(Getty Images)
(Getty Images)

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.

Crisis Stabilization

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.

Editor’s note: This is the third of three stories about psychiatric inpatient services airing this week on The California Report. In part one, reporter Elaine Korry looked at the lack of psychiatric inpatient services for adults. In part two, she examined the lack of services for children

After Years of Budget Cuts, More Psychiatric Resources Coming 18 December,2013State of Health

  • Ann
  • Ann

    What has happened to the 1% millionaire tax imposed in about 2006. Where are those millions going? Why did the reporter not include any information about that in the report? A quick check on Wikipedia states millions each year are already paying for programs.

  • candy

    The 1% millionaire tax has been incorrectly spent on many voluntary programs that are not targeted to help our most seriously and persistently mentally ill. Voluntary programs are good, but this is not the what these funds were intended for. What happens to our most severely ill that live on our streets or are incarcerated because they are simply too ill to help themselves is inhumane. Caring for those around us that are so severely ill is all of our responsibility and we must all act to call for change to our mental health system. If you live in Alameda County, AB1421, also known as Laura’s Law is being proposed by our health directors to our county supervisors. Laura’s Law was passed in 2002 but was left up to each county to adopt. It is an up front tool that tries to partner with a person before they become in crisis or end in tragedy. It involves a team of professionals, including a PD, judge and mental health professionals that try to develop a plan with the person to stay well. It is highly successful and there are two Duke studies that support this. The “black robe” effect, the judicial order, is partly what makes this program successful. However, there is no component of forced medication and no arrest is the person does not comply. This is a humane and compassionate law. This will go before Alameda County Supervisors in mid to late Jan 2014 and requires a majority vote. If you live in Alameda County, please contact your county supervisor and support this initiative. Please pass this information on to any others that you know can help. We have a chance here to make a difference. It will not fix all of what is broken in our mental health system, but it will help some. Please advocate for change.

State of Health Sponsored by

Become a KQED sponsor