Brain Storms

A City Hall plan to downgrade S.F.'s only long-term-care facility for the severely mentally ill has critics up in arms

Two years ago, Donna Mateer lost her grip on reality. She was living in a San Francisco board and care home, a private dwelling that provides limited care for small groups of the mentally disabled. Residents can come and go as they please, and are cooked for and cleaned up after by attendants who usually aren't certified nurses or doctors. Despite their freedom, board and care facilities have some house rules: Residents must be well enough to regularly take their psychiatric drugs, and not present a danger to themselves or others.

So when Mateer, a 45-year-old manic-depressive, kicked an employee during a manic episode (which she says she doesn't remember), she was tossed out of the board and care and taken to the emergency psych ward at San Francisco General Hospital. After she was released, Mateer checked into a Holiday Inn and began racking up hundreds of dollars in calls to expensive party-line numbers and room-service bills for calamari. "I was convinced I was going to be the first woman American president," remembers Mateer. "When I'm on a manic high I'm so grandiose."

These days, Mateer's highs and subsequent lows -- a state in which all she can do is "sit on the porch and smoke cigarettes" -- aren't as debilitating as they once were. For the first time in her life, she has a steady job -- a two-day-a-week gig working the coffee cart at Community Focus, a mental health nonprofit on Market Street. She again lives in a board and care, and feels well.

Mateer credits her improvement to the Mental Health Rehabilitation Facility, a high-level treatment facility for the acutely mentally ill where she lived for seven months following her stint at the Holiday Inn. The MHRF, or "Murf" as it's known, is a locked, residential institution run by the City and County of San Francisco. Operated as part of San Francisco General Hospital, the 145-bed MHRF isn't just the city's biggest facility of its kind, it's the only one. It's the sole San Francisco source of long-term housing for schizophrenics, manic-depressives, and depressives whose lives have spun out of control (about a third of the residents also are drug and alcohol abusers). "The MHRF is a good place for people who can't handle it out there," says Mateer.

Mentally ill people who are admitted receive intensive care from a large staff that includes four psychiatrists, five primary care physicians, about 10 therapists, and more than 40 nurses. Since failure to take one's medications is the No. 1 reason that mental patients lose their ability to care for themselves, MHRF residents are given their meds by a licensed nurse, and receive monthly drug regime reviews by a pharmacist.

By contrast, residents of board and cares typically self-medicate, and there is little monitoring of the effectiveness of their drugs. If a board and care resident refuses to take his meds, there's not much the staff can do about it. At the MHRF, a staff psychiatrist can petition a judge for permission to inject anti-psychotic drugs until the resident's symptoms diminish and he can agree to take the medication himself.

But the MHRF may soon be no more. The Department of Public Health plans to lay off all of the facility's employees in an effort to help bridge the city's $350 million budget deficit. Under the DPH proposal, the MHRF will be relicensed as a board and care and run by an as-yet-undetermined local social services organization.

Scaling down the MHRF is expected to save the city $8.1 million a year, according to local officials who expect to face further cuts as a result of the state's burgeoning $34 billion deficit. But while overhauling San Francisco's only long-term residential psychiatric facility for the severely ill will produce obvious short-term savings, there may be less obvious human costs.

The biggest question is what will happen to the 130 or so people who currently live in the MHRF. In the DPH scenario, two-thirds of them would be discharged to unlocked community residential programs. These include board and care homes, short-term treatment facilities, single-occupancy hotels, and so-called supportive housing. The latter are hotels, such as the Lyric Hotel in the Tenderloin, that are leased by the city and staffed with a handful of social workers to help mentally ill residents stay on track.

Some MHRF staffers and city mental health workers worry that many residents aren't ready yet for life on the outside. To transfer them to less restrictive settings with less staff oversight, critics say, will lead to serious setbacks in more than a few cases.

"Nobody is going to be put out on the street," says Mozettia Henley, the MHRF's program director. "How long they'll be successful at lower levels of care ... is a big question mark."

Some fear that elimination of the MHRF's acute-care services will accelerate what is known among mental health specialists as the "revolving door" effect. That's the cycle in which a mentally ill person breaks down, the cops are called, and he is taken to the hospital emergency psychiatric ward. From there, the patient is transferred to the hospital's acute psychiatric ward for two weeks, then released. But two weeks is not enough time for some to get better; Mateer, for instance, went on her manic Holiday Inn spree after being released from S.F. General. And so the door continues to revolve. Without the MHRF to take in patients too sick for unlocked facilities, supporters say, some of them will inevitably wind up on the streets.

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