First do no harm.
Greek physician, born 460 B.C.
First do no harm is the central tenet of the Hippocratic oath, the words with which the founder of modern medicine defined his craft. Hippocrates held that the body should be treated rationally and as a whole, rejecting the belief common to his time, that illness was the result of evil spirits and disfavor of the gods.
Hypocrisy: The practice of professing beliefs, feelings, or virtues that one does not hold or possess; falseness.
American Heritage Dictionary, Fourth Edition. 2000
A common fallacy is to equate the Hippocratic oath with the word hypocrisy. When it comes to the most prevalent ways in which the oft-twinned (most frequently in a joined-at-the-hip kind of way) topics of substance abuse and mental health are viewed—and, more importantly, dealt with—it’s easy to see how the error came into being.
It’s been said many times that “No one can remain personally unaffected by the current crisis in substance abuse and mental health.”
While that statement might initially strike the ear as overly sweeping, even individuals so fortunate to have walked unscathed through these minefields themselves are almost certain to have at least one relative less fortunate in this regard. Or failing that, most people admit to knowing someone who knows someone who had a problem with [pick one: a) alcohol; b) belligerence; c) cocaine; d) denial; or e) everything previously mentioned plus a whole lot more].
Fact is, all of us are all too likely to be more familiar than we would wish to be with this troubled territory and the terms used to talk about it. The specific jargon used in discussing the entire continuum of substance abuse and mental health disorders reveals a phrasebook rife with rhetoric—from the oldest, most familiar adages of apology for perceived wrongdoing to the newest and most politically correct of catchphrases that seek to mitigate actual negative outcomes.
I’m OK, You’re Addicted and Homeless
For a society that has taken the whole “addictive paradigm” to extraordinary lengths, and in a city known for its broad tolerance of other-than-mainstream behaviors and lifestyle choices, public approaches and private attitudes toward substance abuse and mental health issues in San Francisco remain surprisingly conservative and judgmental, especially as they relate to the City’s homeless population.
While it’s entirely a matter of course to overhear “I’m just an absolute nut about coffee,” or “I’m a TOTAL sugar junkie,” in the buzz of local coffeehouse conversation, if you change the setting to the City’s streets and the words to “I’m just an absolute nut,” or “I’m a stone heroin addict,” the response changes significantly.
This may seem a ludicrous comparison to draw, but think about it for a minute: very real and major recent strides have been made toward improving treatment options for—and even more important to many, removing the stigma from—addictive and/or mental disorders. But the fact is that these improvements fail to reach the already disenfranchised and marginalized homeless population. And if that sounds too theoretical, here’s a concrete example of how this very real difference might play out in practice.
Set and Setting; Stigma and Stimatization
Jack and Joe (it could just as easily be Jackie and Joanna) both have difficulties in dealing with stressful situations and “self-medicate” to cope. However, Jack is employed by a large software firm with a relatively good and enlightened benefits package. So when his coping mechanism of choice gets a little out of hand, and he’s found unconscious in the executive washroom, the resulting ambulance trip swiftly and seamlessly segues into a month-long stay in a comfortable hospital-based residential treatment program. After completion, Jack is welcomed back to his job, encouraged to continue with ongoing counseling on an outpatient basis, and, in general, supported both financially and interpersonally in his “efforts to cope with his lifelong, life-threatening medical condition.”
Contrast this with stresses experienced by the equally tension-hating Joe resulting from his sudden layoff from a job he believed would see him into retirement—a blow rendered doubly devastating by his wife’s prompt decampment for her parents’ house with the couple’s two adored young children in tow. Fast-forward a few months, and we find an emotionally crippled, baffled, and isolated Joe living in the streets when he, like Jack, fails to cope with coping and collapses unconscious.
You see where this is going; if you spend any significant portion of time on our City’s streets, you probably know the drill. First, people walk past Joe with averted gaze (and those are the relatively polite ones, the ones not pointing fingers and shaking heads, muttering about the messy morals of the homeless). Minutes and even hours then pass before some brave soul musters the courage to get in close enough to check Joe’s pulse or listen for his breathing and an ambulance is finally summoned.
The distaste of passers-by and resulting tardy ambulance trip are just the first in a series of less-than-optimal outcomes based solely on Joe’s recently acquired status [read: “lack thereof”] as a member of the homeless population.
At SF General Hospital’s eternally overcrowded ER, Joe receives immediate emergency first aid to keep life in body, but once his vital signs are stabilized, his “treatment” is over before it’s properly begun. Despite obvious psychiatric crisis, as well as no small degree of physical distress, Joe is simply given a list of public programs that might be relevant to his needs and then shown the door. Without financial or interpersonal support, further traumatized by his near-death experience, he looks at the piece of paper, imagines the stress of showing up at some unfamiliar doorstep as a “homeless addict,” and heads back to his street haunts a broken man. Another ambulance ride might be Joe’s last.
Shame on Me, Shame on Us
Shamelessly argumentative, yes. But it serves to illustrate an infinitely more shameful reality: the continuing—and due to public health and social services funding priorities, growing—gap between private sector and public sector responses to sufferers from substance abuse and mental health disorders.
Consider this: The two men in our example had the same medical problem and the same treatment needs; quite simply, one had those needs met, the other did not—and the outcomes were dramatically different. It’s also important to note our story could have stacked the deck even more strongly without stepping outside the everyday reality of this contrast, because for all-too-many real-life Joes, the next few rides might be in a police car headed toward the County Jail rather than in a hospital-bound ambulance.
In our scenario, the private sector response reflected much of the current wisdom regarding “best practices,” another term of art in this arena. Jack was treated as a rational being with a life-threatening, probably lifelong, medical condition. For this he would initially require urgent and later, ongoing, assistance in order to survive, let alone go on to lead a relatively normal and productive life. Jack’s treatment included medication to help ease the strain of transition, and both one-on-one and peer counseling sessions that encouraged him to examine root causes for his unhealthy coping mechanisms and assisted him in establishing new, healthier ways of dealing with stress. In short, Jack received timely, holistic, affordable (because of private health insurance, mind you) treatment in a caring, supportive community context.
Access to Treatment: The First Hurdle for Homeless People
In stark contrast, Joe’s treatment was over before it began. And sadly, this is another area in which our example erred on the side of oversimplification. In Coalition on Homelessness surveys that went straight to the source, homeless people with substance abuse and mental health issues were found to be surprisingly tenacious in their attempts to secure adequate treatment. More specifically, Scoring Treatment: The San Francisco Substance Abuse Treatment Study, a SAMH Workgroup report released just last November, found that a full 75 percent of the more than 300 survey respondents (who had already self-identified as having problems with drugs or alcohol) had sought treatment up to three times. And an amazing nine in ten of those surveyed stated that they would enter treatment that very day if it were available.
Findings like these lie at the heart of the COH’s Substance Abuse and Mental Health (SAMH, familiarly referred to as “Sam”) Workgroup’s efforts. According to SAMH staffer Jennifer Friedenbach, “Our goal is to ensure that our constituents get their basic health care needs both recognized and met with available treatment—treatment on demand.
“People with mental health issues and addictive disorders are engaged in a deadly lifelong struggle, like diabetics. But these conditions have gone untreated forever: Mental health budgets are the first to be cut, and related health care needs are the first to be ignored. And it’s an ongoing, unnecessary tragedy, because suicide and overdose are both preventable deaths.”
First staffed in 1995, the SAMH Project can look back at nearly a decade of achievements and frustrations. Among the former is its ongoing championing of harm reduction policies, including a strong voice in designing McMillan Center, A Woman’s Place, and Oshun—all initially conceived as safe, easy, friendly “low threshold” places where addicts could get off the streets, away from the cops, and interact with supportive staff.
Other positives include the establishment of community-centered planning bodies on which mental health consumers and those with addictive orders are represented, and some major improvements in the mechanisms by which San Franciscans can access treatment.
How bad was it? “Before the changes,” says project coordinator Diana Valentine, “it was easier to get mental health treatment in San Quentin Prison than in San Francisco. Then when the state mandated an 800 number for central access to mental health services, we not only insisted that the city follow suit, we worked for the establishment of actual drop-in centers—places that people could go when they needed care.”
Friedenbach elaborates, “We push ‘standardized’, not ‘centralized’, care, because the ‘centralized’ model creates its own barriers of race, age, and culture.”
Funding Harm Reduction, Fighting Fund Reduction
Like that of its constituents, the SAMH project’s struggle to cope with substance abuse and mental health issues is both lifelong and continually beset by new challenges. Redirecting Matrix funding used for “quality of life” enforcement to create a special City team trained in preventing homeless deaths was a significant victory, as was using “workfare” screening money for SSI advocacy, making San Francisco a national leader in ensuring that its citizens with disabilities retained their benefits during the Contract with America debacle. But for every achievement there also seems to be a downside: a promising program whose funding is cut; a new shortage of staff or shortening of hours.
Currently, SAMH staff members are engaged in fighting what they characterize as a “rearguard action” against proposed City budget cuts. “We’re succeeding for the most part,” says Friedenbach. “Actually, Newsom’s budget didn’t target our efforts for our constituents as badly as Brown’s.”
In fact, prior to his mayoral election, Newsom was regarded by those in the field as “the treatment-on-demand guy” on the Board of Supervisors, so there’s some hope that his administration will produce much-needed improvements in City services targeting those in need of treatment. Efforts now on the table include additional training for police on handling psychiatric crisis calls in an other than “Command and Control” modality, establishment of a 24-hour voluntary drop-in center for those self-identified as in psychiatric crisis, and funding for additional free methadone maintenance slots in not-for-profit programs.
But so far, while not singling out substance abuse and mental health programs for cuts, Newsom has not exactly made this area an administration priority either.
Unfortunately, the strong sensitivity to stigma around substance abuse and mental health disorders tends to further cloud the already cloudy issue of appropriate public policy in this area. Friedenbach says, “We just keep on working to affect policy on behavioral health, to afford avenues for formalized input from both consumers and providers, and to create an agenda that represents the actual needs of the consumers.”