Dr. Kunins sitting in chair answering questions from audience at Manny's on Oct. 26
Dr. Hillary Kunins, left, in conversation at Manny's on Oct.26. Screenshot of event by Anlan Cheney.

Homelessness is one of San Francisco’s most visible and painful realities. How one frames it could be telling: a blight, a problem, an opportunity. If you’re the city’s new director of behavioral health services, though, you’d frame it as an iceberg. 

As in: You only see the tip of it while walking around the city. “Think what is visible,” said Dr. Hillary Kunins, the city’s director of behavioral health services,  in a Tuesday night event at Manny’s at 16th and Valencia streets. “Seeing lots of people on the street, many experiencing mental health and substance abuse problems.”

As for what’s beneath the tip of the iceberg, Kunins summed it up as the precipitating factors of poverty, trauma and lack of housing. 

The highly visible homelessness is part of what she has been asked to “urgently” respond to and fix since March, when she became the city’s director of behavioral health services. She succeeded acting director Marlo Simmons who has since returned to her role as deputy director.   

Kunins said she will also address large-scale challenges facing the community and society around mental health and emotional wellbeing. “The pandemic has exposed our disconnection and that those experiences are not felt equitably across society,” she said.

Dr. Hillary Kunins became the city’s director of behavioral health services in March. Photo courtesy of the Dept. of Public Health.

Kunins came to San Francisco from New York City, where she was a Department of Health and Mental Hygiene commissioner and worked on HealingNYC to address the overdose epidemic. She was trained as an internal medicine and addiction medicine physician, leading programs and research in the South Bronx with disenfranchised populations facing disinvestment, criminalization, and racism.

Her new role also includes leading Mental Health SF, an effort aimed at improving access to mental health and addiction care for some of the city’s most vulnerable populations.

So, what does a director of behavioral health services do? “My job is really to bring together policy and strategy,” she said. 

Kunins explained how she is still learning about differences in public health authority vested in state, county, and city levels in California and the ways in which this determines funding streams and licensing and regulatory processes. Her takeaway is that mental health has been “siloed, stigmatized, and separated,” she said.

As she described it, substance abuse or addiction has been divorced from the health issues related to mental health. “You can show up at one door, and they’ll treat your mental health problem,” she said, “and you have to show up at another door, and they’ll treat your substance abuse problem.”

Such disconnect prompted the creation of Mental Health SF to restructure a “system of care.”  The initiative was created by the Board of Supervisors in 2019, with prodding by supervisors Hillary Ronen and Matt Haney, and Kunins highlighted the effort’s publicly accountable Implementation Working Group. 

The group, which includes city-appointed healthcare workers, experts, and people with “lived experience,”  meets monthly to ensure “access to mental health services, substance use treatment, and psychiatric medications” for eligible San Franciscans.

She said the two big priorities for Mental Health SF are expanding residential care and treatment, and the Street Crisis Response Teams

She said 400 new care and treatment beds will be available in coming years along a spectrum — an “intense kind … for folks that have very serious conditions” as well as drop-in spaces for intoxicated individuals to come off of a high safely, meet basic needs, and get linked to health care.

The idea behind the Street Crisis Response Teams, Kunins said, is to make involvement of law enforcement and the emergency department obsolete when it comes to mental health calls. 

In short, the teams want to: “Address people’s needs, get them off the street, provide them more definitive or long-term care.”

During the audience Q&A, the discussion migrated to inequitable pay between city and nonprofit mental health workers (nonprofit contractors earn less, alleged an audience member who works in the field), staffing shortages and, of course, housing.

“Housing is healthcare,” she said, drawing the focus back to the iceberg and precipitating factors of poor mental health outcomes.

She said she is optimistic and “impassioned” about the opportunity to transform mental health in San Francisco. “Partly what attracted me to come here is that it has a foundation that can be built upon,” she said, alluding to the harm reduction – or ‘meeting people where they’re at’ – approaches adopted during the HIV/AIDS epidemic.

“Those foundational elements and city commitments to develop resources … are extraordinary.”

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"Annie" is originally from Nebraska, where she found her calling to journalism as editor of her high school newsletter. Before returning to the field, she studied peace and political science in the Balkans, taught elementary and middle school, and worked as an epidemiologist during the COVID-19 pandemic. Follow her on Twitter @anlancheney.

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  1. —-Her takeaway is that mental health has been “siloed, stigmatized, and separated

    It is not unusual for us to argue “stigmas”. We learned many times in history to substitute that term for the realities it works so hard to disguise, prejudice and discrimination. It is a blame the victim term we have all too often resorted to, hidden behind.
    Harold A Maio, retired mental health editor