabalot feel threatened, and he had called her and apologized.

She thinks he might be OK. Mabalot gets on the phone with his case worker. They hash out the details.

He’ll move in Friday.

Her 44 beds are now filled again.

workers at Sharp Mesa Vista, the psychiatric hospital, but with the pandemic keeping staffing tight, today he meets directly with patients.

COVID protocols keep Barder at a distance, his face covered by a mask and plastic shield.

Barder speaks with a man who’d voluntarily checked in a day earlier, saying he felt unsafe. But now he’s agitated and worries about missing work.

He can leave if he wants. But Barder suspects he isn’t stable. The social worker steps away and calls the man’s case manager.

This is a pattern, the case manager says. The man works nights and takes drugs in the morning to stay awake.

They trigger hallucinations, so he checks himself in somewhere and then immediately asks to leave.

Barder returns to the man, who’s waiting in a hallway.

What if I write a letter to your boss, Barder says. It won’t give details about why you’re here, but it will say you’re being treated at a hospital and can’t take shifts.

The man agrees to stay.

10:41 A.M.: A woman in Mira Mesa appears to be hanging dead rats from a window.

Adult protective services is called.

138 5150 calls have been logged by this time.

11:11 A.M.: A woman says her sister is holed up in her room in the family’s Vista apartment.

The sister has schizophrenia and bipolar and multiple personality disorders. Voices are telling her to kill their mother and the family is hiding outside in their car.

The closest PERT team is at a school with a suicidal student. Deputies head over.

11:30 A.M.: Wherever Victoria Sahagun and Shawn Keating turn, the request is the same: Do you have housing?

“I’ve been on the waiting list since 2018, 2019,” says one middle-aged man at the Oceanside Transit Center.

Sahagun and Keating make up a Mobile Crisis Response Team. Today, they walk the transit center in face masks, handing out water bottles as part of their outreach work.

The job’s personal for Keating. Before becoming a community health worker, the 43-year-old former Marine was diagnosed with major depressive disorder and PTSD. A back injury led to an opioid prescription, which turned into an opioid addiction, then homelessness.

It’s hard to find support on the streets. Keating found he didn’t qualify for some federal aid because he struggled with both addiction and mental health. Many programs are only built to handle one, Keating says later.

Salvation finally came from a faithbased organization for veterans.

He’s now been sober for seven years.

11:56 A.M.: A 76-year-old says an adult son broke into her Bay Park home.

He pushed a sliding window so hard it snapped the handle, she says.

He drinks 10 to 15 energy drinks a day.

“Why is this taking so long?” she says.

Dispatch asks for PERT. None are available.

NOON: The guy who two days earlier smashed a mirror called Cyra Mabalot.

K.C. ALFRED U-T

Tim Brown, a Navy veteran, lives on the street under Interstate 5 in Mission Valley. He was hesitant to accept help Wednesday from an outreach worker with Veterans Village of San Diego.

VETS HAVE HIGH RATE OF MENTAL HEALTH ISSUES With more than 100,000 active-duty service members and 240,000 veterans, San Diego County has one of the largest concentrations of military personnel in the nation.

increase in relationship issues within marriages, families and with older children since the start of the pandemic, as well as an increase in anxiety among all family members.

Along with that population comes a high number of enlisted personnel and veterans struggling with mental health issues.

Finney said more resources are now available for healing and there is less stigma associated with the need.

Between October 2018 and September 2022, the number of veterans seen annually at local mental health clinics grew from more than 25,300 to more than 27,100 — a 7 percent increase over four years, according to the U.S. Department of Veterans Affairs.

During that time, 22,590 patients sought help for post-traumatic stress disorder. When including non-VA clinics, the number of San Diego veterans seeking help for PTSD increased to 27,800.

Veterans Village of San Diego operates clinics in Mission Valley and Oceanside specifically for post-9/11 service members, veterans and their families. In addition to PTSD, the clinic provides therapy and counseling for depression, grief, anxiety and anger, as well as other kinds of issues, including transitioning out of service and into civilian life.

Shari Finney, regional clinic director of the Steven A. Cohen Military Family Clinics at Veterans Village of San Diego, said the clinics are seeing an

Studies show service members experience a disproportionately high number of mental health issues when compared with the general population. A 2014 study by JAMA Psychiatry found almost 25 percent of 5,500 active-duty, non-deployed Army soldiers were diagnosed with a mental health disorder of some kind — including major depression, intermittent explosive disorder and PTSD — and 11 percent were diagnosed with more than one mental illness.

According to the National Alliance on Mental Health, about 20 percent of American adults experience mental illness each year. Other studies found 3 percent of the population has more than one mental health issue.

A California Department of Public Health report found 583 veterans and active service members died by suicide in 2020, including 85 in San Diego County, more than in any other county in the state, including Los Angeles, which had 81. There were 3,355 civilian suicides in California that year.

GARY WARTH & ANDREW DYER U-T

12:23 P.M.: A therapist asks for a welfare check on a schizophrenic patient who’d said rats were eating her food.

Deputies visit her in Pine Valley.

They see “abhorrent” living conditions, but the woman doesn’t meet criteria for a 5150.

140 5150 calls have been logged by this time.

12:27 P.M.: Someone in Vista spots an older woman pushing a stroller full of broken glass.

She’s behind a restaurant dumpster, yelling that she hates her daughter and wants to die.

1:00 P.M.: Tony Pacheco starts his shift.

Today, the California Highway Patrol officer will monitor Interstate 8, from the coast to the edge of La Mesa.

Married with two children and a baby on the way, Pacheco has been on the job for seven years.

He never knows what a shift will bring.

1:06 P.M.: Deputies and PERT take a teenage girl to the Emergency Screening Unit, a downtown San Diego facility that evaluates kids in a mental health crisis.

The Lakeside 15-year-old tried to kill herself earlier in the month. Now she’s threatening to kill her mom.

1:30 P.M.: Fadi Nicolas steps in front of his computer for a virtual meeting.

The woman who’d lunged for the diaper bag Monday is resisting treatment, and the man whose conservatorship lapsed is on track to soon leave Sharp Mesa Vista. Nicolas deals with similar situations regularly.

Today’s discussion will address a rarer situation: How should clinicians treat a cop in crisis?

Nicolas logs onto Microsoft Teams.

Joining him are representatives from the San Diego Police Department.

They’re hoping to shape a new approach.

The doctor used to get calls a few times a year from first responders concerned about a colleague, he says later. That number increased amid the pandemic.

144 5150 calls have been logged by this time.

THE SAN DIEGO UNION-TRIBUNE

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NELVIN C. CEPEDA U-T

Emmanuel Navarro and Deborah Valera, outreach workers from Father Joe’s Villages, stop Tuesday along 17th Street and Imperial Avenue downtown to check on a person who has lived on the street for the past nine years.

HOMELESS PEOPLE ARE FOCUS OF PROGRAMS

It’s a delicate situation. Officers are afraid of losing their jobs, and they’re definitely hesitant about entering a place where they’ve detained people.

Nicolas hopes the hospital can develop new training in the coming months.

On any given day, it isn’t hard to find evidence of a mental health crisis among San Diego County’s homeless population.

Recently, it was found on 17th Street in downtown San Diego, when Father Joe’s Villages outreach worker Deborah Valera asked a man in a wheelchair if he needed help.

“I’m not all here,” the man told her. “I’ve got PTSD and ADD.” He then began talking about the Illuminati and drawing patterns on a box. He began barking like a dog.

Society has turned a blind eye to the problem for decades, sometimes only reacting in response to violent incidents that result in jail time rather than mental health care.

Restrictions on mandated treatment, a lack of psychiatric hospital beds and an overall shortage of resources have compounded the problem.

K.C. ALFRED U-T

A sign shows the codes for emergency responses at the Sharp Mesa Vista psychiatric hospital in San Diego on Monday.

A “Code Green” is for a “combative individual.”

ER visits for mental health In San Diego County Data for 2015 was unavailable due to a change in data collection.

47,191

50,000

Slowly, things have begun to change as San Diego County, the city of San Diego and homeless service providers have started providing mental health care directly to people living on the street.

40,000

Within the past year, the city and county opened two shelters with a focus on mental health and addiction, and the city plans to open a “safe haven” residency program for addicts.

20,000

Historically, shelters have served a broad population without an emphasis on any population or issue.

55,834

60,000

30,000

10,000

0

’05 ’06 ’07 ’08 ’09 ’10 ’11 ’12 ’13 ’14 ’15 ’16 ’17 ’18 ’19 ’20 ’21

Source: San Diego County

MICHELLE GILCHRIST U-T

Annual counts conducted by the Regional Task Force on Homelessness have found about 37 percent of homeless people living without shelter say they have a mental health condition.

Mental illness, along with generational poverty and substance abuse, can contribute to homelessness.

The realities of life while homeless, however, have been called contributing factors to addiction and mental health issues, creating a vicious cycle for people living on the street.

In December 2021, a 44-bed shelter opened in a city of San Diego-owned building that once was a Pier One Imports store.

With funding from the county, Family Health Centers of San Diego was contracted to provide substance use counselors, peer support, mental health clinicians and nurse practitioners for medical consultation.

The shelter was the first of its kind in the region to focus specifically on populations struggling with addiction and mental health issues.

Since then, several nonprofits, including Healthcare in Action and Father Joe’s Villages, have added mental health professionals to their street medicine teams.

GARY WARTH U-T

ANA RAMIREZ U-T

Lisa Garcia, a program manager at Recovery International, participates in a Zoom meeting from her home Wednesday. The organization focuses on processing day-to-day frustrations.

“Over the last few years, there’s been no season. It’s just been referrals coming every day, all the time.”

Tania Beaudoin

3:50 P.M.: In the San Diego Central Jail downtown, Capt. Carl Darnell walks by a cell.

Through a window he sees two men. One lies still, his eyes closed.

Darnell raps the glass. The man opens his eyes.

The captain moves on.

People die in San Diego County jails at rates far exceeding other large California counties.

One therapist wrote in court records that “I have observed my patients … suffer in what can only be described as filthy, inhumane conditions, and in some cases, die by suicide.”

The Sheriff ’s Department has made changes, like adding more detailed interviews between medical staff and detainees and body scans to check for ingested drugs. Darnell says he talks with the medical director and chief clinician daily.

The Central Jail is the only one of the region’s six detention facilities with a dedicated psychiatric ward, but staffing is difficult. Overtime is required for nurses, and clinicians keep resigning due to poor working conditions, according to department records.

Release from custody can complicate recovery.

One homeless man recently said he was afraid to keep his medication, Deputy Dan Nguyen has said. “He says he can’t have it because he’ll get jumped.”

148 5150 calls have been logged by this time.

5:41 P.M.: Alex Aiello closes the tabs on her computer.

On a typical day, the counselor at Chula Vista’s Southwestern College might meet with four students. Today she saw 14.

Across town, therapist Tania Beaudoin is wrapping up a session with a client.

Beaudoin once saw patient numbers ebb and flow with the seasons.

“Over the last few years, there’s been no season,” Beaudoin says. “It’s just been referrals coming every day, all the time.”

5:53 P.M.: Lisa Garcia looks at a dozen faces on her laptop.

Each is an employee with Recovery International, where Garcia is a project manager.

“This is a place where we can deal with the trivialities of everyday life,” says a man on the screen. “Even though you may have been doing this 20, 25, 30 years, you still deal with emotional distress.”

Garcia believes healing can happen when the sick listen to the sick, and she both leads and participates in Recovery meetings that focus on dayto-day frustrations.

Garcia hasn’t been hospitalized since 1997. She didn’t fall apart when her dad died in 2010, or when she lost her sister a year later.

Sometimes, Garcia will ask her sons about going off her meds.

They won’t have it. She once pinkypromised her youngest that she’d always take her pills, and she’s kept her word.

Even if she did relapse, Garcia knows that wouldn’t be the end of her story.

157 5150 calls have been logged by this time.

18

SUNDAY • APRIL 16, 2023

THE SAN DIEGO UNION-TRIBUNE

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Law enforcement investigate a scene on Interstate 8 in Mission Valley where a California Highway Patrol officer was shot during rush hour on Wednesday. The road was closed in both directions as officers swarmed the area.

“You might feel hopeless,” Garcia tells the group, “but there are no hopeless cases.”

6 P.M.: In China, Xiuqin Li has repeatedly tried to call her son.

Yuhao Du hasn’t picked up.

At this moment, he’s in his Audi, driving east on Interstate 8.

As he nears the 805 overpass in Mission Valley, his car leaves the lane and slams into a concrete divider.

The Audi comes to a stop. A passerby calls 911.

6:16 P.M.: Officer Tony Pacheco is dispatched to a wreck.

He’s near the 805 overpass on Interstate 8 when he spots a car on the side of the road.

The officer stops and gets out.

The car’s driver is outside, blood running down his face. Pacheco gets closer. This guy has a 1,000-yard stare, the officer thinks.

The driver opens his mouth. “I want to kill myself,” he mumbles. “Can you kill me?”

“What?” Pacheco says.

“Can you kill me?”

“No, man,” Pacheco replies. “Stand by.”

We need an ambulance, the officer thinks. Pacheco also needs backup.

He reaches for his radio.

He doesn’t get to it in time.

158 5150 calls have been logged by this time.

6:21 P.M.: Traffic slows in Mission Valley.

Travis Almond turns onto Interstate 8, heading home from work at a yacht management company.

He sees a crash ahead. There’s a wrecked Audi, and an SUV belonging to California Highway Patrol.

Almond’s pickup gets closer. He sees two men wrestling in the road.

One is Tony Pacheco. The officer is fighting for control of his gun, and his leg is covered in blood.

Almond brakes and jumps out.

Pacheco and the other man separate.

K.C. ALFRED U-T

Law enforcement officials work into Wednesday night on Interstate 8 in Mission Valley where a California Highway Patrol officer was shot. A passerby stopped his truck after he saw two men, one of whom was partially covered in blood, wrestling in the road for control of a gun.

“I want to kill myself. Can you kill me?”

Driver standing on highway

“What?”

California Highway Patrol Officer Tony Pacheco

THE SAN DIEGO UNION-TRIBUNE

40%

19

SUNDAY • APRIL 16, 2023

The portion of people shot by police who had a documented or suspected mental illness from 2018 to 2022 U-T data analysis

K.C. ALFRED U-T

The gun lands on the ground.

Pacheco drops to the asphalt.

I’m going to die, the officer thinks.

Almond stops by Pacheco. A bullet hole appears to be in his right thigh.

“Tourniquet,” the officer says. Almond grabs a sweatshirt from his truck and ties it around Pacheco’s leg.

Blood keeps coming.

More drivers stop. One is a nurse, already in scrubs. He cuts straps off his backpack to fashion a better tourniquet.

Others grab the man seen struggling for Pacheco’s gun and push him against a concrete divider.

His eyes and mouth are open, but Almond doesn’t hear him make any sounds. Almond tries to call 911. The line’s busy.

Pacheco asks for his radio.

6:27 P.M.: In San Diego County Sheriff’s Dispatch, a code flashes on every screen.

11-99.

Officer down.

KRISTIAN CARREON FOR THE U-T

Yuhao Du, 25, who is accused of shooting a California Highway Patrol officer during rush hour on Interstate 8 in Mission Valley, speaks to his attorneys several months later during a preliminary hearing at the San Diego Central Courthouse.

“Can you kill me?

Driver standing on highway

“No, man. Stand by.”

California Highway Patrol Officer Tony Pacheco

6:30 P.M.: Flashing lights flood the Mission Valley freeway.

Someone gives the nurse a real tourniquet for Tony Pacheco. He’s taken to Scripps Mercy in Hillcrest.

The second man is arrested.

Officials later identify him as Yuhao Du and say he lunged, unprovoked, toward Pacheco and tried to grab the officer’s gun.

Pacheco says he punched Du four times in the face before he heard a “pop” that caused his ears to ring.

Du tells police that a voice in his head ordered him to crash the car, according to an investigator. Du also reportedly admits to pulling the trigger.

Xiuqin Li knows none of this.

Throughout the night, Li keeps trying to reach her son. Nobody picks up.

She spends hours calling. She tries old friends, classmates.

Li emails a professor. The professor writes back: A police officer was shot and Du is in jail.

159 5150 calls have been logged by this time.

172 5150 calls were logged by the end of the 72-hour period.

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EPILOGUE By the end of the three days, law enforcement received at least 238 mental health calls.

San Diego officers alone logged nearly 350 hours on these crises.

People called for help from transit centers and gas stations, schools and hotels. But most, almost 54 percent, came from homes.

Nearly three-quarters were potential 5150s. Another quarter were related to suicide and at least five people took their own lives countywide.

The call total is thought to be only a portion of the actual number of psychiatric emergencies handled by police. It’s not always clear when someone’s in crisis, and therefore those episodes are not necessarily flagged in the data.

Ninety people were admitted to psychiatric facilities just by PERT and MCRT. PERT spent more than 547 hours handling 212 interventions.

And the calls came from all over the county.

Local officials believe three things must change.

First, they need to hire more people.

While about 17,000 work in the field right now, researchers at the San Diego Workforce Partnership have said the county needs 8,000 more.

That’s complicated by the fact that many current employees are underpaid and burned out, a survey of nearly 1,600 behavioral health workers found. Fortyfour percent said they might soon seek a different job, and some described their work as “merciless,” “brutal” and “incredibly demoralizing.”

In jails, the Sheriff ’s Department is having a similarly tough time recruiting mental health clinicians.

Second, the region needs more facilities. Plans are under way to expand and build new units, especially in nursing homes, short-term care centers and adult residential facilities.

Third, and perhaps most significantly, the county wants to shift mental health care to a more preventive model.

Part of this involves hiring people who’ve been diagnosed with mental illnesses who can act as peer support specialists. By offering help sooner, leaders believe hospitalizations can be prevented.

What this overhaul will cost and how long it will take is unknown.

“We want to reshape the system, and it’s going to take time,” said Luke Bergmann, the county’s behavioral health director and the plan’s principal architect. “But in this moment, we have to stay focused and vigilant on ensuring that there are more acute health care resources available as soon as possible.”

Officer Tony Pacheco was released from the hospital two days after the shooting. Blood clots in his leg and lungs forced two more stays in the following weeks. Months after the shooting, he was still recovering.

Pacheco’s dialogue with the driver of the crashed vehicle was based on testimony the officer gave in court, while most of the shooting’s aftermath was constructed from interviews with witnesses.

Du has not yet testified. He faces several charges, including attempted murder of a peace officer, and has pleaded not guilty by reason of insanity.

If a judge or jury finds he was insane, he could spend years, if not decades, in a hospital.

Fadi Nicolas, the Sharp Mesa Vista doctor, got a call last year from the woman who’d dived for her diaper bag.

Her stay at the hospital had been contentious.

But now she was out, stable and wanted to thank Nicolas for all he’d done.

Angelina Juarez, the woman who cut her own throat, was released from Scripps Mercy after two weeks.

On Aug. 3, she wrote in her journal, “I can’t handle it. My mind is made up. I’m walking out the door but the angel on my shoulder makes my knees hit the floor.”

Two days later, on Interstate 5, she jumped from a moving vehicle into rushhour traffic.

Officials believe it was a suicide.

Elvie Del Rosario prayed the rosary for her son for 40 days. She visits Steven’s grave on Sundays.

Therapy is helping her process the grief. Every night, her older son calls and says, “I love you.”

Crystal Jenkins moved home, got a car and has been allowed unsupervised visits with her daughter, who turned 12 in August. The two went bowling to celebrate.

She never got a job with the National Alliance on Mental Illness, but her GPA was recently 3.4.

Lisa Garcia’s youngest son, who once made his mom pinky promise to always take her medication, got married and moved back to San Diego. Garcia is thrilled.

In Rancho San Diego, Melinda and Bruce Wollitz went more than a year without knowing where their son, Marshall, was.

Then one morning in December, the phone rang. Bruce picked up.

The voice on the other end said Marshall had overdosed and been found face down in a puddle. He was now in a hospital.

“I think I probably sounded funny to the person,” Bruce said later. “I was a little bit happy because, one way or another, he was alive.”

Marshall spent the next several months at two medical centers and was recently moved to a rehab facility. His dad said he’s slowly getting better.

“There’s a little bit of the old guy coming back,” Bruce said. “It’s the first time

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Maria Madriaga holds a photo of her daughter, Angelina Juarez, while going through her belongings last September at home in National City. Months after Juarez stabbed herself, she jumped from a moving vehicle and was killed.

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At their El Cajon home, Melinda and Bruce Wollitz hold an old photo of their son, Marshall. Months later, an unexpected phone call offered them their first news in more than a year about where Marshall was.

Mental health calls from Monday through Wednesday By the end of the three days, law enforcement received 238 mental health calls for service. More than 70 percent of calls were about mental health emergencies, or 5150s. Just over a quarter were suicide-related, or 1145s and 1145Ts. A handful started as some other type of call and were later determined to be related to mental health. The five noted ZIP codes saw the most calls during the three-day period.

Calls by type 172

5150

63

1145 and 1145T

3

Other

Calls by ZIP code

5

10

15

20 MILES

FALLBROOK WARNER SPRINGS

BORREGO SPRINGS

VALLEY CENTER OCEANSIDE CARLSBAD

SAN MARCOS JULIAN

RAMONA

SAN DIEGO COUNTY

POWAY

92105 City Heights

LAKESIDE

9 LA JOLLA

EL CAJON

92101 San Diego

ALPINE

20 92113 Logan Heights

CHULA VISTA

CAMPO

9

91910 Chula Vista

92114 Skyline

12

9

ZIP codes that are gray had no calls from April 25 through 27. ZIP codes can cross city and neighborhood boundaries. ZIP codes listed may include multiple neighborhoods.

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hey’re 911 dispatchers and physicians, judges and police officers.

All have witnessed firsthand the toll of mental illness.

As part of the Union-Tribune’s look at the state of mental illness in San Diego County, we spoke to people on the front lines — people who, beyond the 72 hours, experience it day in and day out. Here’s what they had to say, in their own words.

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No one should have to fi ght addictions without help

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BY FADI NICOLAS

ong before the COVID-19 pandemic, millions of children and adolescents in the United States struggled with their mental health. The Centers for Disease Control and Prevention reports that in 2003, 5.4 percent of youth ages 6 to 17 had previously been diagnosed with either anxiety or depression. The percentage climbed to 8.4 percent in 2011 and 2012.

Unfortunately, the COVID-19 pandemic exacerbated these issues. Our youth had to adapt to difficult changes such as quarantining, social distancing and virtual learning. The CDC states that in 2021, more than a third (37 percent) of high school students reported they experienced poor mental health during the COVID-19 pandemic, and 44 percent reported they persistently felt sad or hopeless in 2020.

When our youth struggle with behavioral health issues, multiple interpersonal problems can arise, causing conflict in school, in families and with peers and friends. Additionally, poor mental health can cause various physical ailments. As a society, we must collectively support the whole health of our children and adolescents.

While any of these predicaments can occur in the present, significant concerns may also develop in the future, as negative mental health can deteriorate our youth’s overall wellbeing and self-worth. This is a stark difference from the effects of positive mental health, which aid in cultivating several vital traits such as discipline, resilience and confidence.

At Sharp Mesa Vista Hospital in Serra Mesa, we offer 14 comprehensive behavioral health programs, including child- and adolescent-specific inpatient, outpatient and partial hospitalization services to ease the growing concern surrounding San Diego’s increasing behavioral health needs.

Our team members include boardcertified child psychiatrists, nurses, social workers, child psychologists, recreation therapists and special education instructors who help treat individuals experiencing significant mental health issues. Together, we care for San Diegans suffering from various kinds of emotional distress, such as suicidal thoughts, severe aggression or self-harm. We partner with a patient’s loved ones to create a personalized intensive treatment plan and use modalities like cognitive behavioral therapy to help them better manage their thoughts, feelings and behaviors.

Our hospital also focuses on treating young patients with substance use disorders. According to the Substance Abuse and Mental Health Administration, the percentage of people in 2019 with such disorders was highest among young U.S. adults ages 18 to 25 — affecting 24.4 percent, or more than 8 million individuals.

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Substance use disorders are complex and result in the inability of an individual to control use of alcohol, medication or drugs. It can cause or contribute to other health conditions, such as depression and anxiety. By integrating behavioral training, group therapy and 12-step recovery principles in our treatment programs, we help teens build and maintain a sober, healthy lifestyle. We also encourage intensive family involvement with multifamily group sessions and parental support and education.

Substance use disorders are a national health issue for individuals of all ages, not just our youth. Last year, more than 100,000 people in the U.S. died from an opioid overdose. Fentanyl — a synthetic drug — is the No. 1 killer among people ages 18 to 45, nationally and locally. In San Diego County, at least 817 deaths last year have been classified as unintentional fentanyl overdoses, and there has been a 2,300 percent increase in fentanyl deaths in the region since 2016.

We provide a comprehensive hospital-based addiction treatment program through Sharp McDonald Center in Linda Vista to support adults with substance use disorders. Through our inpatient and outpatient services, we collaborate with patients to develop a recovery and aftercare plan. Leaning on a community of support gives patients a higher chance of recovery.

Leaning on a community of support gives patients a higher chance of recovery.

That’s why our board-certified addictionologists, psychologists, registered nurses and licensed therapists work with patients and welcome their loved ones into the treatment process.

Tending to our emotional, psychological and behavioral health needs is essential to our overall well-being, as all of these facets influence one’s livelihood. With this belief, we are dedicated to healing and support through our services at Sharp Mesa Vista Hospital and Sharp McDonald Center.

As the San Diego region’s largest private behavioral health care provider, Sharp Mesa Vista Hospital serves as a critical county partner for mental health services. Since 1963, our hospital has provided treatment for approximately 200,000 children, teens, adults and seniors challenged by significant mental illnesses. Visit sharp.com/mesavista to learn more about it.

At Sharp McDonald Center, we believe that no one should overcome addiction alone. We offer the most comprehensive hospital-based program in San Diego that crosses the entire continuum of care. Visit sharp.com/mcdonald to learn more about it.

Nicolas, M.D., is chief medical officer of Sharp Behavioral Health, and a board-certified psychiatrist with specialties in adult psychiatry and addiction medicine. He lives in North County.

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Schizophrenia is devastating and often misunderstood

BY GREGORY LIGHT & NEAL SWERDLOW

S

chizophrenia is a devastating mental illness and one that is often misunderstood. Roughly 1 out of 100 individuals suffers from lifelong symptoms of schizophrenia or its related conditions; this is true in virtually all cultures and countries around the world.

People living with schizophrenia often experience serious symptoms like auditory hallucinations — for example, hearing “voices” when no one else is talking — and delusions, which are fixed, irrational beliefs.

Symptoms often begin in the late teens, though they can begin at any time from early childhood through the third or fourth decade of life. Individuals with schizophrenia often experience significant problems in their attention, memory and problem-solving abilities, all key aspects of cognition that can significantly impact functioning in daily life and make it difficult, perhaps impossible, to live independently, maintain employment and engage in social relationships.

Antipsychotic medications can often blunt the severity of hallucinations and delusions, but they do not generally provide relief for the extremely disabling problems in cognition or life functioning.

But research is identifying other avenues of treatment that can be used in addition to these medications that can bring important benefits to individuals with schizophrenia. In recent years, controlled research studies have demonstrated that specific braintraining exercises, when delivered in the appropriate context, “dose” and intensity, can produce meaningful improvements in symptoms, like hearing voices, and in cognitive and daily functioning, even among those with the most severe forms of schizophrenia.

These brain exercises take advantage of the brain’s ability to change and learn, a process called “plasticity,” to produce meaningful improvements in important areas of functioning by fine-tuning the participant’s ability to efficiently process sensory information.

The training is delivered by computer “games,” in which the computer continuously adjusts the level of difficulty to match the person’s changing abilities and performance. As patients achieve correct responses, the digital exercises adapt to present the perfect amount of challenge to promote maximal learning.

At the UC San Diego Center for

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Advanced Neurotherapeutics, participants are shuttled to our program approximately three times each week to complete these computerized cognitive-training exercises. Everyone in our National Institutes of Health-funded studies gets a “full dose” of these training exercises. In parallel, we are working to identify medications that help patients perform these exercises better and faster.

Rather than target symptoms like hallucinations, these medications are being used to make brain training more efficient. These might be called “pro-plasticity” medications. Importantly, the medications are used only during training periods — typically 10 weeks — and are not intended to be used on a long-term basis.

Current and past participants come to enjoy the training sessions, which can result in an enhanced quality of life, something not necessarily provided by medications alone. The next treatment breakthrough for improving schizophrenia outcomes —

Symptoms often begin in the late teens, though they can begin at any time from early childhood through the third or fourth decade of life.

in addition to new medications targeting symptoms — will include treatments that allow the brain to learn how to repair itself and better process information from the world around it.

It is important to note, however, that the results of the brain-training exercises may vary, and they are not a substitute for traditional medical treatment. In fact, individuals must remain on their current medications in order to participate in these studies.

If you or a friend or family member suffer from schizophrenia and want to participate in our studies of braintraining exercises, you can be evaluated for study enrollment by calling (619) 543-2314.

Light is a professor of psychiatry at UC San Diego School of Medicine and director of Mental Health Research and the Mental Illness, Research, Education and Clinical Center at the VA San Diego Healthcare System and lives in Chula Vista.

Swerdlow is a distinguished professor of psychiatry at UC San Diego School of Medicine and lives in La Jolla.

Our LGBTQ resource center offers help, advocacy

BY MAX DISPOSTI

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hen the North County LGBTQ Resource Center first opened its doors in that warm December 2011, we learned right away that the responsibility and the project we invested in was going to be bigger than what we had initially expected. Since the very beginning, being the only LGBTQI+ service provider in North County has meant being at the center of any request for help, support and advocacy that LGBTQI+ North County families and individuals were searching for.

We quickly learned that just providing services was not going to be enough. Education, advocacy and policy changes were also needed in order to reduce the harm and disparities that centuries of discriminatory practices have inflicted on queer people.

Among our many programs, behavioral health was and still is where these disparities in our community are most noticeable. In fact, the American Psychiatric Association and the American Psychological Association have caused more harm to the LGBTQI+ community than any other community by classifying homosexuality as a mental disorder in 1952. Several religious institutions have crusaded and preached against us as an entire community of humans. It wasn’t until 1967 that homosexuality was partially decriminalized in the United Kingdom and until 2003 that sodomy laws were declared unconstitutional in the U.S. Supreme Court case Lawrence v.

Texas. It wasn’t until 2012 that the American Psychiatric Association withdrew its official position that transgender people had a mental disorder. Until 1973, homosexuality was considered — in the Diagnosis and Statistical Manual of Mental Disorders — a perversion, a mental health disorder often addressed with heavy medications, where practices of lobotomy, isolation, conversion or reparative therapies were quite frequent. Without any scientific or medical research, our community was scrutinized for just existing, and even after 1973, political and religious institutions have used that old criminalizing narrative as an excuse to deprive LGBTQI+ people from accessing education, career paths, and overall equality and representation.

Nowadays, that discrimination and violence is still a known history among LGBTQI+ folks, especially when they are using behavioral health services. In fact, some residual stigmatizations among mental health providers — and at times just plain ignorance and bi-

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ases in approaching transgender experiences and identities — are still the cause of distrust and unpleasant experiences among members of the LGBTQI+ community.

LGBTQI+-affirming practices are still quite rare in California. But in other states, they are often taboo or, when it comes to mental health help for minors, even prohibited by law.

Practices of conversion therapy that have been defined as harmful, lifechanging and traumatic by both the American Psychiatric Association and the American Psychological Association are still legal in the majority of states.

For these very reasons, LGBTQI+ people seek free therapy services at our center even when they have insurance or the means to pay. They come to us because we have LGBTQI+ therapists who understand the psychological implications of trauma that LGBTQI+ individuals experience and how certain heteronormative expectations on how to relate with the opposite sex can affect our self-esteem, and how stigma and bigotry — but also family, religion and violence — can make our existences a challenge when compared to

other non-minority groups. When people also live the intersectionality of being Black, Indigenous or people of color and queer, the reasons for seeking therapy outside the more conventional provider are even more compelling. At our center, 67 percent of the people we serve through our behavioral health programs are also part of a community of color.

When it comes to our youth, the search for an LGBTQI+-affirming mental health provider becomes very difficult even when they are supported by their parents. In fact, many of the providers with competency are private, and those under insurance are usually allowed to cover just a few sessions. It is more difficult when a 12-year-old needs services but doesn’t have family support. In these cases, reaching out to an LGBTQI+ service provider is the only way to go. This is also why a school’s partnership with a local LGBTQI+ Center becomes not only necessary but also vital.

A 12-year-old in California can reach out for behavioral health services without the consent of a guardian or parent, and many fortunately do so.

Research has proved that allowing

minors to seek out help, especially when their family might not be supportive of their LGBTQI+ identity, can be lifesaving. Yet despite the research and the proven validity of these approaches, negative political narratives are taking root in the country, and simplistic headlines about parental rights are undermining the safety and well-being of children. Contesting the right of a child to seek help is an approach that has very recently escalated into book banning around issues of gender identities, protests outside drag show venues, and even violence against LGBTQI+ organizations and individuals.

Accessible and culturally aware behavioral health services for LGBTQI+ people are sometimes the only places where we LGBTQI+ people can be supported, affirmed and recognized. Decades of LGBTQI+ movements, research and struggle did that, and centers like ours are here to make sure we are not going back in time.

Disposti is founder and executive director of the North County LGBTQ Resource Center. He lives in Oceanside.

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As a judge, I know the system can improve — and how

BY CINDY D. DAVIS

A

s a Superior Court judge specializing in mental health cases, I have the unique opportunity to view the intersection of mental health and the justice system from “the trenches.”

You might be surprised how mental health issues weave their way through and touch on so many areas of the law.

Mental health often determines whether, when and how cases proceed, as well as the restriction and restoration of important rights. For example, whether criminal defendants can be held for trial depends on their mental competency. Legal proceedings determine whether they will be released from a mental hospital at their request or receive treatments such as electroconvulsive therapy. Individuals who cannot take care of themselves may become subject to court-ordered conservatorships, permitting certain kinds of life and health decisions to be made for them by others. The Superior Court handles all of these kinds of cases.

But in my years on the bench, hearing these types of cases, certain themes emerge. One common thread I have found is each person that has a mental health issue is a unique individual. The variety of issues, diagnoses, functionality, needs and community placement options differ so widely that any solution to our “mental health crisis” cannot be one-size-fits-all. Someone who is actively experiencing visual and auditory hallucinations, for example, is by no means the same as someone suffering from an anxiety disorder. Additionally, many are dual diagnosed, which means they have a substance use disorder along with mental illness, and the challenges of treating both conditions simultaneously cannot be understated. So we must be creative in our solutions. We need to tailor treatment and resources to the individual.

Working within the existing system, I have seen the frustration of family and community members when, for example, an adult child violates a restraining or protective order and refuses treatment or medication. I have seen families who have run out of options, who must protect themselves through “tough love,” who throw up their hands in despair wishing that the system would do more.

Here is where a greater understanding of one judge’s perspective may be helpful. As judges, we work to maintain a delicate balance. Your adult child is an individual with his or her own constitutional rights and freedom to make choices. There is also a need to protect the community and to provide vital help and care when a tipping point is reached, and individuals are no longer able to make those choices for them-

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selves. We view each person and each case as unique, which means that the process is not simple; complications and delays arise that can engender frustration and even anger. My personal goal in presiding over these cases is to honor and balance all of the competing interests with sensitivity in order to create the fairest and most constructive possible outcome.

How can we improve the system?

Personally, I would love to see more services, more treatment, more beds, more compassion and more alternatives for individuals with mental health issues.

And that is why, when I get up and go to work every day, I am profoundly honored to be able to work with the court, behavioral health services, probation, the prosecution and defense, and all the agencies and individual contributors involved in our collaborative justice court.

In San Diego County, the Behavioral Health Court program is a shining example of what the justice system can do to improve outcomes for justiceinvolved individuals who are living with mental illness. The program, which began in 2009, helps people move from jail to lives of self-sufficiency by diverting participants from prison to group homes, supported by wrap-around

One common thread I have found is each person that has a mental health issue is a unique individual.

mental health services, formal probation and strict oversight by the court.

All participants come to court monthly, and their progress and compliance is monitored and, more important, applauded.

I have seen amazing transformations over the years. Many of our graduates first joined as felony offenders.

They can be mentally unstable and often are homeless. And through commitment, hard work and insight, they graduate as self-sustaining and mentally stable to reunite with loved ones and move on to a much brighter future.

Family members share, often tearfully, how grateful and proud they feel.

I know that not all criminal defendants are appropriate for our community-based program, but the members who do participate (even if they do not make it all the way to graduation) leave better off as individuals and can face their future with more tools for success.

So at the end of the day, when I head home from the courthouse, I know, in some small way, we helped make our community a better place for everyone.

Davis is a judge with the San Diego Superior Court, assigned to the downtown courthouse, specializing in mental health cases. She lives in San Diego. The views expressed in this article are her own.

We all can help prevent suicide. Here’s how to help.

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BY AMY CHAVEZ

uicide continues to be the second-leading cause of death for youth ages 10 to 14 and the third-leading cause of death for those ages 15 to 24. This is a staggering number of lives lost and countless others impacted every day, especially considering that many suicides are preventable.

San Diego Youth Services’ HERE Now school-based suicide prevention and early intervention program focuses on creating awareness, promoting conversations and inspiring connections to prevent suicide — one community, one school, one life at a time. In collaboration with North County Lifeline and South Bay Community Services, HERE Now is now active in over 70 schools across San Diego County, creating a safer place to learn, with suicide and bullying prevention education for seventh- to 12thgraders. The County of San Diego Health and Human Services Agency’s Mental Health Services Act funds HERE Now. This program’s focus on prevention and early intervention starts these conversations at the community level, with youth, families, community members and school staff frankly discussing suicide and mental health. The goal is to talk about these topics that typically have stigma and shame attached to them in a way that provides truth, perspective and hope.

Suicide and mental health can be tough topics for parents to talk about with their children. Many parents are worried that talking about suicide or depression could increase the risk, but that has been proved to not be accurate. Talking about mental health, discussing how to manage stress, asking specific questions about suicide and providing hope to young people gives them permission to speak about how they feel and find the support that they need.

It is so important to stay curious about your children as they develop in their mental and physical health.

Staying curious can involve asking open-ended questions about their day, their experiences, their friendships, and their likes and dislikes. Creating playful rituals around asking could mean a weekly check-in. An example is asking them to share a peak (something positive that they experienced or did) and a pit (a challenge, stress or frustration that they encountered) in

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recent days. You can also share your own peak and pit as appropriate to model how you celebrate and handle challenges.

This can give you more insight as a parent about any themes or concerns, especially if done as a ritual over time.

It also helps establish trust and gives you a foundation to build on when you need to have a corrective conversation or talk about something serious. These conversations can increase mental health and connection, both of which are a big part of suicide prevention.

Since we know a significant number of those who die by suicide will show warning signs, it’s important to educate ourselves on what to look for when someone might be thinking about suicide. This could include extreme and sustained changes in behavior (eating, sleeping and lack of energy) as well as a lack of interest in things that they once enjoyed. Additional warning signs could be disconnecting and

withdrawing from friends and family, verbal or written comments about suicide and engaging in risky behaviors. We don’t want to make automatic leaps without asking, so it’s important to check in with those you’re concerned about and let them know about the specific concerns you have based on their behavior and/or words.

It is OK to ask someone directly, “are you thinking you want to die by suicide?” If the answer is yes, you cannot hesitate to act.

Know that you are not alone. This might mean accessing the 988 Suicide and Crisis Lifeline by calling or texting 988 (available 24/7) or taking that person to get a higher level of support.

If it’s not an emergency, consider tapping into a network of support that could include your child’s school counselor, primary care physician, confidential family and friends, and community and faith leaders.

Providing support services, talking

about suicide, reducing access to means and following up with loved ones are just some of the actions we can all take to help others. We can all help prevent suicide by talking openly about mental health in our families, schools and communities. The followup piece is also important: We must act; we must advocate for our youth; we need to provide hope.

Hope can look like advocating, supporting and providing resources, because hope conveys, “You matter. We will find a solution even if it is plan A through Z. We will never give up.”

Visit sdyouthservices.org to learn more about San Diego Youth Services.

Chavez is a program manager at San Diego Youth Services, a nonprofit that helps the community’s most vulnerable youth, including foster children and those experiencing homelessness, family conflict, abuse and neglect, mental health struggles and substance abuse. She lives in San Diego.

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Dispatchers trained to be calm voices in an emergency

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BY BRIAN JENSEN

rom a very early age, we are all taught that if you have an emergency, you dial 911 and you’ll get help.

When you dial 911, you aren’t talking to a police officer, a firefighter or even a paramedic. You are talking to an emergency telecommunicator, more commonly known as a dispatcher. In San Diego and most other parts of the world, dispatchers are the calm voice in the chaos of an emergency, helping people through their worst days. Dispatchers gather information, ask questions and serve as the vital first link in the emergency response chain. Despite all of that, the most important part of the fire dispatcher’s job is to provide life-saving care until first responders can arrive on scene.

The San Diego Fire-Rescue Department employs up to 51 full-time fire dispatchers who are cross-trained as emergency medical dispatchers. Each fire dispatcher completes a rigorous six-week academy, which includes training in emergency medicine using a program known as the Medical Priority Dispatch System. This system was developed in 1978 by Dr. Jeff Clawson and is now overseen by the International Academy of Emergency Dispatch. Dispatchers are trained to triage a variety of common ailments or chief complaints and then provide post-dispatch and pre-arrival instructions. The triage helps dispatchers determine the most appropriate response level and resource to send to emergencies.

Before leaving the classroom, dispatchers spend an extensive amount of time practicing and learning how to properly use pre-arrival instructions for many crisis situations, including bleeding control, use of tourniquets, how to help someone perform the Heimlich maneuver, how to assist with delivering a child over the phone, and, most importantly, how to give CPR instructions over the phone.

When people call 911, it’s often because they are in a crisis and don’t know what to do. This is where a trained fire dispatcher can immediately intervene with life-saving care in the form of those pre-arrival instructions. Likewise, in a crisis many people are scared, confused, shocked or even angry, so dispatchers are taught different techniques to effectively manage the range of emotions someone may be going through in an effort to ensure effective patient care and a safe scene for the responding units.

Dispatchers spend an additional nine to 12 months on the job with a communications training officer, where they hone their skills as fire and medical dispatchers, learning how to deal with a wide variety of emergencies

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and continuing to practice their prearrival instructions. Every two years, emergency medical dispatchers must re-certify on the Medical Priority Dispatch System, re-certify in CPR, and stay up to date on the latest developments in pre-hospital care by completing a minimum of 24 hours of continuing education.

One area of training that is fairly new for dispatchers is that of mental health and wellness.

When the San Diego fire agency retained Focus Psychological Services to provide counseling for its members, fire dispatchers were included. Dispatchers have the same access to mental health services as firefighters and paramedics, which is crucial because dispatchers can experience post-traumatic stress disorder and mental trauma just as first responders can. New dispatchers get an opportunity to meet the team from Focus during the dispatch academy and learn about what services are available and how to access them. Focus counselors also periodically provide refresher training for all dispatchers on topics including effective coping mechanisms, how to manage stress, and how to avoid bringing the stress of the job home to family and friends.

Being a dispatcher is a tough, stressful and often emotionally draining job, but for all the dark calls, there are a few bright spots.

In addition to the normal services provided by Focus, San Diego fire provides additional mental health services for dispatchers, including a dedicated chaplain, trained peer support personnel and inclusion in critical incident stress debriefs and defusings.

For many dispatchers, once a call is over, it’s forgotten, but there are always those calls that hit differently, calls that are replayed over and over in the dispatcher’s mind, and those calls that always leave you wondering if you did everything you could. Those are the calls that make it so important to have mental health services for dispatchers.

Being a dispatcher is a tough, stressful and often emotionally draining job, but for all the dark calls, there are a few bright spots. Sometimes that immediate intervention by a dispatcher allows a young life to be brought safely into the world or allows someone to have a second chance at life.

Those bright spots, the times you really make a difference in someone’s life, make this career worth it.

Jensen has been a dispatcher with the San Diego Fire-Rescue Department for more than nine years and is currently a fire dispatch administrator. He lives in San Diego.

How 911 dispatchers care for their own mental health

BY ALEXIEUS PERKINS

M

ental health is a complex topic in and of itself. Add fast-paced, high-stress and emergency-based work into the mix and you’ll turn that one complex topic into a tangled web of thoughts and emotions. That web is where most 911 dispatchers live, but fortunately where there is chaos, there is order, and I would say that most of us have found that order. There is no right or wrong way to find inner peace when we listen to the horrors of strangers’ lives almost every day. We all have different ways of finding that peace. Some may be unconventional, but what’s important is that the job gets done.

As I continue to explain the inner workings of the dispatch psyche, keep an open mind and remember there isn’t a standard procedure to mental health.

Not all emergencies are created equal. While we do treat every call as an emergency, many of them don’t emotionally bother most of us. These types of calls are your standard “I’m feeling sick,” cut-and-dried, by-thebook calls that many of us could handle in our sleep. While these calls can become cumbersome over the course of a 12- to 16-hour shift, as any long task would, there is still no emotional attachment involved.

There are also calls of fires, or someone lost on a mountain, or other miscellaneous things; again, no emotional attachment and, for the most part, these calls are forgotten soon after the call is completed.

Then there is the small percentage of calls that aren’t so rare that they’re shocking but that are rare enough to get the heart racing and send chills down your spine. The call of a grandmother holding her dying grandchild because he slipped into the backyard pool, unnoticed. The call of a wife who came home to find her husband not breathing on the ground, not sure how this could be happening to her. Even worse still, the call of a parent who finds their baby, lying stiff in the crib, begging for a reason why this has happened.

Those are the calls most of us spend the remainder of our lives trying to bury. It’s at this point that we can get tangled in the web and that we must find a way to the surface or be consumed by our grief.

So how do we cope? How do we

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continue to answer the constant calls coming in? How do we spend years in this profession?

There are many ways that we do this, and it starts with our dispatching community.

We spend a large portion of our lives with our co-workers, and these are people who understand you in a way that someone outside of the profession couldn’t. We are all in a room together, listening to one half of the call, reading call notes to see what is happening, and when one of us faces a terrible incident, we all flock to that person to give support, love and kindness. We have programs such as Focus Psychological Services that give us the opportunity to speak with professional counselors about emotional and mental traumas, as well as chaplains that can be at the dispatch center immediately for those occasions when the job

is overwhelming. Outside of that, many of us have what is considered to be “dark humor” — we tell inside jokes that someone on the outside would never understand, nor should they.

This type of humor helps us cope with the dark things we hear. We cling to the bits of comedy in our lives that keep the light shining.

Sometimes you have to downplay the humanity of it all and turn things into humor to keep from being consumed by the negative emotions. On top of that, we treat our dispatch center like one big family. We celebrate holidays, special occasions and joyous moments such as birthdays, weddings or births. Many of us will gather outside of work for outings, trips and even game nights. Just like any family, we bicker and squabble, but in the darkest moments, there isn’t a doubt in any of our minds that the person sitting

next to us will provide comfort.

Outside of our little environment, individual dispatchers treat themselves in whatever way they see fit. I personally get monthly facials and massages to help with the physical manifestations of my stress. Some travel any chance they can, and others spend precious moments with their families and loved ones. A vast majority of us have pets and, well, who can be sad with a fur baby giving you kisses?

Our mental health web of chaos may seem frightening to someone on the outside looking in, but for us, we’ve found a way to navigate the tangles and move forward for the betterment of those we serve.

Perkins has been a fire dispatcher with the San Diego Fire-Rescue Department for more than three years. She lives in San Diego.

THE SAN DIEGO UNION-TRIBUNE

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SUNDAY • APRIL 16, 2023

Dr. Patrick Soon-Shiong Executive Chairman

Matthew T. Hall Editorial and Opinion Director

Jeff Light Publisher and Editor

Chris Reed Deputy Editorial and Opinion Editor

Laura Castañeda Deputy Editorial and Opinion Editor

Tania Navarro Community Opinion Editor

Lora Cicalo Managing Editor

Andrew Kleske Reader Outreach Editor

Bella Ross Community Engagement Editor

Steve Breen Editorial Cartoonist

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o call what’s happening to so many Americans, so many San Diegans, so many of our children a mental health crisis is not enough.

We need new words to describe it — and new solutions, too, because help too often is elusive, ineffective, insufficient.

Calling something a crisis means we can’t agree on the solution, means we’ll fight over it. The label relegates the problem to a long list of intractable issues that never get solved because we lack the time, the money, the consensus, the commitment, the fill-inthe-blank to make hard choices and stick to them. Everything’s a crisis these days. Climate change. Housing. Energy. Immigration. You name it.

Calling this a crisis means it’s just one more crisis — when it’s really at the root of so many of society’s problems.

We’re all fraying. We’re straying. We’re saying, “Help!” or struggling to ask for it.

Chronic absenteeism is surging locally and nationwide as mounting mental health issues have left far too many kids falling behind and even out of school. Mounting mental health issues have also left far too many adults in need of limited behavioral health beds, or sleeping on increasingly crowded city streets, or behind bars, where problems in the San Diego County Sheriff ’s Department’s jails can prove fatal.

One in 5 Americans will experience a mental illness in a given year, and 1 in 25 live with a serious mental illness such as schizophrenia, bipolar disorder or major depression. The pandemic’s lockdowns have focused more attention on our nation’s mental health as more and more families have found themselves one step closer to the issues that underlie some of our community’s most grievous problems. The reporting in this section reveals how profound a role mental health plays in overdoses, police shootings, incarceration, homelessness, student behavioral issues, and suicide.

There’s work to be done.

A large number of San Diego County’s 5,000 jail inmates, 8,000 homeless people, 185,000 public high school students and 3.1 million residents need help. The 17,000 people working in the county’s behavioral health field need it, too. A recent survey of 1,600 county behavioral health workers revealed something stunning: 44 percent may soon seek a different job. They’re overwhelmed and using words like “brutal” and “incredibly demoralizing” to describe their work.

So what would help?

Three things, experts agree: More workers. More facilities. More prevention.

Research by the San Diego Workforce Partnership shows that the county needs 8,000 more workers, including people diagnosed with mental illness who could be peer support specialists. Nursing homes, shortterm care centers and adult residential facilities need hundreds of new units. Overall, the field needs a more preventative model to help people before they go into hospitals, facilities, shelters and jails.

One big problem is that so much more help is needed than is being provided. A range of people are doing righteous work individually and collectively, with new momentum building behind tools as varied as red flag laws, conservatorship and nonpolice 911 responses. Just last month, Gov. Gavin Newsom visited San Diego to propose a 2024 bond measure to raise billions of dollars to house and treat thousands of people with mental health issues.

But help is still provided by underpaid and overwhelmed (and demoralized!) behavioral health workers, by police officers being asked to do too much, by nonprofit organizations with lean budgets, and by politicians who mean well but move onto other offices and leave the hard work to the less experienced.

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EDITORIAL

HOW YOU CAN LEND A HELPING HAND

As a community, we say keep up the good work, but we can’t keep up. The aforementioned experts don’t even know how much all of it — more workers, more facilities and more prevention — will cost or when it will materialize. We’re failing.

Consider these details from The San Diego Union-Tribune’s 72-hour project, in which dozens of journalists spent a year analyzing the region’s mental health support system: • San Diego County’s Psychiatric Emergency Response Teams launched in 1996 to assist people having mental health breakdowns. Today, the county funds 72 of these clinicians, but they’re often not available when needed. Depending on the day, there may only be about a third of them working.

• The county’s Behavioral Health Court launched in 2009 to provide alternatives to incarceration for people with mental illnesses. Today, more than 350 people have taken part. Sixty-six people were moving through the program at last count in October. Of the other 291, only 51 percent had completed the program.

• The county’s Mobile Crisis Response Teams launched in 2021. Today, there are 35 teams.

All for a population of 3.1 million county residents.

After reading The San Diego UnionTribune’s 72-hour project, it’s clear something needs to happen. Soon. It’s also clear more work is needed. By all of us, but by the Union-Tribune itself. The 72-hour project is not the end of our work. It’s the start of it.

We’re only beginning to look at this issue holistically, with an eye toward solutions.

Next we are planning a series of in-depth public forums featuring people with expertise and experience in the mental health system. And we are inviting you to take part and help us prepare a variety of new solutions and collaborations. We want to hold three forums this year, in the summer, fall and winter, in person and streamed online.

We will have more specifics soon. We hope the idea intrigues potential co-hosts and participants alike, and we ask those interested to reach out to us with ideas for how we might join forces. For now, we pledge to convene these public forums to listen, to learn and to lead on this fundamental issue of our time and of our region.

For all of us.

In calling new attention to a massive problem, we will celebrate successful approaches that have helped others, spotlight mistakes to avoid repeating them and work to reduce stigmas to allow for an honest, inclusive conversation all year long.

If you are a current or former (or future!) behavioral health worker, we say thank you.

If you or your family are facing mental health issues, we say you are not alone.

To helpers and those in need of help alike, we say that we care about your mental health, that things can get better, and that we truly hope you will seek new solutions with us.

We are interested in your personal stories, your ideas for panelists, and your thoughts on which specific subjects we should explore at these forums.

Please email our journalists today, tomorrow or throughout the year at 72hours@sduniontribune.com and help shape the conversation to come. And please watch this space for more information on the forums as we plan them.

We hope you will lend a hand.

We are in this together, and that’s how we’ll try to emerge from it.

SHARE YOUR THOUGHTS To share your own struggles or ideas about what might help, please email 72hours@sduniontribune.com and include a phone number we won't publish but may use to call you.

STEVE BREEN U-T ILLUSTRATION

THE BACKSTORY Tarcy Connors

PROJECT HAS PERSONAL AND PROFESSIONAL MEANING On Mother’s Day in 2009, my 26-year-old son jumped from the balcony of a fourth-story apartment building. He had been diagnosed with bipolar disorder and, as often happens, he struggled to find the right medications that would treat both his bone-crushing depressions and his highflying mania.

He miraculously survived that leap over the iron railing, but the cost was a shattered back that is held together with titanium rods and an addiction to the opiates prescribed to treat his pain.

And so began the cycle that so many in our community live with: grateful for the moments of joy when my son is sober and stable and we get to share a laugh, despairing when yet again he tinkers with his meds and careens into crisis, destroying everything in his path. And you are helpless.

Over the last 14 years, my son has received a patchwork of care from a variety of providers, some of whom were kind and caring, others who were indifferent and downright contemptuous. On any given day, I was angry, desperate, sad, but most of all determined to protect my son from a system so

fractured it’s a miracle that more people aren’t homeless, disabled or dead.

So I had a very personal reason for wanting to undertake a project that would expose the frailties of San Diego County’s behavioral health system.

But I also have had a professional interest in the subject for decades, first as a Statehouse reporter in Augusta, Maine, in the 1980s. My beat included the Augusta Mental Health Institute, the state-run, locked psychiatric hospital. It was an overcrowded, outdated facility where patients struggled for dignity and basic care, and workers despaired of ever being able to help the state’s most seriously mentally ill people.

It took the death of 10 patients and a sweeping court settlement to initiate action.

Unfortunately, a recent assessment of Maine’s mental health system, which is still under court order, found tens of thousands of seriously mentally ill adults had insufficient care. There was inadequate funding, and seriously mentally ill people often ended up in jail or prison.

Sound familiar?

I moved to San Diego in 1988.

Over the next 35 years, I witnessed the dismantling of the county’s safety net for its most vulnerable residents as the county Board of Supervisors shifted from an elected body focused on offering a hand up to the mentally ill, the poor, the disabled and the homeless to one that perceived any assistance as a handout.

The result: a smoldering suffering throughout our community.

The San Diego Union-Tribune staff has chronicled the breakdown of the mental health system in news stories big and small in recent years. But we weren’t really capturing the immense toll it was taking because it was happening in places we couldn’t see. Like my house.

My son, my only child, was a cheerful, bright, funny human being who loved acting and singing. He thrived in the gifted and talented program in elementary school. In high school, he ran track, sang in the choir and was a member of the history club. I considered his mood swings to be normal adolescent behavior. Until

they weren’t. And then I witnessed the unraveling of a young man who has struggled to remain tethered ever since.

In the summer of 2021, reporters and editors came together and talked about ways we could tell this story. We decided to frame our reporting around a 72-hour period, the amount of time someone can be held against their will if they are deemed a threat to themselves or others.

But we needed buy-in from those with the power to grant us access to places ordinarily shielded from public view.

In mid-July, public safety editor Dana Littlefield, photo editor Sam Hodgson and I reached out to the region’s top officials and invited them to sit down in August to hear about the project: San Diego Police Chief David Nisleit, District Attorney Summer Stephan, then-Sheriff Bill Gore, Mayor Todd Gloria and Supervisor Nathan Fletcher. All except Gloria attended (he sent a representative from his office) and pledged to give us as much access as possible while protecting people’s privacy. To my surprise, they did.

The staff then spent months laying the groundwork for the eventual launch of the project, building relationships and writing stories.

Finally, we decided to launch in late April 2022. For three days — 72 hours — 20 reporters and photographers visited schools, jails, police dispatch centers, the county psychiatric hospital, mobile crisis response teams, crisis stabilization centers, and the homes of parents and those diagnosed with a mental illness.

Because we had sat down with the power brokers, because we had taken time in the months up to the launch to learn from and listen to those in the field, we gained that access we so sorely needed to tell the story. It was a privilege we did not take lightly.

Nearly two years after we embarked on this endeavor, we share what we found with you. My hope is that when we look back in 10, 20, 30 years, we don’t look like Maine and its missed opportunities. I also hope that people like my son will choose to step away from that balcony because they know there is a lifeline out there.

And that people care.

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SUNDAY • APRIL 16, 2023

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NELVIN C. CEPEDA U-T

Deborah Valera and Emmanuel Navarro, outreach workers from Father Joe’s Villages, walk along 17th Street and Imperial Avenue downtown, offering help to people on the street.

ANA RAMIREZ U-T

Lisa Garcia, a program manager at Recovery International, takes her medication at her home in El Cajon. She once promised her youngest son that she’d always take her pills.

ANA RAMIREZ U-T

Crystal Jenkins waits for a trolley to the San Diego Central Courthouse downtown in late 2021. She was recently allowed unsupervised visits with her daughter.