Poverty, the Law, and the Voices of People with Mental Illnesses
by Marykate Connor
Caduceus Outreach Services
In every commentary that the SF Chronicle has printed in response to their full-page editorial "State of Neglect," not once have they chosen to reveal or discuss current laws in context with the issues of poverty and wealth that govern involuntary psychiatric treatment and detention - and the lives and deaths of psychiatrically ill people in our state.
Current law (California Welfare and Institutions Code 5150-) states that a person can be involuntarily detained for 72 hours, then an additional 2 weeks, then an additional three months, and then an additional year - IF they meet criteria for these kinds of detentions. Those criteria are: being a danger to themselves or others, or gravely disabled. Grave disability is defined as being unable to provide basic care for oneself (such as food, clothing and shelter,) due to psychiatric illness. At any time during these detentions if a physician feels that medications are warranted and the patient refuses to take them, the physician can file for a Reese hearing, citing the patient's lack of competency to make decisions and force the patient to take the medicines.
So why are the people in Assemblymember Helen Thomson's (D-Davis) camp agitating for changes in the current laws?
Because the current laws are not being enforced.
Because it has been deemed too expensive to provide real care for the psychiatrically ill, and the stigma of psychiatric illness has relegated people with this condition to third-class status, and thus third-class medical care.
It is far more difficult to get into any level of care at this point than it is to buy alcohol, or street drugs, or a gun. The only way for an uninsured mentally ill person who knows that they need to be in the hospital to be hospitalized is to be involuntarily detained - essentially allowing themselves to be psychiatrically arrested. There are few if any beds for the under- or un-insured, and only those that are required by law will receive acute in-patient treatment.
If a person is so ill that they warrant a conservatorship (which would allow the court to place them in a locked hospital for up to a year) there is a waiting list that is 6 to 9 months long for placement. People who wait in expensive acute care hospital beds are "decertified" by California's Medi-Cal system because they warrant a different level of care, and the hospital is not reimbursed for their stay.
In San Francisco, people who cannot prove residency in this County for at least one year are not eligible for this level of care. If the person is homeless, there are few ways that they can prove such residency.
The only way that this same person can get into supported, subsidized housing is to wait for 18 to 36 months on a list, then pray that when their number does come up someone will come and find them to let them know - and that they are still alive and coherent for an interview where they may or may not be accepted into that housing. There is nowhere for them to wait for housing since all residential treatment programs have waiting lists, and usually take people that have been hospitalized first.
The Chronicle completely overlooks the utter lack of affordable housing for anyone making less than ,000, which in San Francisco is considered "low income". People on SSI receive 48.00 per year. The average hotel room on 6th St. rents for 0.00 per week, or 60.00 per year, leaving only 9.00 per month for food and everything else.
In order to get into a treatment program providing support with medications and social services you have to became so crazy that you become involuntarily hospitalized; even then there is no guarantee that you will get anything other than a brief stay in a psychiatric emergency room and handed a discharge disposition that reads "released to the community" or "released to independent living." Both are euphemisms for dumped on the streets.
There is no capacity in any of our treatment systems for people who need, want and are seeking care, and are living and dying on the streets for lack thereof.
The only thing that would be solved by a change in the laws that govern involuntary treatment would amount to a further ability to blame the patient for their lack of compliance to a treatment system that does not exist.
How did this happen? It does go back to the Reagan years, both as Governor and as President. It has to do with money, more than anything else. When state hospitals were closed, money from the cost savings was supposed to follow the patients released into the community. In San Francisco it did, until 1979 when the so-called "taxpayers revolt" (the Jarvis-Gain tax bill) was enacted. Then there was no longer enough money in the State's coffers to support public services. Services were cut, and "life saving" services like police, fire and emergency medical services were deemed more necessary than treatment for mentally ill people. These cuts, once made, were irreversible.
Residential half-way houses cut their stays from 2 years to 3 months. Outpatient clinics closed, residential treatment capacity was lost, and housing became more expensive.
While Reagan was President these cuts continued, and during the '80s we lost virtually our entire community treatment system.
In the '90s, due to lack of funds, the criteria for treatment became extremely restricted, and the damage was further entrenched. People who tried to get into treatment before they were in acute crisis warranting involuntary hospitalization were routinely turned away from outpatient clinics, and were given excuses like "get treatment for your addiction first, then we will treat your mental illness."
There was no treatment for mentally ill people who were also addicted to drugs or alcohol, who might need medicines to control symptoms of mental illness like paranoia or delusions. The substance abuse treatment system was based on a non-medical model that discouraged and condemned the use of any drugs, prescribed or not. There was no way that a disorganized schizophrenic or someone with bipolar disorder could survive this treatment system, much less figure out how to get into it. The same cuts affected this systems capacity in the same devastating ways as they had the mental health system.
So what is a person who hears voices that tell him that he should cut his throat or kill the President to do? What is available in plentiful supply and works briefly is alcohol and street drugs. Heroin is very useful for voices. Alcohol helps you fight the chill of the street and make friends fast. Speed can clear your mind temporality until you crash, and crack will allow you to feel pleasure for the first time in your life, breaking through the numbing despair of trauma and alienation that prevents feeling anything at all... except fear.
In a horrible and prophetic bit of irony, the California Department of Corrections had broader treatment criteria than the City and County of San Francisco. This was only because of multiple lawsuits faced by the CDC stemming from prisoner suicides.
Combined with racist mandatory sentencing laws, thus began the great increase in California's prison population, and the bitter joke was born that the only way to get treatment was to go to jail.
This continued until '96, when San Francisco's Community Mental Health Services adopted a supposed "Single Standard of Care". It was supposed to ensure that all people, insured or not, would receive the same treatment. What never happened was the allocation of adequate funds and increase of resources, so the Single Standard of Care has become another cruel joke for those poor and homeless people that need it most.
We are in this extraordinary debacle because of lack of political will, which controls funding.
Mentally ill homeless people do not constitute a power base that can lobby for funds that would make it possible to live healthy lives. No matter how many times we go to the Mayors office, or Sacramento, or Washington, we are seen as brain damaged, feeble-minded, and therefore expendable. We are not, and have never been a priority. This is the stigma that surrounds mental illness.
There are always more pressing populations costing less to "fix," and that will be more attractive on the evening news. We also represent a great fear - the fear that any one of you could end up like us, and that there is no cure for this most devastating and complex of conditions.
One in 5 of us will suffer from mental illness in our lifetimes.
Yet we are pitied, or hated, and routinely shunned - especially those of us most visible, forced to live publicly, and too poor to get any relief except a crackpipe or a bottle of vodka. We are the living embodiment of a nation that values property and wealth more than human life; then justifies this with cynical "bootstrap" theories fueled by fear, racism and ignorance, rather than policies and funds to actually provide accessible, voluntary, community-based treatment.
So before the SF Chronicle advocates for "reforming our system" by changing the laws that protect the already fragile civil rights of poor and mentally ill citizens, it should take a hard look at what the reality of the current laws are. They cannot be enforced because of the lack of capacity in all of our treatment systems, and they turn away people in the thousands every year. The only system that doesn't is our prisons.
Before the CHRONICLE advocates for "reform of our system" by eroding laws to protect the already fragile civil rights of poor and mentally ill citizens, it should take a hard look at the reality of our current laws. They cannot be enforced because of a lack of capacity in all of our treatment systems, and we turn away people from treatment in the thousands every year. The only system that doesn't is our prison system.
Because of money... or the supposed lack of it.
If this were any other devastating disease, like cancer or AIDS, there would be a huge public outcry. It would be intolerable that people who have this illness are forced to live and die on our streets, before our very eyes, with the only hope of survival being incarceration.
For every story published of a grieving family member or someone forced into treatment who is better off, we can tell you ten stories of people who have been turned away, who have given up, or who have died. There are no real stories on the criminal state of official neglect that has been in existence for years.
This neglect is not due to laws that protect the so-called civil rights of mentally ill people; it is due to governmental indifference and corporate greed.
"You have the right to live and die on the streets because it's easier to blame you for your own condition than to admit that our health care system and real estate market is governed by greed - and YOU do not generate ANY profit for US. Besides, you are smelly, scary and you don't vote. You barely know what is happening to you or how to fight it, because you are too consumed by your own illness to advocate for yourself effectively. So, in order to appear like we care, we will change the laws and say that its for your own good - even though we know that you will not get any more treatment because of the change in the law - because we are unwilling to fund this for you. And since we have now changed the laws, you are now guilty of not being in treatment that does not exist, For breaking the law, you will go to the place that does have room for you - prison."
Marykate Connor co- chairs the Coalition on Homelessness' Substance [Ab]use/ Mental Health Workgroup (SAMH). For more information about current California legislation on involuntary mental health treatment, or to get involved, call LS or Jenny at the Coalition: 415/346.3740.