By Elaine Korry
Don Fox prepared for his late-night rounds. He collected a few warm blankets and protein bars, then hit the streets, seeking out people in crisis who needed food and warmth. “Our principle is, we hang out where people are,” said Fox. “We walk the streets in those areas, make eye contact, and ask if they need help.”
Fox is an Episcopal priest with San Francisco Night Ministry, a program founded by volunteer clergy in 1964 to serve a then-emerging population of mentally ill homeless people. A half-century later, the problem hasn't gone away.
On a recent night Fox walked San Francisco's Civic Center, where he met a 53-year-old Navy veteran slumped on the sidewalk. The man, a slight figure in a torn sweatshirt and Oakland A’s cap, said he had been homeless and in and out of jail for about six years.
He said that a few months ago, he had run out of his anti-psychotic medication, Risperdal. Late one night he started to feel suicidal and went to San Francisco General Hospital for help. “I wasn't well, put it that way,” he told me. He spent the early morning hours in the emergency department, but then said he was told to leave. “I was telling them that I needed to stay a little longer. They wouldn't let me stay longer, so they made me leave.”
San Francisco General’s psychiatry department is down to 20 acute beds, and all of them were full. The Navy vet said he became even more depressed because he wasn’t getting the help he needed. “So I felt like ending it. And that’s what happened.”
A few hours after he left the hospital, he said he tried to jump in front of a bus, but a friend pulled him away at the last moment, and he wasn't hurt.
At one time this man might have been admitted for treatment. In 2000, for example, San Francisco General had ten times more inpatient psychiatric beds than it has now. But since then there has been a big shift in how psychiatric care is delivered, away from locked hospitals.
Residential vs. Hospital-Based Treatment
Dr. Mark Leary, deputy director of U.C. San Francisco’s psychiatry department at S.F. General, said high staffing requirements make inpatient care the most expensive way to treat severely ill patients. Hospital care is also restrictive and, as some mental health advocates believe, inhumane. Leary said San Francisco closed 180 emergency inpatient psychiatry beds and shifted the funding into residential care.
“We have community services where patients can get intensive treatment in a residential setting,” said Leary. “They're there in a house with mental health staff. They can receive medications, psychotherapy, social support, and safety in that setting, and it doesn't require a hospital to deliver it,” he said.
That sounds like just the type of treatment people such as the Navy veteran need. Yet he and other homeless people with a mental illness remain on the streets. Fr. Fox said San Francisco may have good community services, but it still lacks the one thing many mentally ill homeless people need. “If they need a bed, it's a disaster. There's hardly any places,” said Fox.
A hard-to-reach contingent of people cycle in and out of the ER, sometimes taking their medication, sometimes not, but never really recovering. This population of patients needs more structured intervention, says Michael Fitzgerald, executive director of Behavioral Health Services at El Camino Hospital in Mountain View. “We have streets full of people with significant mental illness who are not receiving the care that they need,” said Fitzgerald. “And when they're in an acute crisis, often they're not going to go to drop-in clinics. It's not meeting the patient where they're at or what they need,” he said.
The problem, according to Fitzgerald, is that people in a crisis often need to be stabilized first, before they can transition to community services. Yet there hasn't been an adequate support system to help them take that crucial first step.
Next year, funding from a new law will begin to provide that missing link.
“What's lacking in the system is the crisis beds that allow somebody to get stable,” said Sen. Darrel Steinberg (D-Sacramento) who sponsored the law. In addition, "the people who can help somebody get from those settings to a place where they can begin to get help.
Steinberg's law, the Investment in Mental Health Wellness Act, targets those gaps by providing $206 million in funding for 2000 new crisis stabilization beds, for mobile response teams and for 600 new triage workers. Steinberg says the new providers are key. The plan is to station these mental health professionals at jails and county emergency rooms to identify people in crisis and connect them with the new services.
Counties will be vying for the new funds, and some already have begun submitting grant proposals. A few mental health providers are even starting to feel hopeful. “We'll see how it rolls out. We'll see if the funding continues,” said Fitzgerald. “Certainly at least it's funding, and the focus on crisis stabilization is a good plan,” he said.
For now, after years of facing budget cutbacks, Fitzgerald is actually optimistic. He said there may finally be a chance of getting effective mental health treatment to the people who have been the hardest to reach.