Mental Cruelty

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.

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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.

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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.

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.

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.

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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."

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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.