Mental Health Battle On

An inconspicuous office building on Mission Street deals with some of the city's most troubled residents.

An inconspicuous office building on Mission Street deals with some of the city's most troubled residents.

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“The more you get to know someone, the more you don’t look at them and think, ‘The police arrested you naked and defecating in the middle of the street.'” says Walter Glaser, an employment specialist at UC Citywide Community Case Management. He pauses. “Really, do any of us want to be remembered at our worst moment?”

In a tough budget year, profound questions about a city’s priorities rise to the surface.  San Francisco’s relationship to its residents who occasionally break down and do indelibly strange and antisocial things in the street can be a tense one.  Citywide is a program whose work with mentally ill criminal offenders seems to work.  A 2007 study of the San Francisco Behavioral Health Court (where 70% of Citywide’s clients come from)  found that 18 months into the BHC program participants had about a 26 percent lower risk of new criminal charges and a 55 percent lower risk of new criminal charges for violent crimes than mentally ill people who had not gone through the program.

To get to Citywide’s offices, you only have to look for the inconspicuous-looking office building on Mission Street that is made conspicuous by people lying on the street in front of it. These are the clients who have started fights inside the center, currently banished from the building (their case managers come outside to visit them, and dispense anti-psychotics). Inside, past a security door, is a room that looks like any other office building common area, except that all of the people there are just slightly off. Eye contact is somehow either too short or too long. Outfits are amazing and eccentric. In conversation, sentences trail off, and topics shift without warning.

To get to anywhere else in the building requires an electronic security badge. Clients often have a history of violent behavior. One of them, a man who nearly killed his mother with a claw hammer, was the subject of an entire chapter in a book called Madness in the Streets, which criticized the widespread de-institutionalization of the mentally ill 1970’s and 80’s.

Citywide was created at roughly the same time that the effects of de-institutionalization were becoming apparent. It became clear that a few individual people were getting arrested and/or showing up in the emergency Psychiatry ward at San Francisco General over and over again. These people were often bipolar,  schizophrenic, or mentally disabled. They were prone to substance abuse, prone to losing or forgetting to take their medication. Often, they were homeless. Their social skills were not the greatest.

“The fun thing about de-institutionalization,” says David Fariello, Division Director of Citywide, “is that there was no model for how it would be done. People in institutions didn’t vote. They didn’t make a fuss. These programs were cut and then it wasn’t until these people started showing up in prisons and emergency rooms that people realized there was a problem.”

So, when the Mayor’s budget proposal came out on June 2nd, Citywide was shocked to discover that the budget for it and its sister program, Community Focus  had been cut by 15% – the largest of any mental health outpatient facility. Since the agency qualifies for federal matching funds, Fariello says that the total amount Citywide stands to lose is closer to 30%. San Francisco’s Behavioral Health Court , an arrangement between the city’s district attorney, public defender, and Superior Court  to shunt mentally ill defendants out of the court system and onto treatment -may be forced to shut down, out of a lack of place to send people to. There’s already a waiting list to get onto the rolls at Citywide – with the 29 staff positions that Fariello estimates he’ll have to cut, that list will grow longer.

Family Services Agency of SF received the next highest cuts – around 11.3%. Other agencies, providing mental health and substance abuse treatment, like Walden House only received a 1.1% budget reduction. Meanwhile, the budget for Healthy San Francisco grows by $9.45 million, staffing levels for the police and fire department stay the same, and mental health services and drop-in centers for homeless have, at varying levels, lost funding across the board. “I am at a loss to explain how this happened,” says Fariello. “I pride myself on being able to track Department of Public Health trends. The party line is that they were trying to save the small programs, so they made most of the cuts to the bigger ones, but still – we had those matching grants.”

It’s a perplexing move for a mayor who built his first election campaign on ideals of direct and highly publicized engagement with the problem of getting the city’s homeless and mentally ill residents into treatment and off the streets.  What this will mean for the city budget long-term (and for the Mission, where a lot of the mentally unstable people that Citywide works with tend to reside) is uncertain.  Citywide is a comparatively expensive program – its case managers only have a caseload of 12-14 clients, as opposed to the standard 30 or so. But it’s also a program directly aimed at people who have a history of using a disproportionate amount of city funds. A meeting between Fariello and Gavin Newsom this Friday remained inconclusive. The mayor only said that funding might be able to be added back in once the budget went to the supervisors. No promises were made, and the mayor’s press office has yet to respond .

In order to qualify for Citywide, a client needs to have problems. An alcohol or  drug or  addiction alone won’t cut it (although over half of their clients do have substance abuse problems). They need to have serious mental health problems  or developmental disabilities – the sort that prevent them from having the presence of mind to manage their own treatment.  Citywide performs many of the functions that an institution once would have done: holding medication and dispensing it day by day to those prone to losing it, holding on to Social Security Income checks so that they aren’t spent all at once, or stolen (their clients tend to get mugged a lot), offering classes on topics like “Grooming and Personal Hygiene” and “Coping With Voices.”

Meanwhile, Fariello readies Citywide’s clients to go to city hall for the board of supervisors meeting on Tuesday, where the budget will be discussed. Originally a community organizer, he was drafted into the army during the Vietnam war. All around him, draftees going through basic training were having mental breakdowns. Fariello’s supervisors told him that since he’d studied psychology in school, he should figure out what was going on with these people.”I told them that I’d studied sociology,” said Fariello. “They said: ‘Close enough.’  And as it turned out, I loved it.”

“These are politicians,” says Fariello, to the assembled crowd of clients in the meeting room. “They will talk a lot. We will have to be patient, and wait our turn.” The crowd is already fidgeting and murmering, a little. “Alright,” says Fariello,”See you on Tuesday.”

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