Health care workers hold signs before a rally to keep the beds at the Adult Residential Facility for permanent residents on the Zuckerberg SF General Hospital campus on Thursday, Aug. 22, 2019. (Kevin N. Hume/S.F. Examiner)

Frightening Embarcadero attack is an opportunity to improve mental health system

By Jennifer Friedenbach

Many San Franciscans now have the images of Paneez Kosarian fighting off Austin James Vincent in front of her Embarcadero condominium building burned into our collective memories.

This story of a young, severely impaired man, assaulting a woman to save her from what he thought were robots incited widespread fear, as mental illness is highly stigmatized and associated with violence even if the “violent mentally ill” typecast is a well proven fallacy. Since this incident, there has been much discourse on how to address the mental health crisis on our streets, from the misguided call to halt the creation of a new Navigation Center on the Embarcadero to thoughtful calls for solutions.

On the heels of this saga, the proposal to cut 41 long term beds in our only public board and care facility is a mindboggling disaster. The city has stated they will put 13 Navigation Center beds here instead; they are needed, but not nearly as badly as board and care beds. Worse still is the discovery that these golden beds have been held empty and all placements have been halted since September of 2018. Meanwhile, people in dire need were told no beds were available.

After Mr. Vincent was stabilized and responding to medication in a residential facility, he was removed and sent back to jail, where likely he will be in worse shape when he eventually gets out. If a board and care bed is available, he can be stabilized and live out his life with the opportunity for transformation, but more likely, with the loss of these beds he will return to the streets and decompensate again. It makes one want to run screaming down the street.

In the early 80s, many San Franciscans first noticed large numbers of people with mental illnesses wandering the streets. It was right after a little known but hugely tragic move by former President Ronald Reagan to remove all recipients from disability benefits. Untold thousands of people with mental health disabilities lost their placements in board and care facilities that their disability benefits had once paid for. As calamitous as that policy was, at least back then we had capacity in board and care facilities. However, in the years since over 2,300 of those beds have slipped away, as the old Victorians they are housed in are sold off to the next generation.

The loss of Social Security benefits was followed by realignment hitting California cities’ mental health budgets hard in the early 1990s. Between 2007 and 2012 the city enacted recession era austerity measures that cut $40 million more in direct behavioral health services, knocking even more folks to the concrete. Each of the last four decades have seen its own sword slashing deep into the heart of our mental health system, and each decade has lacked corrective action. Today, we are in no position to respond to a massive opioid epidemic, further complicated by a homelessness crisis. For the third of our homeless population impacted by mental illness, having no place to live makes recovery almost impossible, and instead they suffer more frequent and severe psychiatric episodes.

A whopping 4,666 homeless people are brought into Psychiatric Emergency Services at SFGH every year, and 1,786 are released back to the streets without even a referral. As we churn people through our system, we amplify harm, disintegrate trust and waste valuable investments. Meanwhile, our policy makers seem more interested in soundbites and juking stats than substantive change. They have shortened stays, so the city can serve more people, giving handy “success numbers” for press releases. They focus on do-nothing proposals that score political points. A long string of mayors take credit for adding programs, while quietly cutting others. Recently Mayor Breed announced adding mental health beds at St. Mary’s, but cut beds out of county. City officials stopped counting turn-aways and eliminated waitlists, so they can claim there are none. When San Franciscans ask, “why do we force people who are mentally ill to wander our streets?” it is a fantastic question, the same question asked by the people who are living it. We are failing our most vulnerable. We are failing our neighborhoods. Our once flourishing mental health system is now in shambles.

More important than “why?” though, is how. How do we get out of this mess? One of the most important things we can do is ensure there are beds at every level of care, from prevention, to crisis care, to residential treatment to most importantly long term housing for those who simply cannot care for themselves. Our system must be engaging and fluid and responsive on demand. We can’t keep separating substance use treatment from mental health, and we need to be real about our system failures. We must incorporate treatment for psychiatric trauma at every level of care. Alarm bells must sound at the sight of anyone with severe mental illnesses who appears homeless on the streets, and intensive assertive care must surround them. Once in care, that care must continue into housing. Otherwise, all that care, while offering important respite, will not mean much if the person is yet again homeless and churned back out to where they started. That status quo has to stop. These are big goals but with the political will that can only come from citizen pressure, they are achievable.

Luckily, there are measures on the horizon that will get us closer – Our City Our Home, which voters passed last November and is held up in courts, will result in over $70 million each year to build up our mental health system with new innovative approaches, while also creating the requisite housing to stabilize folks post crisis. Voters will also have the opportunity to pass Mental Health SF on the March ballot, that will provide Universal Mental Health care. In the meantime, let’s preserve the beds we have. That means holding onto our only public board and care beds at the Adult Rehabilitation Facility, and rising to address the staffing issues. This is too valuable a resource to walk away from. This also means that the city needs to quickly find somewhere for the navigation shelter beds.

When our hearts are broken in tragedy, all those pieces create more surface area, and somehow there is even more capacity to love. As awful as the Embarcadero incident was, it is an opportunity for change. It is our civic responsibility to ensure that the tragedy on the Embarcadero becomes not another missed opportunity but a moment for transforming our system into one that works for all of us.

Jennifer Friedenbach is excutive director of the Coalition on Homelessness.

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