If you go publicly and dramatically crazy on the streets of San Francisco, Paul Linde is probably the guy who’s going to be figuring out why. Linde works at San Francisco General Hospital, the only hospital in the city with an Emergency Psychiatry Ward.
It’s an interesting job, and he’s written a book about it called Danger to Self: On the Front Line with an ER Psychiatrist (University of California Press). Linde was kind enough to talk with Mission Loc@l recently about addiction, free will, and how to talk to a crack-smoking schizophrenic.
Mission Loc@l: Alright – it’s a typical night at the Emergency Psych Ward at San Francisco General. What are you seeing?
Paul Linde: I’d say we have five or six people in the ward because of severe alcohol abuse. Maybe two people on stimulants like meth. Four or five people who have been brought in because they’re in a manic state, and are bipolar, or schizophrenic, or psychotic. And then maybe one person on hallucinogens.
As the public hospital, we’re seeing a higher volume of the sickest patients – more without insurance, and more without MediCal. Maybe 10% of our patients have private insurance.
ML: Do you see a lot of the same people over and over?
PL: We see the most repeats with alcohol, and then next with meth and crack. Alcoholics are the most frustrating group to work with – more so than hard drug users. But when they actually get a handle on their problem, it really does turn their lives around.
We almost never see any of the people on hallucinogens again. Their visit is usually the only time they’ve been in the psych ward and so they can be difficult patients – demanding to be let go immediately, and that sort of thing. Once you’ve been in a psych ward once, you kind of know the drill.
There are some people who come in so often that it is almost like they live there. Some become junior staff, almost. You have to be careful – you don’t want to make them too comfortable, when they could be better served with a relationship to a case manager or a social worker at Mission Mental Health.
That’s usually what we try to do with the regulars, but it’s tough because often the case manager finds them really frustrating too, and then you can get into turf wars. In the ward, we take turns with the most difficult patients. And sometimes one of us can work with a patient that everyone else can’t, and they’ll just take that person on.
ML: In the Mission I see a lot of people on my way to work who are clearly homeless and mentally ill, but sweet and good-natured. They are, however, in very rough shape physically. Are any of those people your patients?
PL: Not usually. They have to be screaming or hassling someone to make it to Emergency Psych. Sometimes the police will bring them in if their hygiene gets super bad. We don’t argue with the police. We try to find out why they’re wearing seven layers of clothing, or why they haven’t bathed in three months, or why they’re eating out of the trash.
ML: What’s their answer?
PL: That it doesn’t bother them.
It’s something that we all struggle with in the mental health field. In the 50’s or 60’s, these people would have been in the state hospital. Probably, a lot of them were. A lot of them have schizophrenia.
Today, California law makes it very hard to institutionalize a person. I see both sides to this, and try to keep to a middle path. I think of the differences between a hotel in the Tenderloin, a state prison, a county hospital. If you give up your freedom, and get to live in humane conditions, is that a fair trade? What if you give up your freedom and live in an institution that’s under-funded and gives sub par medical and psychiatric care? Is it better to have your freedom, and eat out of a trashcan, if you prefer that? What about if you get hassled on the street, or beaten up, or arrested?
ML: Do they have problems with the police?
PL: In other counties. Not so much in San Francisco. I do think the SFPD do a decent job of working with the mentally ill, perhaps because they have so much more experience with it.
ML: People often say that San Francisco is a magnet for the mentally ill. Do you think that’s true?
PL: I think that San Francisco is a magnet for everybody. San Francisco also has better services for the mentally ill than most other counties in the United States.
ML: Are the people who come into your office that self-aware, that they would think, “I have a problem, so I’m going to come to San Francisco?”
PL: I take care of people who aren’t that self-aware, but the majority of people who come in come here knowing they need help.
ML: I’ve also run across statistics that the Mission has a disproportionate rate of alcoholism, and a use a larger slice of city services than most districts.
PL: Well, the Mission has a number of residential hotels, and you’ve got some of the better ones here. I think that if someone is trying to quit using, they would rather be here than in the Tenderloin. So that would also mean that you have a larger number of residents that actually use services.
ML: Do you ever have people who come in that you ultimately decide don’t need help?
PL: It’s a difficult situation. Some of us get cynical and say, “This guy is trying to use us.” Usually it’s people trying to get into residential drug treatment because they need a place to live. It’s not hard to sort out the people who are really ready to quit. And you can’t blame people for trying.
But the vast majority of people need what they’re asking for, and it’s hard to send them away if there’s no room in the residential drug treatment program. During the Willie Brown era he called for something called “Treatment on Demand” – which basically meant that we should have the funding to treat an addict when they’re ready to quit, and not put them on a wait list. I don’t know how much he did to actually implement it, because we don’t have it now. But policy-wise, he had the right idea.
ML: How many of the clients that you see have substance abuse problems?
PL: I’d say about 2/3 of them have a significant problem with drugs or alcohol. And there is a lot of overlap. So a person with schizophrenia may also be smoking crack.
That’s why it’s so important to sit down and talk with them, because often they’re using street drugs to counteract the side effect of their meds. So if they say something like “I was sleepy, so I smoked crack” you can say, “Well, let’s lower your dosage and see if that makes you less sleepy.” You have to be non-judgmental, and you have to know what questions to ask. Your heart has to be in the right place.
ML: Over the time that you’ve spent working with addicts, what has changed in your thinking about addiction?
PL: I’ve become more compassionate. I’ve become more convinced that there’s a large biological component.
ML: What has changed in terms of how addicts are treated?
PL: One thing that has really changed heroin and pain pill addiction is Suboxone. A person can get a one or two week supply at a time, instead of having to go and wait at the methadone clinic every day, because there’s less of a danger of addiction or overdose. It’s easier for someone to be on it and, say, hold down a job.
ML: How has Healthy San Francisco changed how your clients are treated?
PL: Not much. It has helped with primary care appointments and overall medical care. But there’s really no mental health coverage.
ML: But MediCal still covers psychiatry…
PL: As a psychiatrist, it’s cheaper not to see a patient than to see one with MediCal. If you’re doing a psychiatric consultation at a hospital, MediCal reimbursement is $37 – and that’s a 2-3 hour appointment. If that patient has private insurance, you’re reimbursed as much $300 an hour. I never mind seeing MediCal patients – if you have a mix of clients, it all comes out in the wash. But only a few outpatient mental health practitioners will take Medicare, and none take MediCal.
ML: What’s the response to your book been like?
PL: Very positive. So many emergency psychiatrists don’t talk about what they do. Historically, they’ve been a reticent crowd. So people are curious about my job.
I’ve had people show up at book readings who are mentally ill, and I’ve had to deal with that in front of a crowd of 40 people.
ML: How did that go?
PL: It’s actually a lot more comfortable doing that than a book reading. It’s my job. I do it all the time.
Paul Linde’s next reading is Monday May 17th, 7:30 p.m at the Noe Valley Ministry, 1021 Sanchez @23rd