Just five years ago Houston faced many of the same challenges that continue to vex Milwaukee County's mental health system.
Like Wisconsin, Texas is one of a handful of states where only police - and not doctors or health care professionals - can detain a patient in an emergency.
Like Milwaukee, Houston saw far too many people with severe mental illness cycling in and out of emergency care, being hauled in for treatment in handcuffs and shackles after reaching the depths of their disease. Then tragedy forced the nation's fourth largest city to find a better way.
And it started with the police. By comparison, Milwaukee County's latest approach has a panel of advocates and administrators talking to each other about how to change the county's defective system - which still focuses less on continual care and more on emergency psychiatric treatment than any in the nation, despite 20 years of scandals, investigations and promises of reform.
Not one of the 32 members of the Mental Health Redesign Team is a police officer or sheriff's deputy - the people responsible for determining whether to bring a patient into the psychiatric emergency room.
If Milwaukee really wants to improve this time around, it would do well to study some of the best practices found in Houston. Since developing their mental health unit - now a full division - Houston police have dramatically reduced the number of people with mental illness who are detained against their will. They've helped get more than 200 homeless people with severe mental illness off the streets in the past three years.
And they are spending less money for these better results.
Division of mental health Houston is the first police department in the nation to devote an entire division to mental health. The department has five programs aimed at helping people in psychiatric crisis avoid arrest - including a homeless outreach team, a team dedicated to identifying chronic consumers and a team of 10 officers who are paired with mental health counselors to go out on calls for help.
Since 2008, the department has cut the number of its mental illness emergency contacts in half.
Houston's Chronic Consumer Stabilization Unit is especially instructive for Milwaukee as it focuses on ways to reduce emergency care.
When launching that program in 2009, Houston police reviewed all reports involving people with mental illness. They found that more than 200 people in mental health crises had repeated interactions with police officers since 2006, the year the department began compiling the data.
They then narrowed that list down to those who had been taken in on emergency detentions four or more times - a total of 57 "chronic consumers."
Two caseworkers were assigned to the 57. Some could not be found; others were in jail, prison or hospitals. They located 30 people and got them help.
In the six months before the pilot program began, those 30 people had been named in 194 offense reports and 165 emergency psychiatric detention orders.
"This is a total of 359 timeconsuming events which averages close to one hour of work per officer per event," a department report on the program noted.
After intense intervention by the two case managers, the same 30 individuals were reported to have been involuntarily committed by officers 39 times in the following six months - a decrease of 76.4%. They were involved in 65 police offense reports - a 66.5% decrease.
Police estimate they saved 768 patrol manpower hours and 194 investigative hours on those 30 people alone. That doesn't count the cost in time, money and resources of emergency room care, hospitalizations, lawyers and court costs.
One man had been hospitalized 17 times in a sixmonth span before the program. He had 23 contacts with police and was incarcerated five times. The total cost to police alone: $145,938.
In the first six months he was in the program, he was hospitalized twice, had two police contacts and was not incarcerated. The total police cost: $1,764.
Houston has seen a 30% drop in the number of people taken to its county's psychiatric emergency room and a 37% reduction in patients admitted to its public psychiatric hospital. Houston's population of 2.1 million is more than twice that of Milwaukee County, yet in 2011 it had about 28% of the number of emergency detentions - 2, 259 in Houston, to 8, 019 in Milwaukee County.
"We are very proud of what we've been able to do so far," said Mike Pate, who heads the Houston department's Chronic Consumer Stabilization Initiative.
Roots of reform Houston's decision to focus on mental illness began in earnest in 2007 after two people with schizophrenia were shot and killed by police two months apart.
In the first case, a 42-yearold woman had gone to a neighborhood police station with a knife, demanding to be shot. She was killed when she lunged at an officer.
Two months later, police killed a 39-year-old man who had been refused admission at the public psychiatric hospital after doctors determined he did not meet the standard of being an imminent danger to himself or others.
Police Chief Charles McClelland ordered all officers to undergo training to identify signs and symptoms of mental illness.
In addition, Houston dispatchers have been trained to ask two questions at every call: Does this involve someone with a mental illness?
Is anyone in danger of being harmed?
The first step: Find out if the person police have been called about has a mental health history.
"If you are going to help people, you need to know who they are," said Steve Wick, a sergeant in the Division of Mental Health.
Wick and his partner, Jaime Giraldo, keep a bulletin board with the pictures of people they meet on streets and under bridges. They call them by their nicknames, like Spider and Momma D and Sergeant Major.
In two years, these two police officers have found homes for 243 people who were sick, homeless and not getting better.
"Most have stayed off the streets, but some come back," said Wick. "You can only help people as much as they will let you."
Sgt. Patrick Plourde spends big chunks of his day not combing the alleys of Houston but diving through data on his computer screen. He developed a program that allows police to see if a person has a psychiatric history and previous contacts with police.
"You can't identify the sickest people without looking at the numbers," Plourde said.
He reviews 1, 200 reports a month of people who have come into contact with police.
"They used to sit untouched," Plourde said of the reports.
He and his staff investigate firearms sales to make sure people who have been committed do not buy guns; they check credentials of group homes and adult protective service workers.
Plourde stood last week in front of a screen of charts he had assembled to train officers how to find people who suffer from mental illness so they can better respond to their needs.
"It's not a crime to be mentally ill," Plourde said. "We don't have to criminalize them."
Officers in 10 crisis intervention response teams are paired with psychological counselors with master's degrees. They respond together to calls involving people with mental illness.
Last Tuesday, a reporter and photographer were allowed to go with Plourde as he responded to the scene of a man in crisis.
Glancing at his computer screen, Plourde could see that the man, 26, had been diagnosed with bipolar disorder. He had been hospitalized in March at the county's 250-bed psychiatric hospital.
The man's mother told police that he had stopped taking his medication and was extremely agitated. He would not let her leave that morning as she was trying to get to work.
An officer and counselor persuaded the man to go with them to the county's psychiatric emergency room, known as the Neuropsychiatric Crisis Center.
Before the department began focusing on improving its mental health procedures, such trips were rarely voluntary and typically took between four and five hours, as police filled out cumbersome paperwork, Plourde said. Police did not have working relationships with hospital intake workers.
"Now, we can do them in about 15 to 20 minutes," he said. The form police officers fill out requesting that a patient be detained has been streamlined from seven pages to one.
Police in Houston's Mental Health Division share office space with the Mental Health Mental Retardation Authority of Harris County, a quasiprivate mental health agency that contracts to provide services.
"There was a time not so long ago that police officers didn't think it was their job to serve people with mental illness," Plourde said.
Nor did mental health workers see officers as partners.
"Now, we're all about collaboration," said Ann McLeod, a mental health counselor who works with Pate and Plourde. "It doesn't happen overnight, but it can happen."
Baby steps Last summer three Milwaukee police officers went to Houston to learn more effective ways for police and mental health counselors to collaborate.
"It's exciting to see how working together can help," said Karen Dubis, one of the officers.
Dubis heads Milwaukee's homeless outreach team, a part-time assignment for officers who have other duties. She drafted a proposal when she got back last summer for Milwaukee police to develop its own mental health unit after seeing the success of Houston's. She's still waiting for an answer.
Last year, Milwaukee County law enforcement officers brought patients to the county's psychiatric emergency room against their will more than 7, 200 times. Add in people who go voluntarily and more than 13, 000 patients a year are treated for psychiatric emergencies. A Journal Sentinel investigation found one man who was detained 10 times in one month. One woman was admitted 196 times in six years.
Each emergency detention costs a minimum of $150 in police time, said Inspector Carianne Yerkes, who heads the Milwaukee Police Department's program training officers to deal with people who suffer from mental illness.
She estimates the department handles about 5, 000 cases a year, with sheriff's deputies and others handling the rest. If Milwaukee could do what Houston did, and cut the amount of police time in half, the department would save more than $350,000. Yerkes said that any task force seeking to reduce emergency psychiatric crises in the Milwaukee area should include law enforcement members.
"We are the first responders," she said. "So, we probably should be at the table more."
On June 1, Chad Stiles became the first Milwaukee police officer to join the county's mobile crisis team. He has been paired with a psychologist and social worker to go out to the scene of a person in a psychiatric emergency.
"It's a start," Yerkes said.
But that's all it is.
In Houston, all new officers are required to take a 40-hour course on Crisis Intervention Training - a curriculum developed by a Memphis police officer that is now widely practiced worldwide.
Just one in five Milwaukee officers is trained in CIT.
Often that means officers without training or counselor partners are the only ones available when a call comes in.
Last July, dispatchers did not alert officers that John Kriewaldt, 30, had mental illness and mental retardation when they sent two officers to a group home where he was staying overnight. No officers with mental illness training were available to take the call.
Kriewaldt, who had poor communication skills and could speak only in short sentences, struggled with police, who misunderstood him and thought he lived at the group home. Kriewaldt was begging to be taken home to his mother. He banged his head repeatedly in the back of the police car, was wrestled to the ground and eventually stopped breathing. Paramedics restored his breathing and heartbeat, but he died two days later.
An autopsy found that he was suffering from pneumonia, which the county medical examiner said probably led to the angry outburst that had led to the police call.
Dysfunctional dealings No one knows the differences between Milwaukee and Houston's emergency mental health care systems better than Daryl Knox.
Knox is medical director for the psychiatric emergency program for Mental Health Mental Retardation Agency of Harris County, the agency that provides public mental health services. Before coming to Houston, Knox was medical director of Milwaukee County's psychiatric emergency room.
He left Milwaukee, he said, because he couldn't stand the various dysfunctional relationships that prevented cooperation between the County Mental Health Complex, law enforcement officers and public defenders. Too many put their own agendas before helping sick people.
"There is much less mistrust here," Knox said. "Milwaukee is mired in an awful lot of politics."
Knox offered this advice for his hometown: Don't overlook the importance of cooperation between police and mental health workers.
"You can fight it, or you can resolve to figure it out," he said. "It's a lot better for everyone if you work together."