[Hpn] Mental Cruelty in San Francisco

chance martin streetsheet@sf-homeless-coalition.org
Fri, 15 Jun 2001 13:52:12 -0700


>From sfweekly.com
Originally published by SF Weekly June 13, 2001
©2001 New Times, Inc. All rights reserved.
{ http://www.sfweekly.com/issues/2001-06-13/feature.html/page1.html }

Mental Cruelty 
Michael Wise and Susan Owsley are recovering schizophrenics who got the
right kind of help, and got off the street.The mayor's secret budget cuts
will make sure that doesn't happen anymore.
By Peter Byrne 

Michael Wise spent his childhood in the Potrero Hill projects. His
manic-depressive father, a Yellow cab driver, was in and out of state mental
hospitals, where he was repeatedly treated with electroshock therapy. "My
dad was not emotionally demonstrative," Wise says. "At home, he hid behind
the newspaper, not saying much. He wanted to feel that he was better than a
cab driver. When he was manic, he fancied himself as a businessman -- which
he wasn't. He drove my mother crazy. After a while, our family fell apart."

Wise studied journalism at Washington High School, writing a column for the
school newspaper called Wise Cracks. After graduation, his world went mad.
"The times were schizophrenic," Wise remarks. "With political assassinations
and race riots and Vietnam, people were paranoid. Drugs became popular. I
did them to fit in."

But Wise did not fit in. When he used drugs, bad things happened. Voices
commanded him to walk randomly for hours on end, to snatch purses, to break
into houses. In 1968, he was diagnosed as a paranoid schizophrenic. Doctors
at St. Mary's Hospital put him on neuroleptic drugs -- Thorazine, Stelazine,
Haldol -- to control his hallucinations. The side effects, called tardive
dyskinesia, were devastating. Wise's jaw locked up, his tongue lolled, his
mouth sucked involuntarily, his body jerked.

Like many mentally ill people, Wise hated taking the anti-psychotics. He
learned to medicate himself, instead, with street drugs. Occasional bouts
with amphetamines, however, triggered episodes of bizarre behavior that
landed him in jails and locked psychiatric wards. But during his terrible
journey, he had moments of lucidity, and he used them to hook himself into
San Francisco's welter of mental health treatment programs. He found a place
in supportive housing for the mentally ill (that is, residences with social
workers on staff). He received psychotherapy. He worked, off and on, as a
mail handler for the United States Postal Service, which made him eligible
for federal disability payments and medical insurance.

A few years ago, a psychiatrist hit on the right combination of psychotropic
drugs; these particular "meds" produced no side effects in Wise, but reduced
his level of anxiety, quieted the voices, allowed him, finally, to fit in.
"My diagnosis got an upgrade," Wise chuckles, "from paranoid schizophrenic
to schizoaffective, whatever that means." Like many recovering
schizophrenics, Wise says his newfound ability to live in the world can be
attributed to better drugs and to community care programs, especially
self-help programs for the mentally ill.

As Wise, 52, tells his story, it is clear that he is a thoughtful man who is
deeply committed to improving the lot of his fellows. And, indeed, Wise is
doing his bit to raise public awareness about mental illness; he edits,
publishes, and hand-distributes a four-page glossy newsletter, Voices at
Bay, that is packed with news, views, poetry, and art made by and for the
mentally ill. "I had a good idea, and I ran with it," says Wise proudly.

In ugly reality, though, Wise is a rare type of being in San Francisco's
mental health universe, and because the city of San Francisco has in recent
years made drastic, disguised cuts in mental health services, his type is
becoming rarer by the month.

------------------------------------------------------------------------

In the late 1960s, as part of a national trend, then-California Gov. Ronald
Reagan "de-institutionalized" the state's mental hospitals. While these
locked institutions generally kept the mentally ill out of society's sight,
investigative journalists had reported that the hospitals were often
hellholes that held sane people, such as conscientious objectors and
rebellious teenagers, alongside untreated schizophrenics. When hundreds of
thousands of liberated patients hit the nation's sidewalks, local
communities, helped by state and federal funding, were charged with
providing shelter and psychiatric treatment for them.

By many measures, adequate community support failed to materialize, which is
the main reason why America's inner cities teem with mentally destabilized
homeless people. In San Francisco, studies show that about 5,000 homeless
people suffer from serious mental illness; half of them receive little or no
treatment. The homeless are simply the most visible group in the mentally
distressed population, which is much larger than most people think it is.
The California Mental Health Planning Council estimates that San Francisco
contains 65,000 very mentally ill people, of whom the majority are not
receiving any form of treatment, public or private. The city-run mental
health system currently serves 22,000 poor people (up from 19,000 when Mayor
Willie Brown took office).

Dr. Robert L. Okin, chief of psychiatry at San Francisco General Hospital,
says that the public mental health system is endangered, because city
government keeps eliminating the jobs that are supposed to make it work.
Public records and scores of interviews with mental health workers and
patients show that, in fact, massive staff reductions ordered by Mayor Brown
are edging San Francisco's mental health system over a health precipice. The
city's psychiatric wards are overburdened because city money is being
diverted from community mental health care clinics that help tether
outpatients to reality.

The cuts in city mental health services are an extreme example of a
secretive budget process the mayor has visited on many city departments.
Every year since 1998, Brown has ordered all departments to submit "flat"
annual budgets for his approval. Such budgets do not account for price
inflation, and they also fail to account for the growing demand for services
that results from a growing population. As if flat budgets were not bad
enough, the ranks of city employees who treat the seriously mentally ill
have been drastically thinned by use of a sharp bureaucratic knife known as
"salary savings." Here is how salary savings work: A department budget
appears on paper with (for example) $10 million for 200 jobs, at $50,000
each. To meet the mayor's order to create salary savings of, say, 10
percent, 20 jobs are budgeted on paper, but left vacant in reality, thereby
freeing up $1 million. The million dollars "saved" might be used to increase
pay for the remaining 180 jobs, or, depending on the politics of the moment,
it might be returned to the General Fund for use at the discretion of the
mayor and the Board of Supervisors. In any event, the department's official
budget appears to be $1 million larger than it really is.

In explaining why the city uses the salary savings technique to cut budgets,
a finance officer with the Health Department said it is a political tool
that the mayor and the Board of Supervisors use to pump up their pet
projects. Mental health programs have been hit disproportionately hard by
Brown's salary savings regime. According to the City Controller's Office,
the Department of Public Works is required to leave just 3 percent of its
positions vacant, which is less than the normal job attrition rate of 4.5
percent. Community Mental Health Services, on the other hand, is currently
required to keep salary savings above 12 percent. Dozens of jobs were
deliberately left vacant over the last three years as workers retired, quit,
were promoted, or transferred. Seventy percent of those vacant positions are
clinical, i.e., psychiatrists, nurses, social workers, therapists. For
mental health services, salary savings are, in effect, huge personnel cuts.

Public records show that, last year, $4.3 million in salary savings was
eventually stripped out of the $33.5 million that was approved for mental
health salaries by the Board of Supervisors. In addition, dozens of
nonprofit groups that contract with the city to provide supportive housing
and outpatient programs to the mentally ill are being blasted by flat
budgets. In order to stay alive, they are being forced to eliminate jobs
(and successful programs) and use the "saved" salaries to pay hugely
increased rents and cost-of-living raises to employees who have escaped the
knife. 

The combined effect of civil service and nonprofit downsizing is summed up
in a Community Mental Health Services study: "[T]he loss of capacity to the
system [is] debilitating and counter to our mission to provide
community-based alternatives to emergency and acute hospital based
services." As clinic staffing levels are reduced by as much as half, the
report asserts, caseloads increase for already overworked clinicians, and
patients are turned away. When outpatient centers close their doors, their
clients end up wandering the streets, harassed by voices they cannot
silence, until they are thrown into the overcrowded county jail, or the
locked psychiatric wards at S.F. General.

The crisis generated by the city's flat budget and salary savings policies
caused the San Francisco Mental Health Board to pass a resolution in May,
for the second year in a row, asking the mayor to declare a health
emergency, so that state and federal disaster monies could be tapped for
mental health services. Last year, the mayor declined to sign the emergency
declaration, even after it was approved by the Board of Supervisors.

Mayoral spokesman P.J. Johnston referred questions on mental health matters
to the city's Public Health Department.

------------------------------------------------------------------------

In the stairwell of a slum hotel in the Tenderloin, "Jack" (a pseudonym used
to protect patient confidentiality) argues with his social worker, refusing
to take his daily dose of psychotropic drugs. Anxious, unshaven, he
obsessively cradles a radio. He says the pills are plastic and that they
hurt his arm, which is, indeed, twisted and withered by an old accident.
Today, the social worker is accompanied by Dr. Okin, who sits on a filthy
stair to talk with Jack.

"You'll end up back in the hospital," Okin cautions the middle-aged man.

Jack fears the hospital, but the logic of future events is abstract to him.
He has trouble sleeping in the present. He wants money. Okin focuses on
these concrete needs. He assures Jack that the pills will calm him, help him
to rest. Jack teeters on the edge of decision. He glances slyly at Okin, who
wears a sports jacket.

"Gimme five bucks?" he asks.

Okin pulls out a fiver. "This is for two days of taking the meds, OK?"

"OK," Jack says, gobbling the pills.

Driving back toward San Francisco General Hospital -- and its locked wards,
where Jack is a frequent guest -- Okin comments, "It's hard to know the
experience of being psychotic. The mind becomes the enemy. Nothing makes
sense. Ordinary things are frightening, radios broadcast personalized
messages. 

"But no matter how distressed a person becomes, the ability to hold onto
simple freedoms, some element of choice, becomes utmost in their minds."

Personal choice is often obliterated by public psychotic breakdown. When
someone on the street begins to behave in extremely agitated ways, acting
out horrible delusions and frightening passers-by, police get called, and if
they judge someone to be a threat to him- or herself, or others, they can
"5150": handcuff and transport the subject to S.F. General. (Section 5150 of
the state Welfare and Institutions Code allows involuntary commitment to a
psychiatric institution.) Only the most suicidal or violence-inclined people
spend any significant amount of time on the wards. Clinical staff at S.F.
General say distressed people are often simply sedated and released,
because, as a result of flat budgets and salary savings, the hospital does
not have the beds or staff to serve the 600 people a month who come through
the door. 

The way to reduce the load on the psych ward, says Okin, is to follow those
who have been committed out the door when they are released. He is
nourishing pilot outreach programs, known as Assertive Client Treatment, or
ACT, that target repeat users of the psychiatric wards, such as Jack. Teams
of social workers from the city's three ACT programs visit hundreds of
clients every day, bearing the daily dose of medication and a few bucks for
food. They, necessarily, do psychotherapy-on-the-run, helping their clients
deal with small things that have large consequences, such as teaching a man
how to punch an extra hole in his belt, so his pants stay up.

San Francisco's ACT program follows a national model that has been shown to
be the most effective treatment for impoverished mental cases. Front-line
social workers say, however, that they are able to reach only a small
percentage of people who are, literally, dying for attention. Ever-worsening
staff shortages throughout the mental health system mean that even people
who are reached are not likely to receive the comprehensive medical and
psychiatric attention that they need for stability.

"Sara" is in her late 30s; she's blond and has a penetrating glance. Sara is
typical of the all-too-few homeless women whom San Francisco's mental health
system has been able to embrace. Sitting in an outpatient clinic at General,
she tells her story. "I was the victim of a series of assaults; I
disassociated, hallucinated, became homeless. I locked myself in the
bathroom to sleep because I was very ... vulnerable ... in the shelters. I
used drugs. I got 5150'd to General twice and, also, St. Luke's [Hospital].
Then I met my case manager."

Sara's face glows. "I got better meds. I got a therapist. I got a room in a
house. I learned budgeting and cooking. I learned to fight for my own life,
to ask for help when I need it."

Time and again, ACT clients attribute the beginning of their recovery to the
personal ministration of a trained social worker, nurse, or therapist -- the
very clinicians being purged from the mental health system by salary
savings.

------------------------------------------------------------------------

"Martha" smiles sweetly. "I'm not particularly attached to people. I love
frogs," she says. "See the frog art on the wall? I made that frog art."

A dozen people gather around a table under the frog art. Some are
schizophrenic, some bipolar, some both. All of them are heartachingly
distressed about the destruction of their day treatment center, the Bayview
Clubhouse on Hyde Street in the Tenderloin. The program has lost 50 percent
of its staff and cut back its hours by a third. Its clinic -- the busiest
dispensary of psychotropic drugs in Northern California -- has lost two of
its three psychiatrists. People are turned away daily.

The clubhouse is based on a treatment method geared toward vocational
training. Members run a thrift store, operate a snack bar, assist the
professional cook in preparing and serving breakfast and lunch, do
janitorial and clerical work, act as security, and take computer classes.
Counselors and members work together on these projects and engage in group
therapy and social activities, among them poetry readings. The atmosphere in
the clubhouse is very convivial, very safe.

Rudy Mason, the cook, says that clubhouse meals are the only source of food
for some members. He used to feed 100 people a day. Now attendance is down
by half because the club no longer has the staff it needs to operate at
capacity, he sighs. There used to be a job placement person who got members
half-day work in corporate mailrooms downtown. That position got zapped by
the flat budget. 

Mason frowns. "The worst thing was that for months the members had
trepidation about the situation. When we were forced to close on Saturdays,
they asked me every five minutes if it was the end. Now they have gotten
used to the uncertainty and only ask every few hours."

The clubhouse and clinic are owned by a middleman organization, the
nonprofit Bayview Hunters Point Foundation, which receives $6 million a year
from the city to operate a dozen mental health and substance abuse programs.
The current administration of the foundation has been sanctioned repeatedly
by government auditors for serious financial irregularities. The U.S.
Justice Department penalized the foundation last year after vials of
methadone, a substitute for heroin used in addiction-treatment programs and
abused on the street, went missing. But the foundation's executives remain,
apparently, the darlings of the budget-slashers. For years, the executives
have quietly gone along with Brown's budget cuts, refusing to fill vacant
clinical positions, but giving themselves raises of as much as 24 percent.

The foundation's executive director, Karen Patterson Matthew, wrote a thank
you letter to the Department of Public Health a few months ago: "[F]unds
that were made available though our elimination of particular staff
positions permitted rather impressive salary adjustments throughout our
programs. Everyone is excited."

Perhaps not everyone. Public records obtained from the Department of Public
Health are filled with plaintive letters from the Bayview Hunters Point
Foundation's field workers literally begging high-ranking officials to
restore funding for lost clinical positions. For instance, last December,
Dr. Thomas Ryan, the Bayview Clubhouse psychiatrist, pleaded, "The clubhouse
and other mental health programs are dying. Please do something."

In April, the Public Health Department sent a letter to its mental health
contractors telling them to prepare for significantly greater cutbacks in
next year's budget. This is bad news not just for the clubhouse, but for the
entire mental health outpatient system, which is heavily dependent upon
nonprofit contractors. For example, the Bayview Hunters Point Foundation's
mental health program for children in the Bayview District has seen its
regular clientele diminish from 100 children to 30 during the last three
years. Program Coordinator Diane Scarritt says that since her staff fell
from seven to two psychiatric professionals, suicidal children have been
turned away for lack of counselors. The foundation's adult mental health
treatment program, called Bayview Thunderseed, is also a shambles due to
staff cuts. 

In an interview, Dr. Mitchell H. Katz, San Francisco's director of health,
said that he is working with the foundation to address its problems. Katz
said that the Community Mental Health Services' large salary savings were
put in place by previous Health Department administrations. He said he
spends all the money he is given by the mayor and the Board of Supervisors.

------------------------------------------------------------------------

The home of Spiritmenders, a self-help group run by and for the mentally
ill, is located at the far corner of a damp basement in the Mission
District. Furniture in the dingy office is worn and saggy. An old television
screen is filled with electronic snow. The place can grow on you, though.
Hot coffee steams next to a clutch of cups. People sit comfortably around
the space, chatting about who's in the psych ward, who's sleeping with whom,
how to get into a homeless shelter, where to eat for free. There is little
room for pretension here.

Membership in Spiritmenders, a nonprofit group funded by grants and
donations, is open to "all people who have suffered emotional turmoil
through the firsthand experience of mental health services." There are a few
basic rules: No drug or alcohol use on the premises. No fighting. No
cursing. 

Democratically elected leaders of the group, such as Voices at Bay Editor
Wise, strive to set good examples of behavior for the membership, which
includes people who are hallucinating because they can't get appointments
with a psychiatrist to get medication, people who are tweaking on crack,
people who are lonely, hungry, ready to end it all. Then again, some of the
members have part-time jobs, go to college, live in their own apartments,
serve on community boards as representatives of mental health consumers.

The sense of social ease in the room can be traced to the good work of
clinicians and case managers in San Francisco's community mental health
network. The stable people here are hooked up with therapists, regular
medication, affordable housing, and monthly checks.

Susan Owsley, who wears black half-moons of eye makeup, illuminates her
world. "I'm a raccoon. That's what some of us like to call ourselves," she
confides. "Many years ago, I was a nurse's aide, a single mom with two kids.
I had a nervous breakdown. I got schizophrenia with anxiety and depression.
I was homeless for two years. Now I'm in supportive housing. I'm on
Benadryl, alprazolam, nortriptyline, Librium. I stay out of the psych wards
because I take my medication.

"I love my psychiatrist," she says with a charming smile. "How many people
get a real Freudian psychiatrist these days? I used to see him two times a
month. Now managed care only lets me see him once a month."

Owsley works in the Spiritmenders office. She volunteers at the ASPCA,
petting cats and doing chores. She is connected to other people. Should the
fragile lifelines that connect her to San Francisco's mental health system
snap, however, Owsley, and thousands like her, could be cast adrift.
"Society is asking for trouble," says Mark Adamek, a longtime Spiritmender.
"If this safety net continues to crumble, there will be more upset people on
the street, more crime, more police, more medical emergencies, and more tax
dollars [spent]. It's only common sense."

------------------------------------------------------------------------

Right now, mental health patients all over San Francisco are registering for
"advanced housing directives." These are legal documents that empower a
person's friends to save his or her hotel room, or apartment, if he or she
disappears into a psychiatric ward or jail cell. The problem with being
locked up, Spiritmenders members say, is that your plants shrivel, your pets
starve to death, your landlord throws all your worldly possessions into the
garbage.

Advanced housing directives are being filed apace, at least in part because
of state legislation that Spiritmenders and many other mental health
treatment groups adamantly oppose: Assembly Bill 1421, which would make it
easier for people to be committed to locked psychiatric wards against their
will. The clinicians and patients of San Francisco's mental health world
seem, by and large, appalled by the San Francisco Chronicle's recent barrage
of editorials in support of this legislation. Critics find many reasons to
oppose it: Existing involuntary commitment laws adequately balance civil
rights with the need to commit dangerous actors. The acute-care system is
overwhelmed by a shortage of nurses and cannot handle an increase of 5150s.
Scientific studies clearly show that access to community-based treatment --
if sufficiently funded -- greatly decreases the need for involuntary
commitment. 

Dr. Peter L. Forster has an impressive 21-page résumé. Besides being an
associate professor of clinical psychiatry at UCSF, he was, until recently,
the medical director of Community Mental Health Services in San Francisco.
During the last 15 years there has been an explosion of knowledge about what
works in public health psychiatry, Forster says. Intensive case management,
for instance, is a superior therapeutic practice. It also pays for itself,
because it greatly reduces the high costs of treating patients repeatedly in
the acute-care psychiatric wards.

Since 1998, the amount of money available to San Francisco's public mental
health system has been restricted by a managed-care system that calculates
state and federal payments based, partially, on the number of people
treated. Forster and other experts say San Francisco is shooting itself in
the foot by cutting back on city funding and treating fewer people --
because the city cuts cause corresponding reductions in state and federal
mental health funding.

San Francisco's mental health crisis, Forster says, has been brought about
by the mayor's flat budget and salary savings mandates. "The cutbacks have
made it very difficult, and at times impossible, to provide good quality
service at [the city's] mental health clinics," Forster says.

If city money alone is not enough to fix the failure of the nation's overall
approach to mental health treatment, it can go a long way toward making sure
that San Francisco's progressive mental health programs do not continue to
collapse. Mental illness may always be with us, but experience shows that
its effects can be softened and diminished -- that people can literally be
saved -- when a proper mix of medication and caring is made available to
those who need it most.Michael Wise and Susan Owsley are recovering
schizophrenics who got the right kind of help, and got off the street.

The mayor's secret budget cuts will make sure that doesn't happen anymore.
{ http://www.sfweekly.com/issues/2001-06-13/feature.html/page1.html }

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