A Court of Refuge

by Ginger

  They all came with the same question: What was the court doing to promote mental health care over punishment and how was it doing it? The court answered this question case by case through its preservation of human dignity and its unconditional belief in recovery.

  The court’s growing reputation coincided with a growing sense of urgency for mental health reform, as Congressman Ted Strickland of Ohio sponsored legislation to establish pilot mental health courts. America’s Law Enforcement and Mental Health Project Act passed the 106th Congress unanimously (the Senate in September 2000 and the House one month later) and was signed into law on November 13, 2000, by President Clinton. In 2002, I was appointed by President George W. Bush to the new Freedom Commission on Mental Health. A single community’s call for compassion had led many—even policymakers—to question the conventional approaches of national and international law to mental health.

  This fundamental change in criminal justice and mental health, spurred by Broward County’s Mental Health Court, is greater than what can be measured in statistics such as the number of courts or mental health consumers served. Instead, the court sparked—and ignited—the idea that institutional change is possible if there is a will to fund adequate resources and commit to transform mental-health and behavioral-health care. This spark drove the proliferation of mental health courts across our country and others.

  According to the Council of State Governments, today there are an estimated four hundred mental health courts, behavioral health courts, and other hybrid models across the United States and in several other countries. These courts function differently in different states. In Florida and other states, where healthcare budgets and spending on mental health are constantly being reduced, mental health courts connect consumers to limited community resources. In rural states such as South Dakota and Arkansas, where there are large pockets of poverty, mental health courts provide much-needed access to mental health care and treatment facilities through the referral process. In every region, however, mental health courts are a way to promote access to care, reduce incarceration, and promote accountability. Moreover, mental health courts have answered the need for a response to the national opioid crisis and its collateral impact on the criminal justice system.

  In addition to these gains brought by the new mental health courts, one of the most tangible of our successes is the way the new court touched Broward County: in the twenty-first century, for the first time our county became a harmonious, tight-knit community. The mental health court itself was a rising star with its own homeless shelter, the Cottages in the Pines. The creative solutions created by the court were unparalleled.

  On the heels of the court’s successes, in 2001 I made a presentation about the Broward County Mental Health Court at a national mental health conference, to be held that year in Miami. I brought with me a woman named Rosemarie Stratton so she could share with conference attendees her experience with the court. My intention was to use this opportunity to humanize the court for the audience and showcase the experience of a mental health court consumer.

  Rosemarie, thirty-four, had been diagnosed with schizophrenia and a co-occurring intellectual disability. Despite her challenges she was making great strides in her recovery and had established new goals of returning to school and work. Rosemarie had attended school up to the tenth grade, when she was diagnosed with a serious mental illness. Since then she had been evaluated under the Baker Act many times and had never truly engaged in mental health care for any sustained period. Rosemarie had been arrested for shoplifting at a local retail store and had been referred to the mental health court by her assigned division judge. After my portion of the presentation, I provided the audience with a summary of how Rosemarie was referred to the court and noted that she currently resided at the Cottages in the Pines, where several court participants had formed a supportive, rehabilitative community.

  Rosemarie greeted the audience and took questions. She appeared confident on stage and spoke excitedly about her plans to return to school and to pursue a professional career in accounting. I was incredibly proud of her.

  “This was one of the most exciting things I have ever done in my life,” she told me after she left the stage.

  When news of Rosemarie’s appearance at a national mental health conference made its way to the executive team at the Henderson Behavioral Health Center, I could tell it represented a new milestone and ignited a new sense of pride and vision for the future. This was a milestone for the mental health provider stakeholders, particularly Henderson, which had lent the court a staff person to commence operation because the court had no funding to hire specialized personnel. It was a milestone for the members of the criminal justice and mental health task force that had met for several years without reaching consensus on what could be done to respond to streamline the criminal justice process for people being arrested with mental illness. And it was a milestone for the individuals and families in Broward County, that a modest local effort to try something to create a safety net to prevent or mitigate the criminalization of people with mental illness was having a positive impact on a local and national level.

  Broward County needed to raise the bar in terms of recovery, and many mental health consumer activists in the community with ties to the Florida Department of Children and Families began to work toward formalizing a Peer Specialist Recovery Certification Program.

  The foundation for US peer leadership and workforce development has its historical roots in the experiences and work of path-breakers in the past. According to the consumer advocate Gayle Bluebird, the history of the consumer-survivor movement goes back to early pioneers such as Clifford Beers, a Yale graduate whose suicide attempt in 1901 led to his confinement in a psychiatric hospital. His autobiography, A Mind That Found Itself, published in 1908, ultimately led to the establishment of Mental Health America, now formally known as the Mental Health Association.1

  The early certified peer recovery/peer specialist movement was led by Howard Geld beginning in the mid-1980s. According to his obituary in the New York Times, Geld, who died in 1995, got his nickname, Howie the Harp, from playing “his harmonica on the streets of Greenwich Village to earn money for food and a place to sleep.”2 He had written “proposals that led to $150,000 in financing from the state and other organizations for the Peer Specialists Training Center to train former patients to help others like them.”

  This served as an early model for the Mental Health Association’s peer specialist certification and has led to an emerging US workforce where people with mental health problems, substance abuse issues, and physical challenges can legitimately work as a service provider in an integrated healthcare setting such as a mental health center, rehabilitation program, or supportive housing program. Not only does the ability to leverage one’s lived experience in recovery offer the benefits of learning how to manage one’s health from a “hands-on” perspective, but peer recovery support systems also promote social inclusion and break cycles of poverty for persons with disabilities by providing a ladder to financial independence and economic mobility.3

  In Florida, peer recovery leaders such as Bill Schneider, Sally Clay, Patrick Hendry, Jeffrey Ryan, Tim Lane, and the members of the Florida Peer Network worked tirelessly to develop a forty-hour peer recovery specialist curriculum and certification process in the state of Florida.4 In a program funded by the Florida Department of Children and Families, the Florida Certification Board administers the process whereby an individual can become a certified recovery peer specialist. There are three certifications: adult peer, family peer, and veteran peer. The Peer Support Coalition of Florida defines a certified recovery peer specialist as “an individual who self-identifies as a person who has direct personal experience living in recovery from mental health or substance use conditions, has a desire to use their experiences to help others with their recovery, is willing to publicly identify as a person living in recovery for [the] purpose of educating, role modeling, and providing h
ope to others about the realities of recovery, and had the proper training and experience to work in a provider role.”5

  In addition to a minimum of a specified number of years of “lived experience” for each category, individuals applying for certification must meet minimum educational requirements and complete a forty-hour training curriculum, which includes advocacy, mentoring, recovery support, professional responsibility, and electives.6 Applicants must also provide documentation to support five hundred hours of related work or training, pass an exam, and comply with all other ethics and certification renewal requirements.7 According to the Florida Certification Board, there are more than fifteen thousand certified peer recovery specialists in Florida. Their leadership has laid the foundation for an emerging consumer-centered mental health system in Florida, even as community systems of care in Florida, and around the country, continue to face budget shortfalls and reductions in services.8

  The moment Sharon Nardelli was referred to the mental health court, in 2003, we began to alter our expectations of the population we anticipated to see. Sharon was a college graduate who, in her early forties, decided to take her shot at success in the entertainment field. Her dream was to become a recording star. Sharon had been arrested for disorderly conduct at a local nightclub. She had been diagnosed with bipolar disorder but was too busy to spend much time thinking about her health. Sharon was determined to break into the music field and spent a great deal of time trying to find work as a backup singer.

  As Sharon herself remarked, she wasn’t getting too far in South Florida, and her money was running out. Before too long Sharon found herself evicted from her apartment, and her mental illness was out of control and quickly turning her life upside down. Sharon’s bipolar disorder had become unmanageable; she was swinging between extreme swings of “up” and “down.” When she was manic, she described going on “adventures” that could last for days. When the depression hit, she barely could lift her head off the pillow of a couch that she slept on in a friend’s apartment. By the time she was arrested, Sharon was emotionally and physically exhausted.

  “I need help,” she said in a strained voice that reflected her general fatigue.

  There was a female bed available at the Cottages, and Sharon accepted it without hesitation.

  Not long afterward, Sharon was joined by Margaret Smith. At forty-four years old, Margaret suffered from both post-traumatic stress disorder, stemming from childhood physical abuse by her mother, and an eating disorder. Margaret and Sharon were the same age and seemed to meet at an opportune time in life. Both women were single, at risk of homelessness, and extremely bright and vivacious. Margaret had been arrested for allegedly defrauding an innkeeper.

  “I accepted a dinner invitation from a man I had met at a singles event,” she said. The man said he was a financial consultant. He invited her out to dinner at an expensive restaurant on Las Olas Boulevard in Fort Lauderdale. Their first date seemed to be going well, but at the end of dinner, her date excused himself from the table.

  “He never came back,” she said. “It was one of the most embarrassing moments of my life.”

  When the waiter delivered the check, Margaret did not have enough cash or a credit card to pay the $196 bill. Margaret was aghast when the restaurant manager called the police. She was arrested on what became known as “the worst first date” anyone could have experienced. Later, that would become no surprise to me when I learned that Margaret had been a competitive tennis player when she was younger and relished a win any way she could get it. She told the story with so much conviction that we were transfixed. All the female lawyers in the courtroom began to shake their heads in disbelief as a sign of sisterhood and solidarity with Margaret’s obvious humiliation.

  At the Cottages, Sharon and Margaret established a community newsletter, the Consumer News, which included contributions from all Cottage residents. Poetry, favorite foods, essays, and a Community Events column was published every month. Howard Finkelstein’s “Club Med for the Head” was thriving, and before too long the community was having an impact of its own.

  So when word came from Henderson Behavioral Health Center staff that Margaret had had a psychiatric setback and her psychiatric status was not improving, the court personnel and members of the Cottages community were shocked and saddened. No one could have anticipated Margaret’s health decline. I was not informed of the details, only that her psychiatric condition had severely deteriorated and that she needed to be hospitalized. She had been doing so well and was due to leave the Cottages and resume her life in the larger community. Some speculated that she may have been concerned about transitioning to more independent living in the community. Perhaps the thought of leaving the safety and security of the Cottages was too much for her consider. Whatever the cause of Margaret’s psychiatric episode, she had immediately been admitted to the hospital and was under a doctor’s care.

  As I checked on her health status soon after her admission, I learned that she was not improving. I asked for the name of her treating psychiatrist and placed a call to him. Because of privacy rules I understood that the doctor could not provide any patient information to me, but I could provide him with information about Margaret that might help him to understand the direness of the situation.

  I explained to him that Margaret is well known to the court and had been living at the Cottages for close to a year. I summarized Margaret’s capabilities, talents, and love of tennis. But I could tell that her doctor was getting frustrated.

  “Judge, the woman is ill,” the doctor said. “She is diagnosed with schizophrenia, which means she is ill. What do you want?”

  His voice carried such a clear tone of disrespect that I became incensed. I took a deep breath, forcing myself to pause. Perhaps the doctor was busy, but he did not seem to be listening to what I was trying to communicate, namely, that I cared deeply about this woman, and she was obviously not getting better.

  “What do I want, Doctor?” I asked. “I’ll tell you what I want—I want you to treat this woman properly and understand that she has been living an active and quality life! I want you to treat this woman so she isn’t ill anymore.”

  I thought about Margaret’s first court appearance and her story about being abandoned by her date at an expensive restaurant on Las Olas Boulevard in Fort Lauderdale. She had made such a lasting impression on the court. This was the first time I could recall hearing a diagnosis of schizophrenia.

  I immediately called Pam Galan, a registered nurse and the chief operating officer of the Henderson Behavioral Health Center.

  “I need your help on behalf of one of Henderson’s mental health consumers,” I said as soon as she answered the phone. I discussed my concerns with Pam, sounding more like a member of Margaret’s family than a judge who had presided over her case. I suggested that a second opinion on Margaret’s diagnosis was needed. This was a request that, as a judge, I have had to make when I feel additional advocacy is required. Providing such advocacy for those in need is a stated mission of the court.

  “Let me review the situation and I will get back to you,” Pam said.

  I thanked her, but intuitively I had a negative feeling. I was not sure what had happened to Margaret, but whatever it was it seemed serious.

  After a couple of hours, Pam called me back.

  “Judge, I spoke with the charge nurse and reviewed Margaret’s chart and the psychiatrist’s orders,” she said. “I believe that Margaret is being treated properly.” Pam explained that Margaret was very ill when she was admitted to the hospital, and they were having difficulty stabilizing her.

  My voice was breaking as I tried to argue with her. “Pam, please . . . is there any way to get a second opinion?” I struggled to hold back the tears.

  “Judge, let me see what I can do,” Pam replied.

  Within a matter of days, Pam called me back. She wanted to let me know that she did arrange for a second opinion and that the reviewing psychiatrist believed Margaret�
�s diagnosis and resulting treatment plan was appropriate.

  That Friday, as soon as court was over, I got into the car and drove over to the Cottages. I did not announce my visit. I pulled into the long U-shaped driveway in front of the pale-green cottage that housed the administrative office. I just wanted to spend some time with the residents. I was sure they would be as concerned as I was about Margaret’s status. The Cottages had grown into such an intimate, supportive community that it was almost like a family. And, like family, it was important to support one another.

  When I entered the administration office, I learned that some of the residents were at group, and a few were working, but I took a seat in the living room and chatted with one of the staff members. Within a few minutes, Sharon walked in. The look on her face told me that she was surprised to see me.

  “Judge! What are you doing here?” she asked. “It is so great to see you.”

  “Did you hear about Margaret?” I asked. We sat together on the almond-colored couch and I updated her on my concerns and the information that I had received from Pam. Clearly, everyone was worried.

  “I should show you what the residents have done for Margaret,” Sharon said after I had finished speaking. Sharon led me outside and we walked down the pine-tree-lined block to the pink house on the cul-de-sac. There were four people to each cottage, and every home had its own identity, which reflected the collective personality of its residents.

  When we approached Margaret’s house, I could see the other residents had made a welcome-home sign out of colored soap across the front bay windows. When we walked in, there were personalized welcome-home notes and drawings hung on the walls around the living room area. A vase of homemade multicolor tissue paper flowers in a plastic vase sat in the center of the kitchen table.

  I was overwhelmed but not surprised about the outpouring of love of the residents for Margaret. She had touched the lives of Cottage residents the same way that she had touched the lives of everyone in the mental health court—and the way she had touched my own.