Physicians Organizing Committee members and mental health advocates launched a campaign this spring to force the San Francisco County Department of Behavioral Health and the Department of Homelessness and Supportive Housing (DHSH) to close the growing gap between their declarations and their actions that leave the severely mentally ill without treatment, despite their pledge of supportive housing units for these patients. Advocates demand that the County construct more such units, correct the dysfunctional nature of current units and provide a full accounting of where the tens of millions of dollars in Mental Health Services Act (MHSA) money has gone.
According to a May 11, 2016 news release from the Office of the Mayor, DHSH has committed to ending homelessness for at least 8,000 people in the next four years. However, the Department of Public Health left $21.8 million in MHSA money allocated for the severely mentally ill unspent in 2016 – enough to house over 1,000 homeless people for a year.
In a series of meetings the Physicians Advocacy and Information Task Force (PAITF) held between February and May, physicians with expertise in various aspects of treating the mentally ill agendized the problems they saw, ranging from the acute locking psych units to supportive housing.
The late John Rouse, M.D. spoke about the problem of Medi-Cal refusing to pay for patients admitted to the locking acute ward he supervised at SF General Hospital. “Medically they needed to be in an acute psychiatric care setting, but Medi-Cal said they were ‘not sick enough’ to qualify. Yet the lower-level, community-based Locking Sub Acute Treatment (LSAT) units refused them because they were ‘too sick.’” Rouse described how the absence of a clear path from acute to sub-acute treatment denied the severely mentally ill the opportunity to achieve enough stability to progress to an independent community living situation. Instead, he reported, patients ended up stuck on his ward for more than 200 days, while others who were denied admission often ended up back on the streets.
Adam Nelson, M.D. noted that many of the chronically homeless living on the streets, who are often classified as drug addicts, are in fact, self-medicating to cover an underlying mental illness – including returning veterans suffering from PTSD. “This is important in terms of making plans to resolve homelessness, as a portion of this population will not succeed in housing without wraparound supportive services,” noted Nelson.
Although many people attribute the overall increases in homelessness to the release of severely mentally ill people from institutions, most patients were released from mental hospitals in the 1950s and 1960s. Yet vast increases in homelessness did not occur until the 1980s, when incomes and housing options for those living on the margins began to diminish rapidly.
Psychiatrist and POC member Robert Okin, M.D. describes the dire effects of homelessness on every aspect of the chaotic lives of the severely mentally ill in his book Silent Voices: compromised physical health, fragile psychological stability, increased use of illegal drugs, inability to keep appointments, access services, find and maintain employment or manage complex medication regimes.
Providing supportive housing for this population has proven to reduce morbidity and early mortality, according to the pioneering work of Jim O’Connell, M.D. who applied the ‘Housing First’ approach in Boston in 2006. This approach prioritizes getting people into housing first, then actively encouraging their participation in therapy and various services to stabilize their lives such as drug rehab, occupational therapy, counseling, medication review, group activity and job training to be able to live independently; vs. waiting until they are stable, sober and sane enough to move into housing.
“However, if you are not making sure the mentally ill get the services they need to stabilize their lives, you are just moving the conditions they face in the streets into the housing units and, in effect, warehousing the mentally ill in the name of reducing homelessness,” noted POC Administrative Assistant Virginia Lewis, LCSW. “Some nice buildings get built, developers make money, people get jobs working on the construction while it’s going on, but homelessness and especially the mentally-ill homeless remain.”
San Francisco State of the Art
According to clinicians and psychiatrists who rotate through the Richardson Apartments, one of San Francisco’s state-of-the art, purpose-built 120-unit supportive housing facilities, problems of drug use, physical threats, intimidation and failure to engage in and participate in therapy persist. Yet these facilities are considered the ‘Cadillac’ of SF’s supportive housing programs due to their modern architecture, high clinical staff to client ratio, and the on-site presence of case managers, social workers and an RN through UCSF’s Department of Psychiatry Citywide Program providing on-site psychiatric services eight hours a week.
In a March 27 meeting with Sam Dodge, Deputy Director for Communications and External Affairs for DHSH, Lewis and POC President Geoffrey Wilson discussed the agency’s plans to maintain the current supportive housing units and establish additional units in the city. Dodge explained that DHSH is reconceptualizing programmatic goals and objectives and re-organizing program operations at existing sites to de-emphasize the services emphasis and prioritize housing. The previous approach was to provide services to residents with mental health conditions (some of whom also have physical disabilities) and acuity was a factor in determining eligibility.
Dodge said that going forward, “the priority for eligibility will be ‘length of homelessness.’” he also said, “The primary purpose of DHSH is housing the homeless, not necessarily focusing on stabilizing the severely mentally ill. If an applicant/resident needs a different level of assistance that person belongs in the Behavioral Health System or a hospital.”
“It may be consistent with the criteria for DHSH’s funding sources to de-emphasize services, but it defeats the whole purpose of supportive housing to ignore a person’s mental condition and the tragic consequences when they don’t get the treatment they need,” noted Lewis.
According to Jennifer Friedenbach, Executive Director of the San Francisco Coalition on Homelessness, to qualify for supportive housing by these criteria currently requires documentation of twelve years of homelessness.
Other supportive housing models work from the direction of providing residential treatment and only incidentally lodging. Recognizing that supportive housing is a scarce resource, they believe it should be reserved for people participating in treatment and likely to benefit from the treatment-affiliated housing. Some include language in their leases such as, “Refusing to continue with mental health treatment means I do not believe I need mental health services. I understand that since I am no longer a consumer of mental health services, it is expected that I will find alternative housing. I understand that if I do not, I may face eviction.”
However, at the Richardson, once the agreement is signed the placement is permanent, leaving staff with no ability to sanction or intervene in behavior when it begins to become self-destructive or a threat to other residents.
“They are hijacking MHSA money intended to treat those with schizophrenia, bi-polar illness and other severe brain disorders and using it for general housing needs. Instead we need to wage a political battle to demand more affordable housing and higher pay for workers to be able to afford housing,” noted Lewis. “We don’t need to take from Peter to pay Paul. Some with severe mental illness end on up on the street, while others forced to live on the street due to economic losses, develop mental problems. Both need to be addressed. We must correct the economic conditions – diminished income and housing options – that cause most homelessness (including for millions of children) and provide treatment for those who need it.
Lewis gave a report at the May 17 PAITF describing her site visit to the Richardson Apartments, including her observations and subsequent discussions with staff members and residents as well as with Eric Brown, Program Director of Citywide’s Roving Team that covers the Richardson Apartments and Fahad Khwaja, Housing Operations Supervisor with the Community Housing Partnership (CHP) that owns and manages the facility. Lewis confirmed problems of extensive drug abuse, physical threats, disruptive behavior and failure of the Citywide services staff to be able to effectively engage the residents in services. Valerie Gruber, MPH, Ph.D. who sees patients in the facility, corroborated what Lewis reported and spoke to the problems of residents refusing to engage in services.
Lewis gave the example of a frail resident who suffered from serious mental and physical health problems as a result of living on the streets for many years. She lived at Richardson for five years and was initially considered a success, but was later evicted. Over time her increasingly unhygienic housekeeping led several residents to complain. She became increasingly paranoid, refusing all offers of support, including counseling and housekeeping. She denied staff access to her apartment, engaged in persistent substance abuse, and underwent mental deterioration, which led to a violent incident with the desk clerk and a subsequent hospitalization where she continued to refuse assistance.
Lewis noted that several Citywide staff members maintain that this type of tragic downward spiral is avoidable and cited incidents of residents stopping medications and refusing to engage in therapy, at times lacking insight into their disease with a subsequent misperception of threats or danger leading to aggressive confrontations with staff or residents, incarcerations and expulsions.
The current CHP staffing pattern serves to reduce the costs of personnel and insurance, but leaves the 120-bed facility under the authority of a single minimum-wage desk clerk with no security personnel. There have been documented violent encounters in the facility, which have resulted in resident injuries and evictions. “Nighttime is extremely problematic,” explained Lewis, “as the lone desk clerk on that shift cannot control traffic in the building, nor the drug dealing, resident confrontations and violence that results.”
Lewis reported that “methamphetamine use” was identified by one Citywide staff member as the most serious problem there and that police have not been responsive to their requests for assistance in resolving potentially violent disputes between tenants. Fearful tenants sent a petition to CHP requesting the agency hire a roving security guard to monitor and deescalate hostile situations. Their request was verbally denied by the CHP Deputy Director, but not documented, and no steps were taken to alleviate the security problems. Absent is any formal organizational channel to address either resident or staff complaints. A Citywide administrator said, “Since the tenants are aware that complaints are not addressed, few are made.”
“Even the best supportive housing can’t solve the social conditions that exacerbate the problems of the mentally ill in the first place, but the DHSH is moving away from the relief this treatment option could provide by expecting brain-disordered, bizarrely behaving persons to make rational decisions for or against receiving help and left to suffer homelessness or engage in behavior that can get them shot and killed by the police unless they ‘volunteer’ for services,” said Paul Weisenburger, POC staff and retired SF parole officer.
Based on Lewis’ report, the PAITF participants developed an initial set of demands for the SF Department of Behavioral Health including:
- scheduling clinicians on site for 24-hour coverage – not just daytime hours
- creating formal organizational channels such as tenant councils to insure that tenant grievances are known and addressed
- requiring clinical input into placement decisions to determine a person’s likelihood of benefiting from supportive housing vs. basing eligibility strictly on duration of homelessness
- developing sanctions against the management agencies contracted to run the facilities to insure that incidents such as acts of violence, drug use and residents destabilizing get reported and resolved
- re-working the lease agreement to include a probationary period for all new tenants transitioning out of homelessness and a requirement of a minimum level of participation in supportive services
- placing security guards at all facilities; providing them with adequate training in how to deescalate conflicts and interact with residents suffering from severe mental illness
Prior to bringing these demands to San Francisco’s Director of Behavioral Health, Kavoos Ghane Basiri, the PAITF consensus outlined that POC conduct a series of meetings to develop allies and track down where the MHSA funds are going that had been allocated to both construct and operate supportive housing units.
“Supportive housing units alone will of course not be enough to reverse homelessness,” commented POC President Geoffrey Wilson. “The income inequality that is increasing daily leaves a growing part of our population unable to survive – generating fear, anger, despair and more. It creates an increasingly unhealthy society, rendering more and more people homeless due to economic pressures, a loss of mental health, or both.”
On March 6 Wilson, Lewis and Gruber met with Supervisor Malia Cohen’s aide, Yoyo Chan. Upon hearing POC’s analysis of the misspending of the MHSA funds earmarked for the severely mentally ill in SF County, to pay for phone “help-lines” for the not quite suicidal; hoarding and cluttering support groups and other programs not designed for the severely mentally ill, Ms. Chan offered to do the preliminary work necessary to have the board of supervisors conduct a public hearing on the matter.
Wilson, Lewis and POC staff members Laura Suddes and Mark Dudley met with Supervisor Jane Kim’s aide Noelle Duong on April 7 to discuss sources of funds to construct supportive housing. A November 2016 ballot initiative in San Francisco raised the percentage from 12% to 25% of a project’s total costs that developers must spend on affordable housing. In the meeting with Duong, POC staff queried how to earmark a certain portion of those funds for the construction of supportive housing units for the mentally ill. Duong said she would research if the ballot measure gave the board that authority or if that had to go back to the voters.
POC President Geoffrey Wilson commented, “We know that even if this funding is made available, it will only address a very small part of the problem of housing some of the most vulnerable of our homeless neighbors. The fact that eligibility for such housing currently requires a twelve-year history of homelessness indicates how inadequate our housing resources are and how poor and destabilized working people have become. Living for over a decade on the street with all its attendant horrors will only create more people unable to live without supportive services.”
Clinicians who have experienced the inadequacy and insufficiency of mental health services in San Francisco should contact POC at (415) 434-9335.