Often it starts with a call for help. A family member, a caretaker or even a stranger dials 911 seeking paramedics to treat someone in a psychiatric crisis. But when there's a threat of violence, the first responders are usually police, and what started as a call for help can quickly turn deadly for a person with a treatable illness.

That's what happened when Christine Goias called 911 seeking help for her son, 34-year-old Errol Chang, who was in the midst of a schizophrenic breakdown at his father's Pacifica home in March.

"He has paranoia and he's thinking people are wanting to assassinate him, and now he doesn't trust anyone," Goias told the dispatcher.

She said her son wouldn't go with them in the car and, in response to a question, said that he had a "little ax" in his pocket. "I hoped that they would be able to come and help us to take him to the hospital," Goias said.

Errol's brother, Matt Chang, said that when police arrived he was with Errol in the backyard, trying to calm him down. Responding officers from Pacifica were trained in crisis intervention, according to San Mateo District Attorney Steve Wagstaffe's review of the incident.

Matt Chang said police told his brother they were there to help, and his brother responded that he didn't want their help.

A series of escalations led Chang to barricade himself inside the house. The Daly City SWAT team arrived with assault rifles and an armored car.

According to the DA review, police were worried Chang might find a .22-caliber rifle and ammunition hidden separately in the house. The SWAT team held their assault rifles trained on the house and took cover behind the armored car.

Over a loudspeaker, an officer droned a repeated message for Chang to come outside. No response. Police threw flash-bang grenades into the house trying to scare Chang outside and, at one point, threw a phone through the window, but Chang didn't answer it.

"People with schizophrenia, they’re afraid people are trying to hurt them, which is why my brother was armed," Matt Chang said. "They need to feel safe. Holding 20 AR-15s at this person, with a tank and all the stuff, and then throwing flash grenades, it doesn't make them feel safe."

More than six hours after Goias called 911, Daly City SWAT officers breached the house. Chang had built a barricade in the hallway. Two officers climbed over a mattress and furniture and ran into Chang, who was now holding a knife and stabbed an officer in the arm.

The SWAT officers shot Chang eight times in the chest, killing him.

The DA review found the shooting was legally justified, and commended the two officers involved in the shooting for their attempts to avoid that outcome.

And, Again

Less than three months after Errol Chang was killed, 18-year-old Yanira Serrano-Garcia was shot and killed by a San Mateo sheriff's deputy in Half Moon Bay, 14 miles south of Pacifica.

Serrano-Garcia's brother called seeking medical help. His sister was refusing to take medication prescribed for schizophrenia and was arguing with her parents.

But before sheriff's Deputy Menh Trieu arrived at the family home, Serrano-Garcia took her medication and had calmed down, according to her brother's statements to the dispatcher.

According to the San Mateo DA's review of the shooting, when the deputy arrived, Serrano-Garcia burst off the porch and chased him with a kitchen knife. He fired a single shot into her torso, killing her.

“They not only killed Yanira, they killed the entire family,” Serrano-Garcia’s mother, Carmen Garcia, told reporters in Spanish, at a press conference announcing a civil rights lawsuit against San Mateo County and Trieu. “The goal is to prevent any other family from suffering this kind of pain.”

The DA review found the shooting was legally justified.

By The Numbers

Shootings like these have recently gained national attention. The fatal shooting in March of a man with a history of mental illness in Albuquerque, New Mexico, led to explosive street protests and preceded the U.S. Department of Justice's findings that the city's police department was too quick to use force on mentally ill people.

A 2013 report by the Treatment Advocacy Center and National Sheriffs' Association estimates half of the people shot and killed by police in the U.S. "have mental health problems," and as many as one-third of officer-involved shootings are attempted "suicides-by-cop."

According to a media review, this year in the Bay Area there have been at least seven fatal police shootings of people in psychiatric crisis.

Additionally, a KQED review of 51 San Francisco officer-involved shootings between 2005 and 2013 found that 58 percent -- or 11 people -- of the 19 individuals killed by police had a mental illness that was a contributing factor in the incident.

There are common elements in many of these instances when a fragile situation turns life-threatening for a person in crisis: That person often has a weapon, police issue commands, the person becomes more agitated, police respond with force.

That very police response, however, is the subject of a civil rights lawsuit stemming from a non-fatal shooting by SFPD in 2008. The outcome of the case could expand the rights of the mentally ill in confrontations with police.

The Mission District Case

It seemed obvious from her behavior in August 2008 that Teresa Sheehan hadn't been taking her medication. She had been wearing the same clothes for a week and had stopped eating, according to comments a social worker gave to police.

Sheehan's own lawsuit says she had stopped showing up for house meetings at the Mission District co-op for people with mental illness, where she lived.

According to a report to the city's police commission, when the social worker entered Sheehan's room one morning to check on her, she threatened to stab him.

The report says when police arrived, she threatened them, too. They withdrew into the hallway, and she locked herself in her room.

Officers then prepared to re-enter her room by force, the report says. They drew their guns. They broke in her door. Sheehan had the knife over her head, and she began advancing toward them.

According to the police report, when Sheehan was about 3 feet away, Officer Katherine Holder shot her. Sgt. Kimberly Reynolds shot her. Sheehan then fell down, says the lawsuit, or she lunged, says the police report. Reynolds shot her again.

Sheehan survived and was charged with multiple counts of assault. A jury cleared her. She filed a federal civil rights suit alleging violations of the Constitution and the Americans with Disabilities Act.

Here's the question before the court: If police know they are dealing with a person with mental illness, and they use confrontational tactics that can agitate the person, are they violating the Americans with Disabilities Act?

The 9th U.S. Circuit Court of Appeals ruled that the ADA applies to police conduct when arresting people with mental illness. That ruling was appealed to the U.S. Supreme Court, which has not decided whether it will hear the case.

If the 9th Circuit's ruling stands, it could require police departments to provide specialized training to officers in how to interact with people with mental illness, said Ben Nisenbaum, Sheehan's attorney.

"You've got to be trained in how to deal with people who suffer mental disabilities," he said. "It's not something that's kind of optional."

The state of California doesn't require police to have special training in responding to psychiatric crises. Even so, most large Bay Area police departments have adopted a model aimed at reducing fatalities and diverting people with mental illness away from the criminal justice system and into treatment. It's called a Crisis Intervention Team, or CIT.

Crisis Intervention Team

The Oakland Police Department hosts CIT training for all Alameda County law enforcement departments that have CIT programs.

At a training earlier this year, Oakland police Officer Doria Neff, the department's CIT coordinator, didn't waste time introducing the goals of the course to a room full of cops, deputies and probation officers.

"Am I going to ask you to become a social worker? Absolutely not -- that's not our role," she said. "Do I ask that you open your eyes a little bit and be a little bit more empathetic to folks with mental health challenges? Yes."

At the police academy, officers get six hours on people with disabilities. Neff told the class CIT training is like that, on steroids. For the rest of the week, officers got a crash course in psychological disorders, psychiatric medication, street drugs and de-escalation.

Officer Jeff Shannon, Berkeley Police Department's CIT coordinator, teaches that part of the class.

"De-escalation is a cornerstone of the training," he said, "because we know the vast majority of police interactions can be managed without the use of physical force."

Shannon is also a licensed therapist who spent 15 years working with people in crisis in the community mental health system before becoming a police officer. He didn't learn about CIT until after becoming an cop. He wrote the proposal for Berkeley to adopt the program, which they did in 2011 when Oakland hosted its first class.

"The way that we ask officers to calm people down is to be a calming force themselves," Shannon said. "That starts with the tone and inflection of your voice and your nonverbal behavior."

Officers in CIT class learn that nonverbal cues -- like speaking in a soft voice, slowing down and resting a hand at one's side instead of on one's gun -- are likely more important that what they're saying. The reason has to do with the hierarchy of the human brain.

Berkeley clinical psychologist Mitch Radin teaches that, in a crisis, the more evolved, cognitive parts of the brain get overruled by the more primitive amygdala, which is responsible for emotional reactions.

"You can only hope for agreement, not understanding," Radin said.

Radin asked the class why police officers generally dislike responding to mental health calls. The answers varied: "They're unpredictable." "What's the point? They're going to be out before I finish the paperwork." "The frustration is with the lack of resources to give them what they need."

That last response rings true for Radin.

"The mental health system in America is distressing," he said during a class break, and after a sigh of frustration. "I don't think police officers would be dealing with these mental health crisis situations nearly as much if there were more resources out there."

Few departments, if any, track how often officers respond to mental health crises. But, anecdotally, officers often report they respond to more 5150 calls every year. That's shorthand for California's Welfare and Institutions Code 5150, which allows peace officers and some mental health workers to take a person into custody who is a danger to themselves or others due to a mental illness.

Shannon says he has responded to hundreds of these calls.

"If I'm on a 10-hour patrol shift, there's a good chance I'm going to place someone on a 5150 hold," he said, "and sometimes it's just call after call that seems to be someone in a psychiatric emergency."

Crisis Intervention Training has been around since 1988, when it was developed in Memphis, Tennessee, after an officer-involved shooting of a man with mental illness.

The goal of the Memphis Model is to establish a specialized unit of officers with in-depth training in mental illness and in tactics more likely to resolve incidents without injury. CIT also aims to strengthen relationships between police and mental health providers so officers can more easily take people in for treatment instead of to jail.

It's not new, but departments in the Bay Area are just beginning to implement it.

Slow Uptake at the SFPD

The San Francisco Police Department adopted the Memphis Model of CIT in 2011, after three years in a row in which every person killed in a police shooting had a mental illness.

But it’s clear implementing the program hasn’t been fast or easy.

Three and a half years into the program, the department has trained about 18 percent of its patrol officers. Ideally, somewhere between 20 and 25 percent of officers are trained, with the goal of at least one trained officer at each station for each shift.

Finding the right officers for the training hasn’t been easy, and that’s true anywhere, said Major Sam Cochran, who founded CIT while at the Memphis Police Department.

“There are some officers that are not ready to be CIT officers,” said Cochran, who is now at the University of Memphis. “They don’t have the experience. Some officers don’t have the maturity level.”

In some cities, like Berkeley, the program is so valued that officers must compete to get in. But as it launched in San Francisco, few officers volunteered, and station chiefs simply had to choose who got sent to training. Cochran says it’s the the role of a police chief to elevate the status of the team so officers want to be a part of it.

"That chief needs to make sure that those men and women understand that they have an identity and that they have a role," Cochran said.

Cochran’s model calls for CIT to be a specially trained and cohesive team within the department. In an interview with KQED, San Francisco Police Chief Greg Suhr said he’d prefer it not to be a separate team.

"Police officers by nature find niches," Suhr said. "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."

That’s how SFPD Commander Richard Corriea once felt. He’s the third person to lead SFPD's Crisis Intervention Team in three years.

“I’m a convert on the issue of team,” he said. “I think it inspires officers who are engaged in this. They have a special skill. It makes them feel part of something. And the outcome is better and better service.”

A team creates a feedback loop, said Angela Chan, a former police commissioner who spearheaded the program. The unit is supposed to learn from each response. It allows officers perfect their skills, share information with other CIT officers and establish strong relationships with mental health providers.

But in the beginning that didn't happen much, say mental health advocates -- not when the role of the team wasn't fully supported inside the department, and so few officers were trained. Added to that, there was also no official way to dispatch CIT officers to a scene.

While the Police Commission resolution called for 911 operator training and CIT dispatch protocols, getting that to happen wasn’t easy.

San Francisco operators at 911 are under the Department of Emergency Management, not SFPD, and DEM's policy is not to make changes to how it dispatches SFPD officers until it gets a directive from the police department itself.

“What they’ve explained all along is that they follow the direction of the San Francisco Police Department, and so whenever SFPD is ready, they’re ready,” said Chan.

SFPD wasn’t ready for more than three years. In late April 2014, Suhr issued the directive. Now, 911 operators are trained to recognize CIT-appropriate calls and to issue certain radio codes to send a CIT officer to the scene.

It’s hard to know whether CIT is helping reduce violent encounters between police and people with mental illness. Data collection -- also mandated by the resolution -- has taken a back seat as the department worked to catch up on training officers and creating a dispatch policy, which it has done under Corriea's leadership.

Studies from elsewhere indicate CIT shows promise in reducing fatal incidents. One 2008 study published in the journal Psychology Services found CIT officers were less likely to use force, even when facing a threat of violence.

An Internal Affairs review shows that in the first three years of the program, three of the seven people killed in San Francisco police shootings had a mental illness. That’s about the national average, which includes departments with and without CIT.

Several years down the road, SFPD has now trained a corps of officers and organized dispatch. Corriea is planning the next step: how to get people into services instead of taking them to jail.

Still, there are likely numerous Bay Area jurisdictions without CIT. There aren’t numbers for California, but nationwide only about 15 percent of law enforcement agencies have CIT programs. That leaves thousands of people with mental illness in the Bay Area subject to the actions of police who aren’t trained to help them.

Part of the information present below comes from this SFPD Officer-Involved Shooting Memo.

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