A homeless, mentally ill man walks into a Decatur restaurant, makes a loud disturbance and refuses to leave. As nervous customers look away, the exasperated restaurant manager picks up the phone and calls the police - again.

It has happened before. For reasons known only to himself, the disoriented vagrant is fixated on this restaurant. Each time he returns, the police charge him with criminal trespass. Once in jail, he can't make bond. He is locked up for 60 days - and once released, he ends up at the restaurant again.

This time, however, the cycle is broken.

Within 48 hours of his arrest, a mental health case worker in the jail determines his main problem is a combination of mental illness and homelessness.

On a Thursday morning, he is taken to mental health court.

The assistant solicitor and public defender agree this man needs psychiatric treatment, not more incarceration. With the help of local community mental health workers, they devise a treatment plan and a place for the man to live. He is released on bond - with the condition that he get treatment.

That's one less mentally ill person in jail - leaving one more jail bed for a serious criminal.

"It completely takes the adversarial nature out of the hearings," said DeKalb County Chief Magistrate Winston Bethel. "Everyone's working for the benefit of the (mental health) consumer."

Mental health advocates say Bethel's court is an example of the innovations that could provide recovery instead of incarceration for Georgians with mental illnesses.

Others include:

• Aggressive outreach efforts called ACT, short for Assertive Community Treatment. Instead of waiting for clients to come to a clinic, ACT teams seek people with mental disorders and treat them where they live.

• Better housing and employment services to ensure that people with mental illness have a decent place to live and something meaningful to do with their lives.

• More substance abuse services for people who have a combined mental illness and drug problem.

There is an ongoing debate about another approach as well: Strengthening laws under which a court may order a mentally ill person to receive treatment, whether in a community setting or a hospital. Some advocates believe it's an essential tool, while others in the mental health consumer movement believe it is unnecessary.

Most of these things are being tried on a small scale somewhere in Georgia, but none has yet become widespread.

Mental health courts

One of the most talked about alternatives is the mental health court, pioneered in Broward County, Fla., and King County, Wash. Georgia has two mental health courts, in Atlanta and DeKalb County.

Bethel says advocates and court officials started the pilot program in his county "because jails are becoming the repository for people who are mentally ill."

His court, funded by a three-year federal grant, targets suspects who are arrested for nonviolent misdemeanors when there is some indication that they suffer from a mental illness.

"Once the system becomes aware of that at any stage, from a police officer to the booking procedures, their name is given to our pretrial coordinator," Bethel says. Within 48 hours, staff from the DeKalb County Community Service Board evaluate the prisoner and recommend a treatment plan, if appropriate.

"Housing is always the biggest problem," Bethel says. "We exhaust whatever means to locate a place for the individual."

Once treatment and housing are lined up, the defendant is released on a signature bond, on the condition that he or she complies with the treatment plan.

"The carrot is that if they're able to do this, then the charges would not be prosecuted," Bethel says.

Dr. William Brickhouse, director of mental health in the DeKalb County Jail, says the special court has begun to reduce his caseload.

"I do see an impact," he says. For example, in a recent session the court ordered three misdemeanor defendants into treatment instead of jail. Community mental health workers were on hand to craft a plan the court could agree with.

"If the court were having an impact on 10 people a month, those are 10 people who didn't get that before," Brickhouse says.

In the Atlanta Community Court, Judge William F. Riley has statistics to show that mental health courts and drug diversion courts reduce recidivism rates.

In the first half of 2001, the Atlanta court's clinical evaluator assessed 134 mentally ill defendants. Two-thirds of them had a dual diagnosis of mental illness and substance abuse. The court was able to divert 60 percent from jail to community treatment.

A similar approach is in its infancy in Bibb County.

"The concept of a mental health court is good," says State Court Judge Bill Adams. "I support the concept 100 percent."

On a limited basis, Adams has worked with Sheriff Jerry Modena and the staff of River Edge Behavioral Health Center to divert jailed mentally ill people into treatment.

"We've had a number of folks who we've identified as candidates for some kind of mental health or substance treatment that's available - or if it wasn't available, as soon as it was, (we would) get them out of jail on the condition that they go into that treatment facility," Adams says.

Adams believes more diversion courts, coupled with more treatment options, could have an impact.

"It's up to the Legislature, ultimately, to find a more dependable source of funding," he says. "This is a statewide issue."

Gov. Roy Barnes requested money in the 2001 legislative session to set up more mental health and substance abuse treatment courts. The money was deleted during budget negotiations. This year, Barnes has not requested any funds for treatment courts. Mental health advocates hope to persuade legislators to find the money to pay for more courts and the services to support them.

Assertive outreach

More than 20 years ago, mental health officials in Madison, Wis., pioneered a new approach. Teams of doctors, nurses and social workers would go out and find people with mental illness and treat them where they live. The approach has come to be called the "Madison Model."

Social worker Dave DeLap runs the Community Treatment Alternatives program for the Dane County Mental Health Department in Madison. He operates one of several PACT teams - short for Program for Assertive Community Treatment. His team is specifically geared toward treating mentally ill people who face criminal charges, and keeping them out of jail.

"There really has been a tremendous reduction in the number of days people spend in jail when they get the treatment they probably should have gotten all along," DeLap says.

He says that after a year of PACT treatment, his clients' time in jail drops 73 percent, compared to the years before they were treated.

His program costs an average of $8,500 per client per year, less than half the average annual cost of jailing an inmate in Dane County.

Advocates have lobbied for similar services in Georgia for years. But not until this year have community mental health agencies been able to bill such services to Medicaid. After years of lobbying, state officials finally chose to use the "rehab option" of Medicaid reimbursement.

"Under the rehab option, the providers have a number of services they can deliver in community settings where people live," says Cherry Finn, chief of adult mental health services in the Department of Human Resources' Division of Mental Health, Mental Retardation and Substance Abuse.

The services include Assertive Community Treatment teams. With low caseloads - one staff member to 10 clients - the team is supposed to operate 24 hours a day, seven days a week.

"I think it will impact the consumers who have been running into problems with law enforcement agencies," Finn says. "It isn't necessarily making a huge impact at this point because we're four months into the (fiscal) year."

But some community agencies that provide mental health services say they still can't afford ACT teams. Local mental health directors say instead of having more money for new services, Georgia's "revenue maximization" plan for Medicaid reimbursement has left them with less money than before. Under the plan, the state withheld $23.4 million in community mental health funds and instructed the community centers to increase their Medicaid billing.

DHR Commissioner Jim Martin acknowledges that there have been problems putting revenue maximization to work. But he expects that will turn around.

"Ultimately," he says, "if we can keep state dollars in the system - and this is really critical - the revenue maximization will help us to address this problem."

For the treatment teams and court diversions to make an impact, advocates say indigent clients need a home and a meaningful daily occupation.

"We can go into the community and deliver mental health services, but if they don't have a place to live and something to do to keep them occupied during the day, they will run into trouble," says Karen Bailey-Smith, director of forensic services for the state mental health system.

But finding resources for housing or ACT teams or other innovative approaches has been nearly impossible.

As Bailey-Smith put it, "Unfortunately, the funding for services for mental health in Georgia has not increased in 10 years."