MIAMI -- The front lines of the mental health crisis unfolding in Miami-Dade County -- home to the nation's largest ratio of people living with a serious mental illness in an urban community -- are not in the psychiatric hospitals and behavioral counseling centers where patients seek help.
They're in the county's jails and courthouses, and on its streets, mental health advocates say. And very often, when an adult in Miami-Dade experiences an acute psychotic episode, the first person to respond is a police officer.
Many times, those encounters have proven tragic. Since 1999, more than 25 people with a serious mental illness have died during an encounter with police in Miami-Dade.
Those who weren't killed would cycle through the criminal justice system, trapped in a revolving door of arrests, usually for petty crimes, followed by court hearings, then mental competency evaluations and ultimately to jail or back on the streets.
"There was no system to do anything with them," said Miami-Dade County Judge Steve Leifman, who has become one of the nation's foremost authorities on the criminalization of mental illness. "This went on for years."
Each year, about 11.4 million people are booked into local U.S. jails, where on any given day 745,000 of them are held. About 16.9 percent of jail detainees have a serious mental illness, which means nearly 2 million people with such illnesses are arrested each year.
With private insurers often refusing to pay for mental health care, and Florida ranking at the bottom among states in funding for public mental health programs, the Miami-Dade County Jail became the largest psychiatric warehouse in the county -- symbolized by the notorious ninth-floor ward, which was closed in January 2015.
Among those found guilty of a crime, people with mental illnesses were staying in jail four to eight times longer than someone without a mental disorder, for the same charges. The costs to Miami-Dade taxpayers were staggering.
"We were spending $218,000 a day," he said, "which is about $80 million a year to warehouse people in these really sub-par conditions."
But things began to change in 2000 after Leifman, working with local law enforcement, mental health providers and community leaders, launched the Criminal Mental Health Project or CMHP -- a program that diverts people with mental disorders out of the criminal justice system and into community treatment.
There are now fewer people incarcerated in Miami-Dade jails, from a peak average of about 7,000 in 2008 to about 4,700 in 2014. More than 4,600 police officers have received special training for identifying and handling individuals with mental illness. And the county has saved millions by diverting people with mental disorders out of the criminal justice system.
The program's success has earned Leifman accolades from the U.S. Supreme Court, and this month the New England Journal of Medicine held out the CMHP as a Miami model for the nation.
Still, a lot of work remains.
By Leifman's count about 192,000 adults and 50,000 children, or 9 percent of Miami-Dade's population, has a serious mental illness, such as schizophrenia, bipolar disorder and severe depression. Yet, only about 1 percent or an estimated 26,000 adults, receives help in the public mental health system.
Because Miami-Dade also has rising HIV/AIDS rates, more deaths from heart disease and diabetes than Florida averages, and the greatest number of uninsured working-age adults in the state, the county's mental health crisis has taken on greater urgency.
"There's a lot of people with mental illnesses still in our system," Leifman said. "We're getting better, but it's still too many."
The CMHP got a boost from the Florida Legislature and Gov. Rick Scott this year, who approved a bill sponsored by Sen. Miguel Diaz de la Portilla, a Miami-Dade Republican, that will make the program a statewide model.
"My bill creates a framework for mental health and the courts throughout the state," Diaz de la Portilla said. "These are people who don't belong in jail. They're non-violent."
The bill also gives county judges the authority, beginning on July 1, to order defendants with mental disorders into treatment. Leifman said 80 percent of defendants offered a chance to enter the program take it.
Those who choose to enter the CMHP receive a mental health treatment plan, temporary housing, and public assistance, from Medicaid to Supplemental Security Income, if they qualify. They are also assigned a peer specialist who guides them through treatment.
Leifman said the recidivism rate for defendants in the misdemeanor program has been reduced from 75 percent to about 20 percent a year, with repeat offenders typically being people who are incompetent to stand trial. The recidivism rate for people who complete the program after being charged with a felony is 6 percent compared to an 86 percent repeat offense rate nationally for persons with severe mental illnesses.
One of the program's success stories is Justin Volpe, 32, who said he might be in jail or on the streets with no effective treatment for his mental illness were he not diverted through the CMHP in 2007.
A graduate of the program, Volpe is now one of seven peer specialists who helps guide others through treatment and toward a stable life.
"It's really helped my recovery," he said of helping others. But it wasn't easy for Volpe to get to this point.
Diagnosed with a mental illness while involuntarily hospitalized in New Jersey in 2006, Volpe said he was arrested the following year in Miami Beach after an argument with a co-worker at a restaurant led him to take that person's bag and throw it in the trash.
4,600 Police officers in Miami-Dade who have received Crisis Intervention Team training
Volpe said he was prescribed medication for his psychiatric diagnosis, which he declined to reveal for fear of being stigmatized. Like many people with mental illness, though, Volpe said he began to feel better from the medication and returned to his old habits, including drinking alcohol and using cocaine and marijuana.
"I thought I was cured," he said. "I felt better, thought I could get high again."
Volpe said he was experiencing paranoid thinking and delusions when he got into the argument with his co-worker. After his arrest for grand theft -- the bag had expensive jewelry in it -- Volpe said he was sent to the ninth-floor psychiatric ward of the county jail, where he spent three weeks.
The experience only traumatized him more, Volpe said. He shared a cell with a violent felon who had stabbed his wife in the chest with a pair of scissors, and showed him the pictures from his case file. He heard guards pummeling inmates. And he was given fistfuls of pills without knowing what he was taking.
His parents, though, had begun to petition the court for leniency because of his diagnosis of mental illness, leading the judge to reduce Volpe's charge to petty theft and offer him a chance at the diversion program.
"After what I had just experienced," he said, "I said, 'Yeah.'"
Volpe said he struggled to overcome substance abuse, and often felt overwhelmed trying to help others with mental illness while still battling his own demons. But getting sober, married and adopting a healthy lifestyle has helped, he said, and Volpe now regularly speaks to groups of people recovering from the same things that once held him down.
"I feel like I'm giving back," he said.
Feeling like a member of the community is an important step not just for recovery but in seeking help for mental illness, said Harley Tropin, a South Florida attorney and mental health care advocate.
"One of the major barriers to seeking treatment is the stigma and embarrassment," said Tropin, who helps underwrite Shatter the Stigma, a campaign to raise awareness and funds to support mental health research and services by the University of Miami Miller School of Medicine. "That is a huge barrier to many of them seeking treatment and harboring feelings of shame instead of them and their families obtaining health care."
For police officers in Miami-Dade, the CMHP has made a difference in how they approach people with mental illness, said Habsi Kaba, who leads the Crisis Intervention Team or CIT training, a 40-hour course that teaches police how to identify signs of psychosis and how to de-escalate situations.
Kaba said CIT training has led to reductions in police officer injuries and use of force. For every 5,000 CIT police calls, typically 10 to 20 lead to arrests, according to program data. By comparison, for every 5,000 regular police calls, there are typically 400 to 500 arrests.
Sgt. Maria Bustamante of the Miami-Dade police said the training helps her decide whether or not a person needs to be arrested and taken to jail.
"We're the ones who have to deal with individuals in the street," she said. "CIT helps us out tremendously because once you have that person in custody, then what do you do with them?"
Typically, police officers will take a person with a suspected mental illness to a receiving clinic where they are involuntarily held for evaluation.
When Sgt. Norberto "Bert" Gonzalez started as a Miami-Dade police officer in 1983, he said there were three receiving facilities in the county for people with mental illness. Now there are 17, in part because CMHP has helped coordinate services.
"We're leaps and bounds over where we were when I started," Gonzalez said.
In about two years, Gonzalez and other police officers in Miami-Dade will be able to take people with suspected mental illness to a new Mental Health Diversion Facility, which was once home to the South Florida Evaluation and Treatment Center.
Leifman envisions the facility will be a "one-stop shop" where defendants with mental illness will be able to walk in and get counseling, medication, vocational training in culinary arts, or help with government benefits. He anticipates the facility will house 16 crisis stabilization beds and about 190 longer-term residential beds where patients can stay for up to 90 days while they get help reintegrating into society.
Those who achieve recovery will continue to face challenges, though, including a depth of ignorance about mental illness that in the past, Leifman said, made it difficult to get funding for programs and pass laws that would help address the problem.
"These are organic brain illnesses," Leifman said. "Recovery rates for people with mental illness are actually better than for people with diabetes and heart disease. The key is identifying the illness early, just like any other illness, and treating it early. The outcomes are much better when you do that."
Miami-Dade and City of Miami police officers responding to calls involving persons suspected of having a mental illness have led to fewer arrests due to Crisis Intervention Team (CIT) training that teaches them to identify symptoms of psychosis and how to de-escalate situations.