I Rode Along with the San Francisco Police Department's Only Mental Health Liaison

As I'm standing with three cops in the kitchen of Julian's cramped San Francisco apartment, one of the officers knocks on his bedroom door. In youth custody for most of his life and now in his 30s, Julian (whose name has been changed) has a rap sheet several pages long consisting of various violent offenses committed after his release. He's paranoid, delusional, and often violent, San Francisco Police Psychiatric Liaison Sergeant Kelly Kruger explains.

We show up after his roommate calls in complaining that Julian tried to light something on fire, causing an electrical problem.

Julian opens the door. He's a big man—standing more than six feet tall and weighing about 240 pounds—wearing gray sweatpants and T-shirt with a towel draped over one shoulder. Seeing Sergeant Kruger and two armed cops, he sizes up the situation pretty quickly and follows their instructions. " I don't need to go to the hospital," he pleads, well aware that's exactly what is about to happen.

The cops search Julian and find $700 in cash and a knife. The short glimpse of his bedroom I got revealed a dresser full of cleaning products and a messy single bed. They take him outside and stuff him into the marked squad car, a black and white police cruiser. He's on his way to San Francisco General Hospital, the city's only public hospital with emergency psychiatric care, to be placed on a what's known as a 5150 hold (fifty-one-fifty)—the police radio code for a mental illness–related detention. In general, a patient has to be a danger to themselves or others to get that status. If either condition is met in California, cops and designated county clinicians can detain patients for up to 72 hours against their will.

Earlier that day, Kruger explains as we're driving to Julian's place in an unmarked car that he's a known entity around town. She suspects it will be necessary to detain him. "In large part it's because of his past and my knowledge of his case file," she says. "He also doesn't recognize his paranoid delusions and that's why he can get dangerous."

San Francisco has developed something of a reputation for being a seven-mile-by-seven-mile treatment center for the mentally ill. It is not entirely undeserved. Kruger is expected to review the 250–300 monthly incident reports from the population of citizens suffering from a variety of mental illnesses. In part that's because of San Francisco's population of roughly 7,000 homeless adults and children, many of whom suffer from mental health problems. Initially that justified a corps of officers to handle the related calls for service. "It started at 18 people," Kruger says. "Two of the country's first officers with PhDs worked in the unit."

But for the last 15 years, San Francisco cops have had just one officer on the mental health beat, leaving Kruger to conduct an uphill battle on the fringe of America's dire healthcare system.

One reason the SFPD only has Kruger on the job is that it strives to train at least a quarter of its officers with the crisis intervention techniques necessary to diffuse situations involving the mentally ill. The idea is that there should theoretically be at least one officer in every police district, on every shift, available to handle mental illness concerns that require law enforcement's attention. "Police officers by nature find niches," SFPD Chief Greg Suhr told KQED last year when the public news organization did a major story on how police treat the mentally ill. "I don't want cops to find a niche and be expert on what they do and don 't do. I want them to do it all."

The SFPD began training officers in crisis intervention in 2001, and graduated its first class of 30 in May of that year, according to department documents. By the end of 2006, at least 544 officers had completed the training, but the KQED report suggested only about 18 percent of the city's police has received the training as of last fall.

One reason police are trained to handle encounters with the mentally ill is that government funding for institutionalized treatment was cut in the 1970s across the country. Deinstutionalization, as it's called, was a response to overcrowding and patient abuse , but the problems that appeared its wake—chronic homelessness and crime—worsened as the feds further cut funding for institutionalized treatment throughout the 1980s. Now the public health concern has been handed off in large part to agents of law enforcement.

"Crisis intervention has become quite a land mine," Kruger says. We're on our way to the Emergency Psych Ward, riding the green Taurus assigned to her for the day. It's 80 degrees out and the air conditioning doesn't work.

Born and raised in California, Kruger, now 50, says that after years working as a psychiatric technician at a state hospital in the world-famous wine-growing region of Napa, what ultimately nudged her into becoming a cop was a patient's obsession with her. "I had a gentleman who raped and shot a female park ranger get fixated on me," she recalls. "He told me that he wanted to make me his wife. So after that I felt like I was one of the blonde girls in a scary movie, walking out to my car late at night and then something bad happens. The hospital couldn't provide protection, so I told the chief of police in Eureka how I didn't feel safe, and he gave me a permit for a concealed weapon. I'm thinking that was probably the transition from doing mental health care to being police—because I wanted to protect myself."

She ended up buying a Smith and Wesson .357 caliber revolver, although she hasn't killed anyone in the line of duty.

Kruger earned her badge in 2001, and has been the psychiatric liaison since 2005. "There are a lot of layers," she says about each case she handles, describing one with a quarreling, possibly alcoholic parent who "puts his head in the sand" when dealing with his son. The adult son is experiencing psychiatric symptoms but doesn't know or understand that he is. But the state's standards for a law enforcement intervention require patients to be in imminent danger of hurting themselves or someone else—or unable to provide for basic personal needs like food and shelter. The adult son didn't meet any of the criteria, and Kruger wasn't able to act.

"We had a guy with a substance abuse issue that had gangrene and was going to lose a limb," she says to illustrate her point. "There were maggots climbing around an open wound. He had this corner that he had made up, and people would give him money. 'I'm not moving,' he said, and he was fine crapping and urinating on himself." But because the man wasn't dangerous to himself or others and explained how he planned to feed himself, Kruger's options were limited.

One thing Kruger can do is navigate the complex bureaucracy and treatment options that are available once a 5150 call is made to the SFPD. That's why we're driving to the hospital, so she can oversee and monitor Julian. While on duty, she also helps other officers handle mental illness–related calls. "It's helpful to have me navigate the system," she says. "If I can't go, I just monitor the situation, and make sure the ball doesn't get dropped."

When we arrive at the hospital, Julian has already been escorted into the Psychiatric Emergency Services section. On the ground floor, and close to the building's southern entrance, a sally port is the only way to get in or out of the psych emergency unit. When I try to walk in with Kruger, the clinician refuses me. I don't get a glimpse of anything more than a white desk, and can't spy Julian from my vantage point.

Kruger emerges a few moments later. I ask what they're going to do by way of treatment, and she replies that the clinicians will likely replenish his medicine supply. They'll also conduct a psychiatric evaluation.

With Julian handled—relatively speaking—Kruger moves onto her next case for the day. A man named Greg called earlier explaining that he planned to shoot a video of his entire experience being treated at the hospital for an unknown medical condition. For privacy reasons, it's against the hospital's regulations to allow any patient to record their entire visit. "There's not a chance he's getting in here," says one of the nurses. "He's got a plan, and he monopolizes a lot of my time."

After a brief confrontation with Kruger backed up by two Sheriff's Department deputies, Greg expresses frustration, and leaves a brown paper bag—containing what he says are urine samples for the doctors—on the ground. One of the deputies throws it in the trash after he leaves. "I'm concerned with his health," Kruger says, "but he's not allowed to videotape inside the hospital."

In 2012, of the 6,293 patients admitted to San Francisco's Psychiatric Emergency Services unit, 5,144 were involuntary, according to San Francisco Department of Public Health communications director Rachael Kagan. Of those 6,293 admissions, about a third had no address. The cops are involved in about half—many of which are the result of 9-1-1 calls—although the city's Mobile Crisis Team and other organizations have an impact as well, according to a Department of Public Health study conducted on psychiatric emergency response in 2006.

"The SFPD plays an influential role in San Francisco 's mental health system," the study concludes. According to SFPD records, Kruger processes—whether by handling the case herself or reviewing it—about 3,800 5150 service calls a year. Many of the calls she receives are related to substance abuse, often booze and drugs. Suicide threats are also common, as are threats of violence.

When I ask Kruger how she copes with her job, she says she just wants to help people suffering from mental illness who are often caught up in a system poorly designed to treat them.

"That's what I love about San Francisco, that people have the right to be who they are and not be judged," Kruger says. "The hard part of that—and I don't mean to be dramatic, but it does rip my heart out—is when you see somebody in need of treatment and you're unable to help them."

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