Santa Clara judge creates ‘gold standard’ for mental health courts

Santa Clara County Superior Court Judge Stephen Manley refers to defendants in his courtroom as “clients” – an indication of the unusually informal and conversational tenor of the Behavioral Health Court he created more than two decades ago.

“It tends to break through a barrier,” Manley said in a recent interview with Capitol Weekly. “Defendant is the word of the court. Client or patient is the word of treatment. Stigma is still a major issue. . .They all know they’re defendants. If we act like they’re ‘bad’ or charged with a serious crime, the focus is only on the negative. Obviously, there are consequences, but I try to get them to focus not solely on their criminal charge, but on treatment and changing behavior. ”

In practice, he added, “I generally use their first names.”

Established in 1998, four years after he created a similar drug treatment court, Manley’s behavioral health court was the first such court in California, one of the first in the country, widely described as the “gold standard” for mental health courts nationally. His unusual – and highly successful – approach to keeping mentally ill defendants out of the criminal justice system has been adopted throughout California and in other states. Manley has received widespread news coverage and multiple local, state and national awards from criminal-justice and mental-health groups.

Designed to break the tragic pattern for people whose mental illness underlies their crimes — too often landing them, repeatedly, in jails and prisons ill-equipped to help them – Manley’s courts now serve 1,500-2,000 mentally ill offenders annually. Nearly 70 percent of them successfully completed their requirements and many charges were dismissed, according to Manley’s recent report to the Santa Clara County Board of Supervisors..

“Judge Manley was the pioneer, the dean of judges in this area (mental health courts),” says Randall Hagar, legislative advocate for the California Psychiatric Association. “He has more people go through his court than any other mental health court.”

“He was the trailblazer for collaborative mental health courts,” says Mark Gale, a well-known mental-health activist who is the Criminal Justice chair for the Los Angeles County Council of the influential National Association on Mental Illness (NAMI), and has long worked to make the courts a reality in more California counties — including his own, the massive Los Angeles County court system, which now has a variety of alternative courts and diversion programs.

“This is a team effort. We are the court, and the judge is joining with behavioral health, custody, probation. We’re all partners.” — Stephen Manley

Manley’s courts are often used as the template for successful mental health courts, and his tenacity overcame concerns from prosecutors suspicious of non-traditional courts and mental-health clinicians who questioned how additional treatment would be funded.

Manley credits support from other judges and the board of supervisors for the success of the courts. He emphasizes a coordinated approach involving multiple local agencies, from prosecutors and probation officers to public defenders and clinicians, to successfully divert cases – and people – from a costly, overwhelmed and overcrowded criminal justice system.

“This is a team effort,” Manley said. “We are the court, and the judge is joining with behavioral health, custody, probation. We’re all partners.”

Many California counties have some form of mental health courts, according to statisticscompiled by the state’s Judicial Council.

But few have attained the broad success of the Santa Clara courts, which now include two judges and two psychiatrists, as well as  prosecutors, public defenders, behavioral health specialists, probation officers, Veterans Administration staff and a host of programs to provide intensive treatment and specific services.

It’s a proven and cost-effective way to keep mentally ill offenders out of jail – and save public funds spent on the huge costs of incarceration, hospitalization, homelessness.

When a new county Family Justice Center Courthouse was opened in San Jose in 2016, space was set aside for a full range of services to keep people in treatment, with resources available for on-site treatment, from psychiatric consultations to help with medications, housing assistance, even a clothes closet.

Coordinated efforts are key to effectiveness in mental health courts, Manley said, and recent remote hearings via Zoom during the COVID-19 pandemic have been surprisingly effective.

“When they’re in the streets, they’re going to the ER or to jail.” — Stephen Manley

“It’s a very interesting and new way to work with people,” he said. “You have the DA and the public defender and the treatment team, perhaps 12 people involved on the same Zoom call. But it’s basically the judge talking directly to the client.”

Immediate intervention is essential to resolving the frequent crises bedeviling mentally ill offenders, often landing them in jail.

“The important thing is that you intervene as quickly as possible,” Manley said, to resolve an immediate barrier to recovery, like housing or accessing a program that provides free phones. In a traditional court system, the pace is often glacial at best, while quick resolution of major and minor issues requires a radical new approach in mental health court, to keep participants housed and in treatment.

“When they’re in the streets,” says Manley, “they’re going to the ER or to jail.”

Shortly before the first of two Capitol Weekly phone interviews — which Manley apologetically asked to reschedule for later in the day, because he was hearing cases, working through lunch – he had just conducted a Zoom session with a man calling in from a bus stop, where he was headed to a meeting with a caseworker. “If you have the case manager with the defendant,” Manley marvels, “you can do all kinds of things, like finding housing.”

“So often in the courts, we hear very formal testimony, and we get reports in writing,” he adds. “The pandemic has put the courts in the position of doing things differently. In the remote hearing I did this afternoon, the client was in the [treatment] program, meeting with his caseworker. Before, they’d say, ‘come and see our program,’ well, I couldn’t. Now, remotely, I can.”

‘Chaotic, noisy’ – and it works
Manley’s mental health courtroom is often described as “chaotic” or “noisy” in the many articles about him over the years, with a variety of legal and behavioral-health experts consulting in the courtroom – the revolutionary “team approach” that characterizes his court.

Insurers have historically refused to recognize dual-diagnosis, and often would not cover mental-health treatment if that individual also abused drugs

“There are [clients] who will scream, yell, sometimes spit,” says Manley, who cuts an imposing figure with his shock of white hair and a black eye patch over his left eye, the result of a long-ago accident. “We have plexiglass. . .

“Then, I see them 10 days later, after they’ve started their medication, and they’re doing much better. I understand stubbornness. Judges can be very stubborn. But if you can get out of that and move an inch forward, that’s incredible. Once you get past the first hurdle, the next one is easier.”

Manley was also an early adopter of “dual-diagnosis” mental health treatment – recognition, only recently widely accepted, that substance abuse and mental illness are closely related, and cannot be successfully treated separately.  Insurers have historically refused to recognize dual-diagnosis, and often would not cover mental-health treatment if that individual also abused drugs. Yet people with mental illness frequently turn to street drugs because they aren’t getting the prescription medications they need, or experience difficult side effects and are “self-medicating” with dangerous street drugs.

Recent state legislation requires that insurers approve both mental health and addiction treatment.

“Most people don’t understand that 80 percent [of mentally ill offenders] use drugs or alcohol,” says Manley, “because those are  ‘solutions’ to their problems when they’re feeling depressed or manic, when they’re hospitalized or homeless in the streets, which is traumatic. Going to court is traumatic, being in jail is traumatic. So they turn to street drugs.”

“There’s a stigma with the mentally ill that they are more dangerous, which is not true.” — Stephen Manley

Often, that drug is methamphetamine, which is widely available on the streets, cheap – and particularly disastrous for the mentally ill. “There is so much meth-induced mental illness,” Manley said.“If you can get people to stop using meth and get help for their substance-abuse problems, their paranoia clears [as do] meth-induced schizoaffective disorders, bipolar disorders, whatever. You have to concentrate on both.

“If you can’t stay sober for a day, what are we going to do about your mental health? If you don’t take your medications, we can’t help you.”

Manley, who often sounds more like a mental-health clinician than a judge, earned a Bachelor’s degree in behavioral health at UC Berkeley before getting a law degree from Stanford.

“I’ve worked with mental health clients for years, and I know our traditional method is to ignore them,” he said in a 2005 Q&A interview with the Center for Court Innovation, a public/private partnership originating in the New York courts that studies and proposes innovative programs in state courts.

“We either cycle them through quickly or we give them long sentences,” Manley said. “There’s a stigma with the mentally ill that they are more dangerous, which is not true. Some are, some are not. They are, however, far more difficult to work with. It makes absolutely no sense in my view to warehouse someone who is mentally ill and release them into the community with no services, when we know they will be rearrested again and go right back into jail.”

While he now has the full support of his colleagues and other county officials, Manley said in that interview it was an uphill battle to start the courts: “So I went to war with — or had discussions with — mental health [officials], and we changed things.”

“Serious mental illness has become so prevalent in the U.S. corrections system that jails and prisons are commonly called ‘the new asylums’.” — Treatment Advocacy Center, 2016 report

Not all judges are suited for mental-health court, he said: “A judge has to be committed, very patient, and willing to accept criticism from clients. Mentally ill people are very honest. They will tell you what is and isn’t working—if you ever bother to listen to them. Trying to meet the needs of these clients is an incredible challenge. There is no court that requires a more sophisticated and committed team than mental health.”

“Success,” he added, “is small things: Clients who are able to function, who learn how to take the bus, who learn to find a place to live that is somewhat permanent, who are able to get social security or their disability reinstated.

“I have different expectations and goals for every client.”

‘The new asylums’
Official estimates of the number of mentally ill inmates in jails and prisons differ widely – and are often outdated — but mental-health and criminal-justice experts consistently say the numbers are rapidly increasing, as are suicides in adult correctional and juvenile detention facilities.

A 2016 report based on 2014 numbers by the highly regarded mental-health policy nonprofit, the Washington-D.C.-based Treatment Advocacy Center (TAC), said “serious mental illness has become so prevalent in the U.S. corrections system that jails and prisons are commonly called ‘the new asylums’.”

The report estimated one-fifth of local jail inmates and one-fourth of state prisoners are seriously mentally ill.

“Based on the total inmate population,” the report continued, “this means approximately 383,000 individuals with severe psychiatric disease were behind bars in the United States in 2014, or nearly 20 times the number of patients remaining in the nation’s state [mental] hospitals.”

Estimates are based on state and local figures that are notoriously unreliable for myriad reasons. Many mentally ill inmates are never diagnosed, much less treated. Some refuse to participate in studies or don’t believe they are mentally ill. And the numbers may not include those with less severe mental illness, which can worsen without diagnosis or treatment, particularly while incarcerated.

A lengthy 2014 survey of state prisons and jails by TAC and the National Sheriff’s Association, found wide variation in state statistics. And the statistics are tied closely to the dearth of mental-health services in the community.

Among California’s 58 counties, the study noted, 26 have “no psychiatric inpatient beds whatsoever, public or private,” to treat mentally ill people in the community, and the remaining state mental hospitals – which were mostly closed in the 1960s and 1970s — house primarily those deemed criminally insane by the courts.

The Los Angeles County Jail has long been described as one of the largest mental-health facilities in the country…

“The consequences are as predictable as they are tragic,” the 2014 survey concluded, with jail suicides increasingly common, as well as attacks by other inmates, too often resulting in deaths. In line with national data, the California Department of Corrections and Rehabilitation estimated in the TAC/Sheriffs’ survey that one-fourth of inmates were mentally ill in 2012, a 6 percent increase over 2009, with 11,000 (9 percent) in solitary confinement, a common practice known to severely worsen mental illness.

As California prisons have been ordered to reduce population — as a result of court orders, legislation and more recently because of COVID — more inmates have been transferred to local jails, or released, too often ending up on the streets.

The Los Angeles County Jail has long been described as one of the largest mental-health facilities in the country, along with other, aging correctional horror chambers in Chicago (Cook County Jail) and New York (Riker’s Island).

Incarceration is expensive, but locking up mentally ill prisoners is exorbitant, with additional staff and prescription costs — assuming the prisoners are treated at all. In addition, there frequently are costly lawsuits stemming from injuries and deaths in custody and the vulnerability of mentally ill inmates to jailhouse brawls and attacks.

According to figures from the federal Bureau of Justice Statistics, a 2006 study that is available on the California Judicial Council website found a whopping 56 percent of state prisoners, 45 percent of federal prisoners and 64 percent of jail inmates had a mental health diagnosis or symptoms of mental health problems in the year before the study.

In addition to being more vulnerable to suicide and assaults, mentally ill prisoners are more likely to receive longer sentences.

For juveniles, the numbers were even worse – an estimated 65 to 75 percent of juveniles had a “diagnosable” mental health disorder in the 2006 study.

A 2016 report, “Justice that Heals,” by a panel of San Francisco Bay Area mental-health and criminal-justice experts, also concluded that, based on local and national studies, nearly two-thirds of  jail inmates across the country have mental-health problems. And the incidence of mental illness in jail and prison populations is worsening, with a patchwork of local, state and federal programs too often working at cross-purposes.

They recommended creation of a Behavioral Health Justice Center in San Francisco, which has long had active behavioral health treatment and diversion programs in the jails and courts. But budgetary and political barriers reportedly intervened, and then the COVID-19 pandemic, and the proposed center was never realized.

‘Restoration of competency’ – or not
In addition to being more vulnerable to suicide and assaults, mentally ill prisoners are more likely to receive longer sentences.  They are twice as likely to be charged with rule violations, according to the 2016 TAC report. They also experience longer pretrial detentions, particularly if they require psychiatric evaluation or “restoration of competency” to stand trial, causing growing waitlists for evaluations in the remaining state mental hospitals.

“Mentally ill inmates in some states are reported to spend more time waiting for competency restoration so they can be tried than they would spend behind bars convicted of the offense for which they have been charged,” the report concluded. Some are never declared “competent” and are consigned more or less permanently to state mental hospitals for the criminally insane.

“Many individuals were subjected to repeated instances of involuntary treatment without being connected to ongoing care that could help them live safely…” — State Auditor Elaine Howle

Often using the model developed in Santa Clara County, increasing numbers of California courts are creating similar mental health and other so-called “collaborative” courts (DUI, drugs, veterans, and others aimed at diverting specific cases), with widely varying methods and limited statewide requirements or data collection. A major criticism in a recent California Auditor’s report on mental-health care, was the lack of statewide data and follow-up care, particularly after incarceration or hospitalization.

“Perhaps most troubling, many individuals were subjected to repeated instances of involuntary treatment without being connected to ongoing care that could help them live safely in their communities,” state Auditor Elaine Howle  wrote in a cover letter  to the governor and legislative leaders.

In Los Angeles County alone, she said, “almost 7,400 people experienced five or more short-term involuntary holds from fiscal years 2015–16 through 2017–18, but only 9 percent were enrolled in the most intensive and comprehensive community-based services available in fiscal year 2018–19.”

At the local level, many mental health courts report considerable success in reducing incarceration and hospitalization by requiring intensive mental-health treatment and follow-up by caseworkers and the courts, although the number of participants in such courts remains small in many counties.

According to a 2015 report by a state task force, 30 California counties then had adult mental health courts, and some counties (a mere seven in the 2015 report) had juvenile mental health courts as well. That number has since increased to 36 counties with 50 adult mental health courts and 11 courts for juveniles. The task force of judges and court administrators was convened by state Supreme Court Justice Tani G. Cantil-Sakauye and the state Judicial Council to establish procedures for local courts to follow in establishing mental health courts.

Blaine Corren, a spokesman for the Judicial Council in San Francisco, said the Council has an active Collaborative Justice Courts Advisory Committee co-chaired by two Superior Court judges with long experience in mental health and other collaborative courts, Richard Vlavianos in San Joaquin County and Lawrence Brown in Sacramento.

The mental-health crisis in California’s criminal justice system – and on the streets – has a long, tortuous history.

He said the committee – which includes a mental health subcommittee chaired by Judge Manley – is expected to present a report to the Judicial Council’s annual meeting in January that will discuss “progress on the (2015) mental health task force recommendations,” as well as  current issues and concerns “related to the intersection of criminal justice and mental health.”

In addition, Corren said, the Judicial Council “partners with the Council of Criminal Justice and Behavioral Health, the Council of State Governments, and the County Behavioral Health Directors Association to do four regional trainings related to mental health diversion courts,” although training has had to be moved online during the COVID pandemic.

The Judicial Council’s Center for Families, Children and the Courts  also recently completed studies on the need for more juvenile mental health courts.

Many mental health and criminal justice experts say state legislation – and funding — is necessary to expand mental health courts and collect more comprehensive statewide data on the courts. Yet funding remains a perennial challenge, and proposals to expand the courts and provide more funding were stymied this year by pandemic-imposed state budget restrictions.

The mental-health crisis in California’s criminal justice system – and on the streets – has a long, tortuous history.  Closures of the state mental hospitals more than a half-century ago and the passage of laws to correct the horrific human-rights abuses of the hospitals, have resulted in a nightmare of equally epic proportions, playing out in plain sight in homeless encampments throughout California, in hospital ER’s, courtrooms, jails and prisons – at huge public expense and untold human suffering.

Clearly, new methods must be developed to evaluate and treat the growing numbers of mentally ill people who regularly, repeatedly tangle with a criminal justice system they often don’t understand and is ill-equipped to help them. And little real progress can be made, experts say, without more – and earlier – intervention and treatment programs in communities, to diagnose and treat people before they commit crimes.

“I go back again and again to the lack of capacity” in community mental-health care, says Manley. “There should be much more effort with young children and their families. We should be working with 2- and 3-year-olds. “We need to do far more work on the front end,” to create more local programs to help traumatized kids deal with dysfunctional families, poverty, violence.

“To be really successful, diversion shouldn’t be in the courts.”