A new report from the Board of Supervisors’ Budget and Legislative Analyst gives some alarming answers, and here’s hoping it spurs action from the politicians who could make a difference.
The
report examines conservatorship — compelling mentally ill people into
treatment even if they’re too sick to realize they need help.
Despite the growing crisis on our streets, the number
of conservatorship referrals in San Francisco plunged by almost 50%
percent between 2012-13 and 2018-19. Per capita, San Francisco has a
smaller conservatorship caseload than nearby counties including San
Mateo, Marin, Alameda and Contra Costa — and a smaller per capita
caseload than California as a whole.
Progressives
may say that’s a good thing since conservatorship arguably takes away
civil liberties. But in doing so, they’re fighting, in some cases, for
people’s freedom to deteriorate and die on our streets.
And
we actually have more people per capita on short-term holds lasting up
to 30 days than other counties, perhaps signaling San Francisco is OK
with whisking troublesome people off our sidewalks but unwilling to
ensure they get the long-term treatment they need.
That may also explain why seeing clearly mentally ill people stumbling
around our sidewalks in hospital gowns and ID bracelets is sadly not
uncommon.
Supervisor Rafael Mandelman requested the report and plans to hold a hearing on the subject this fall. He knows the heartache of watching a loved one fall into a mental health crisis.
He was raised by a single mother who was diagnosed with bipolar
disorder, schizoaffective disorder and borderline personality disorder.
She
suffered psychotic episodes, spent days in bed, and was in and out of
the hospital throughout his childhood. Mandelman had to find food for
himself by age 9 and left her Laguna Beach home at age 11 to be raised
in San Francisco by a string of extended family, foster parents,
classmates’ parents and teachers. She died in 2017, and Mandelman, his
half-brother and aunt plan to scatter her ashes next month in Big Sur.
Despite
his progressive bona fides, Mandelman vehemently disagrees that it’s
compassionate to prioritize a very sick person’s civil liberties over
helping them get better.
“It’s completely inhumane,” he said. “If you have
known a friend or a loved one and seen that person in psychosis and seen
how far that psychotic individual is from their true self, you cannot
believe keeping that person in that state is somehow honoring their
autonomy.”
The
report Mandelman commissioned looks at San Francisco’s response to the
state’s Lanterman-Petris-Short conservatorship law. The law, which took
effect 50 years ago, was intended to end the indefinite commitment of
mentally ill people against their will, but some think the pendulum
swung too far the other way because of the long, complicated legal
process it created to obtain a conservatorship.
“From a civil rights perspective, it’s good, but in terms of what’s best for the patient, it’s not,” said Dr. Paul Linde, who used to work in the psychiatric emergency room at San Francisco General Hospital.
Under
the law, people causing an immediate danger to themselves or others or
who are gravely disabled and cannot secure their own food, clothing and
shelter because of serious mental illness or chronic alcoholism can be
compelled into treatment.
Under
a complicated process, an initial 72-hour hold can be extended for 14
days and 30 days and then become a temporary six-month conservatorship
before becoming a renewable, one-year conservatorship.
There
are many safeguards in the law. Conservatorship starts with a
recommendation from a psychiatrist and involves an investigation by the
city’s public conservator within its Human Services Agency and a hearing
before a judge.
If
the one-year conservatorship is approved, the Department of Public
Health is tasked with coordinating the patient’s care including placing
him or her in a facility, which can range from a locked hospital to an
unlocked board and care home. The public conservator makes decisions on
the patient’s behalf during the conservatorship.
It’s not clear if the law itself is the problem or
rather San Francisco’s loose interpretation of it. The report describes
how some counties have more tolerance than others when it comes to
referring patients to conservatorship. Counties also have different
takes on the term “gravely disabled” and just how dire someone’s mental
health must be to meet that standard.
San
Francisco has a low tolerance for conservatorship. Fewer than 1 person
per 10,000 San Francisco residents is part of the county’s
conservatorship caseload versus more than 5.5 people per 10,000 in San
Mateo and more than 4 people per 10,000 in Marin.
San
Francisco in 2017-18 referred 141 people for conservatorships, a big
drop from 284 people in 2012-13. Its overall caseload has decreased by
13% in that time.
The
report says that one reason conservatorship may be dropping is that
there aren’t enough beds to treat those who are held. The number of
acute inpatient psychiatric beds at San Francisco General Hospital
dropped from 88 in 2008 to 44 in 2011 — and they haven’t been restored
during the economic boom. The number of sub-acute mental health care
beds fell by a third between 2012-13 and 2017-18 to 241 treatment spots.
Jeff
Cretan, spokesman for Mayor London Breed, said the mayor has added
funding for 212 additional beds throughout the city for patients with
mental illness, drug addiction or both. All those additional beds will
be open by next year.
“There
are too many people suffering on our streets who cannot care for
themselves, and we need to get them the care and services they need,”
Cretan said.
Another
problem the report found is that the public conservator’s staff has
shrunk due to retirements and delays in hiring, meaning there are fewer
people to handle ongoing cases. The under-staffed office isn’t
coordinating well with the Department of Public Health. The two
departments are only now starting to share data on patients and to set
regular meetings to discuss patient progress. (I recently called City Hall “sloth-like.” Perhaps that was too generous.)
Jill
Nielsen, a deputy director in the Human Services Agency who oversees
the conservatorship program, said she appreciates the report’s
recommendations — and that she’s working to increase the coordination
among various departments and that last year the number of
conservatorship referrals rose slightly.
Breed has added two new positions to the public conservator’s office to allow for an expanded caseload.
Part
of those expanded services will help address those who are severely
drug addicted and can now be conserved under a change in the state law
initiated by State Sen. Scott Wiener.
Wiener
said he is glad the politics around conservatorship are slowly shifting
in San Francisco, as evidenced by the Board of Supervisors voting to
opt into his expanded conservatorship law.
“For
the large majority of people on our streets, conservatorship is not the
right answer — there are other tools that will help them like voluntary
services or a shorter psychiatric hold,” Wiener said. “But for a small
percentage of people on our streets, they are in such severe crisis,
they can benefit from a conservatorship.”
Full Article & Source:
Why are more mentally ill people wandering SF streets? Report gives answers
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