Mental Cruelty

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.

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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.