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San Francisco General is the city’s main public hospital, and also the main provider for the city’s

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San Francisco General is the city’s main public hospital, and also the main provider for the city’s poorest and most vulnerable residents. On an average day, about 20 people suffering from mental illness walk through its doors asking for psychiatric help. It’s often a last resort for people without a support system or anywhere else to turn. But ongoing state and city budget cuts have forced San Francisco General, like many other public hospitals in the state, to make tough decisions. The psychiatric emergency rooms have been hit the hardest.

Since 1995, California has lost around 30 percent of its psychiatric beds, which amounts to nearly 3,000 beds. In San Francisco alone, 60 percent of its beds for acute psychiatric care were cut. The burden of these cuts clearly falls on the patients who are unable to receive care, but when those people are left to fend for themselves out on the streets, it also falls on the San Francisco Sheriff Department.

And not using appropriate tactics when coming across the mentally ill in law enforcement can have deadly consequences. In July 2011, a mentally ill homeless man died after a violent confrontation with six Fullerton police officers. A judge may decide to dismiss the two of the officer’s manslaughter charges at a January hearing.

In San Francisco, deputies are getting the tools they need to safely deal with this changing population in and outside of jail.

Last October, a couple dozen deputies from the San Francisco Sheriff’s Department are gathered around a conference table. Like most trainings, they start things off with coffee and doughnuts. Today’s topic is an everyday reality of the job, but that doesn’t make it any easier to talk about.

A public health department worker begins day one of the training talking about rates of suicide in county jails. This course, designed by the San Francisco Public Health Department, is meant to give the deputies a few strategies for dealing with people suffering from mental illness.

Unlike the San Francisco Police, the Sheriff’s Department mostly handles calls from government buildings and oversees county jails.  But over half of the calls it gets are from San Francisco General hospital, to help with a patient experiencing a psychiatric issue.

California cut more than $580 million from mental health care programs in the last two years. That means the criminal justice is picking up the slack. Deputy Bill Kelleher says the more training the department can get in this area, the better.

“Dealing with mental health issues and the public in general, from a law enforcement standpoint is very difficult,” he says, “because when we deal with them out in public, the problem we face is, is this person a person that is a criminal? Or this a person that just needs help? And we have to make judgments and considerations based on limited information.”

In this training, they discuss issues deputies deal with everyday, like suicidal behavior in jail.

The training also addresses the revolving door between jails and the psychiatric ward, different diagnoses and side effects of psychiatric medicine. And on the third day, deputies visit mental health clinics around the county, where they get advice directly from public health workers. In their discussions, the workers are aware the deputies work under much different circumstances than they do.

“I would never say to a deputy, ‘Oh the way you have been doing it, it’s all wrong, do it like this instead,’” says Ian Albert, who works with the San Francisco County Jail Psychiatric Services and is at today’s training.

“A lot of these guys are very good at what they do,” Albert says. “I have seen them deescalate really out of control inmates without violence – they just use their words, and their presence is wonderful. But the more tools that we can put in their toolbox, the more skills that we can help them develop then that’s awesome.”

The San Francisco Sheriff and Public Health Departments work closely, despite having different philosophies on how to reach the same goal. Security and enforcing the law are first priority for the deputies, while public health workers may be willing to give a person more chances.

“I think ultimately the end goal is the same,” Albert says. “I want to come to work do my eight hours and leave safely and I think everybody feels that. Nobody wants to put their hands on anybody, nobody wants to hurt anybody, and nobody wants to get hurt. No deputy, I ever met, wants to hurt anybody. No public health official, that I ever met, well is OK with a mentally ill person acting violent or suicidal.”

This kind of collaboration between public health officials and deputies is becoming more relevant as state and local mental health programs deal with ongoing budget cuts. On top of that, realignment, the state’s new criminal justice law that shifts responsibility of low-level offenders to the county, is changing the jail population as well. Deputies now have to deal with a different kind of inmate, one that is more likely to suffer from mental illness, says Assistant Sheriff Paul Miyamoto.

“And I think that’s very interesting, because that’s probably an offshoot of not having the bed space outside and having people interact with public safety and get arrested,” Miyamoto says.

Many counties like San Francisco say realignment is an opportunity to provide this group with more services at the county level, and to help them transition back into their communities. In addition to providing reentry services, the Sheriff’s Department started a program last year in the female housing unit that treats both mental health and substance abuse issues. The department also built a new jail in San Bruno to replace an older facility that wasn’t safe for severely mentally ill inmates. But trainings like these prove that there’s more to it than just building new facilities and programs, Miyamoto says.

“You’re looking at something deeper,” he says, “and you realize that there are other issues behind what’s motivated their behavior. So, you have more of a background on substance abuse disorders, on cognitive disorders, things that you may not take to the consideration when you’re dealing with someone who continually wipes feces on their self.”

When someone who walks in with a psychiatric emergency at San Francisco General, it can be hours before a bed becomes available. That’s when the hospital turns to the Sheriff’s Department for help. Miyamoto says it shouldn’t have to come to that.

“We deal with it, because they’re part of the criminal justice system at that point, but I don’t think it’s the right place to warehouse people, with mental health issues,” Miyamoto says. “I really think, the emphasis should be on getting them to proper care, within our current system.”

At the training, it’s clear that the deputies realize they have a role in helping people get care before they get arrested. No other sheriff department in the state is providing such extensive training on mental health as this one in San Francisco. In the next two years, the county aims to have all of its 850 deputies trained, and hopefully better prepared to be on the frontline of mental health care for those in need.