Mental Cruelty

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.

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"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.