I started work at San Francisco General Hospital’s Department of Psychiatry in 1987, when there were four inpatient psychiatric units and a wide range of outpatient services. Each of our inpatient units had multi-lingual staff, where patients could receive culturally-sensitive and appropriate care that was unique to their needs. Our LGBT unit, Asian and Latino-focused unit, African Americanfocus unit—they were award- winning. I was proud to work there.
I still am. But San Francisco’s mental health system is a shadow of its former self. While we once had 88 acute care beds, we now have only 22, and 22 subacute beds. We have a jail unit that can hold up to 12 patients.
I started at the General knowing that it had a patient population with complex challenges. We take the uninsured that the private hospitals do not, the homeless, the patients you see with mounds of belongings in shopping carts, occasionally muttering to themselves while walking down our streets.
Mental illness is a major contributor to homelessness. To end and help prevent homelessness, our city leaders must ensure we are meeting the immediate needs of the mentally ill and those experiencing homelessness. It takes a community of healthcare providers to care for patients with complex mental and physical health problems.
At SF General, nurses provide the around-the-clock care. Nurses inform the doctors of what kind of state the patient is in at any given time, dispense medication, write the 5150s—the involuntary legal holds—when necessary, delouse and clean up patients, get collateral information from available family members. We take on the functions social workers used to do because there are few of them left in our department.
We get assaulted by agitated patients who are detoxing or symptomatic from a paranoia, thinking we are out to harm them. We do it short staffed. We do it around the clock, on weekends, holidays. We care for our patients regardless of the circumstances.
Despite declining city investment in the work that we do or the hours nurses spend commuting to work because we can’t afford to live in this city, the psych nurses at the General do it all with aplomb. We do it because our patients need us and have no other place to turn to.
It’s a revolving door at our inpatient psych units, and far too frequently our homeless patients return in worse situations that when they’d come through the doors just days before. It doesn’t have to be this way. Study after study has shown that programs that provide long-term, stable housing with additional mental and medical supportive services improve outcomes for mentally ill homeless patients.
But in San Francisco there are few places to discharge our mentally ill patients, few facilities with room where they can’t do harm to themselves or others, few “halfway houses” that provide medical as well as psychiatric care, or anything in between. Instead we have patients stay at our subacute unit for many months awaiting placement or worse, they return to the streets without access to food, shelter, or other basic needs.
While I’m painfully aware of the shortage of psychiatrists in the department, I’m even more acutely aware of the shortage of the people who do most of the work there: nurses. We do the heavy lifting of delivering care to the mentally ill community in San Francisco, but the hospitals and clinics routinely violate the safe staffing ratios in place that keep nurses and patients free from harm.
San Francisco is one of the richest cities in the country, yet thousands sleep in our streets each day with many more on the verge of homelessness. The irony of it is that mentally ill, homeless patients must go to a hospital named after a billionaire who donated what to him is probably less than a day’s work, while the taxpayers ponied up ten times more than that.
Nurses cannot do our jobs if we are consistently under-staffed or lack the resources to provide wrap-around services to patients on the continuum of mental illness.
Services to the mentally ill have been cut not just to the bone but to the marrow and beyond. Those who suffer it have no lobby in Washington or Sacramento. We must be their voice. And our own.
Meg Brizzolara is a psychiatric nurse and member of SEIU Local 1021’s nurses bargaining team who has worked at San Francisco General Hospital for 32 years.