The Coalition on Homelessness is an organization consisting largely of homeless and formerly homeless people, as well as front-line staff of homeless service agencies. Many of our members have been impacted by mental health and substance abuse issues. We feel that it is critical to have consumers themselves included in the creation and implementation of policy that affects their lives. The Coalition is excited about the potential the Mental Health Initiative presents for addressing both the symptoms of psychiatric disorders and the factors that cause and contribute to mental illness. Proposition 63 has the potential to transform the mental health system here in San Francisco and across the state.
The Coalition on Homelessness has a number of recommendations for the Mental Health Services Act (Proposition 63) that we would like to see implemented. The link between the absence of affordable housing and the exacerbation of homelessness and mental illness is well documented.
Following the trajectory of San Francisco’s Housing First homelessness policy, the Coalition on Homelessness would like to see more funding directed toward the development of permanent housing accompanied by wraparound support services to ensure that people impacted by psychiatric disorders placed in housing are able to remain there. However, “Housing First” must not be interpreted or implemented as “Housing Only.” According to homeless people with psychiatric issues, they need safe, clean and permanently affordable housing—but they also need real treatment, jobs and medical care.
Homeless people would like to see treatment that is comprehensive, individualized and flexible. They want to direct their own treatment plan, and have a strong voice in the creation and operation of programs. Many want medications, many want therapy, many want peer support, and many would like to have activities that relieve the sense of isolation.
In the context of Proposition 63, and all the potential it brings to transform San Francisco’s mental health system, the Coalition would like to see these policy changes implemented and funding directed towards these new initiatives and programs that embrace these concept recommendations.
Client Centered Processes
People with psychiatric diagnoses need to be included in the organizational structure of the agencies that are mandated to serve them. The voices of clients can and must be incorporated in as many aspects of program planning and development as possible. “Client centered” means more than taking an occasional survey or having a client sign off on a treatment plan. A truly client-centered program involves the clients in its own design as well as in its ongoing operation. Clients are at the center of the treatment plan, and plans spin out from them, as opposed to being a footnote. Clients are hired onto staff, at the management level, and clients serve on the Board of Directors.
Easy Access to Services
It should be simple for persons requesting help to receive it. There should not be extensive initial paperwork or eligibility requirements and emphasis should be placed on meeting the clients where they are. Extensive waits for appointments often result in losing potential homeless clients from treatment. Positive first impressions are also important in engaging people in treatment, and clients should get a strong sense they are going to get something tangible from treatment as opposed to getting the proverbial runaround.
There is a need for intensive social supports as an integral part of mental health treatment. Intensive social supports include methadone treatment, legal assistance, housing subsidies, transportation, ID, food, and overall community development. Without these supports, psychiatric symptoms tend to be exacerbated.
Structural Economic Factors Exacerbating Mental Illness and Social Pathology
The Coalition on Homelessness supports the development of diverse programs and treatment modalities that are culturally relevant to disadvantaged populations. Our organization endorses an assertive anti-oppressive orientation in order to address and challenge factors such as institutional racism, cultural imperialism and marginalization.
It is also important to address the fact that poverty and homelessness are primary factors contributing to the severity of psychiatric symptomology. People with psychiatric disorders are more able to manage their conditions and avoid hospitalization when they have permanent housing and access to supportive services such as medication and psychotherapy. People with jobs that pay an equitable living wage who have stable, affordable housing are more likely to avoid homelessness and a worsening of psychiatric problems they may be experiencing.
While we are enthusiastic about the potential that the MHSA presents not only for deepening the mental health services funding stream, but also for going beyond addressing the effects of mental illness and social problems to address their causes. Mental health (and medical) services should be universally available and housing should be recognized as a fundamental human right. We feel that homelessness is a public health emergency that can be remedied by the creation of more affordable housing, mental health treatment and living wage jobs for people in compromised housing situations.
24 Hour Voluntary Psychiatric Emergency Centers
There is a need for a 24 hour drop-in program that can serve sub-acute people in crisis who do not meet the criteria for 5150 but who are in need of stabilization, monitoring and medication evaluation in order to avoid emergency hospitalization or police intervention. These programs should have a low threshold of engagement and provide a mixture of peer and professional services. This consumer friendly drop-in center would serve people with mental illnesses after hours and be accessible both in person at the center and by telephone. Peer and medical crisis intervention would be provided to individuals in mental health crisis. This program should be primarily client run and staffed and it should be recovery based. It needs to be designed as a respite or safe haven where persons in distress are served by other mental health consumers and psychiatric survivors.
There are no after-hours psychiatric services in San Francisco, with the exception of Psychiatric Emergency Services at San Francisco General Hospital. Individuals who experience psychiatric crisis after hours are dealt with by the police, and when necessary taken to the hospital. In fact, one in four police calls are responses to individuals in psychiatric crisis, or individuals “acting with bizarre behavior,” with the overwhelming majority occurring after hours (SFPD, 2000).
This is counter-therapeutic, and often leads to permanent distrust of psychiatric services on the part of the consumer. A large proportion of homeless people with mental illnesses requested 24-hour services, as documented in the survey report “Locked Out” by the Coalition on Homelessness.
After-hours crisis services would lead to a decreased reliance on San Francisco Psychiatric Emergency Services. After-hours services would also prevent psychiatric episodes from escalating in most cases, avoiding the need for expensive hospitalization.
Programs for Under-served Populations
There is a need for special focus on program development and population-specific mental health treatment for underserved populations including homeless, youth, transgender, undocumented immigrants and families. Programs should also be culturally specific, not only because cultural and language barriers functionally exclude many communities from treatment, but also because treatment is more effective within a cultural context. Programs should either be culturally specific, or if multi-cultural, should be able to be inclusive.
Alternative Treatment Paradigms
The Coalition on Homelessness believes that the definition of mental health treatment needs to be expanded to include alternative modalities, especially the self-help and peer-based service models as well as the clinical model. We would like to emphasize our concern for continued development of agencies that incorporate consumers as part of the service delivery system. The traditional dichotomy between professional service provider and person in client status reinforces disempowerment and maintains classism by sustaining a hierarchical relationship in which a formally educated expert is considered to be the only one who is qualified to serve as agent of personal change. The development of culturally relevant community development centers that utilize paradigms such as retraditionalization and political activism for social justice as therapeutic trajectories within marginalized and immigrant communities should be supported.
We are strong supporters of the harm reduction approach to treatment and feel that Proposition 63 funds should be directed towards agencies that incorporate it. Abstinence from drugs and alcohol is often too great a step for someone to accomplish initially, so efforts should be made to reduce the harm caused by drug use. We at the Coalition believe that people should not be denied medical or mental health services because of co-existing substance use disorders, and programs should adhere to health based education and intervention in substance abuse.
Linkage to federal entitlement programs should be an essential aspect of mental health treatment. Assessment and documentation of disability as well as advocacy to federal agencies should be coordinated with any services received. Additional SSI advocacy is needed as there are thousands of individuals in San Francisco who should qualify for disability benefits and MediCal, but because of the difficult application process and arduous documentation requirements, cannot get it without legal assistance. This assistance should be on-going as data shows a disproportionate number of mentally ill people lose their benefits during re-evaluation.
Because the Social Security Administration process is so difficult to navigate, individuals need assistance attaining and retaining disability. This not only improves people’s lives with increased incomes and medical benefits, but also saves the city substantial amounts of money. The city is able to recoup General Assistance funds, as well as medical costs. For every individual receiving benefits, an average of $15,400 is saved annually. An additional 60 people added onto disability rolls, for example, saves at least $621,000 in GA costs and $765,000 in MediCal costs, for a total of $1,386,000 in direct city savings.
No Forced Treatment
The Coalition would not like to see funds from MHSA to go towards the implementation and perpetuation of involuntary, forced treatment. We want the money from MHSA to be used only for voluntary, community-based services that are client-centered and support choice, autonomy and self-determination.
Reinstate Single Standard of Care Policy
In San Francisco’s mid-year budget cuts, an arbitrary change happened to eligibility requirements for medically indigent persons utilizing mental health treatment as a way to save funding. This change was a reversal of the single standard of care whereby individuals without insurance and without the right diagnosis lost their access to treatment. Uninsured individuals who suffer from anxiety disorders, mild depression, and post traumatic stress disorder no longer qualify for treatment. This policy must be reversed.
The Coalition supports providing mental health services to anyone who requests them. Psychiatric symptoms can be life threatening and should be provided to anyone regardless of their medical, financial or immigration status. Persons who are uninsured by MediCal or private insurance should be able to get the same level of care as someone who is. No one should be denied these vital services.
Reduce Criminalization of Persons with Mental Illnesses
To ensure a truly positive transformation in mental health, there is a critical need to reduce the numbers of people who are arrested and incarcerated as a result of their illnesses. All parties involved should be included in this effort to make it a reality. This includes the judges, police, public defenders, district attorney and sheriff departments.
There is a need for better planning and increased resources for discharge from hospitals and other institutions. While the efforts over the past year have made some positive progress, there continues to be a need for work in these areas. We feel that no one should be discharged to streets, and that there must be services/housing in place, not just linkages to services/housing. This can be incorporated in the national trend toward the Housing First model. Discharge into Single Room Occupancy hotels is not adequate for mental health treatment.
Given the high frequency of co-occurring disorders among indigent mental health consumers, we support the ‘no wrong door approach’ to accessing substance abuse and mental health treatment. There should be multiple access points to the system, and all should be easily accessible. We support treatment on demand, meaning that persons with addictive disorders should receive treatment at the point in time that they need them. Historically the lack of easy access to mental health services has fueled a tendency among poor and homeless people towards self-medication with drugs and alcohol.
Vision for the Future
The Coalition on Homelessness is enthusiastic about the potential for substantive changes to the public health system the Mental Health Services Act holds. Funding should be prioritized towards client-centered programs that incorporate consumers at all levels of program design and implementation. Twenty four hour emergency psychiatric care must be made available to all people regardless of income or immigration status.
Furthermore it is essential that these programs reflect the concerns of disadvantaged communities by providing culturally relevant, accessible services.
Participation in the MHSA Task Force subcommittees is a vehicle by which the interests of consumers can be reflected through the formulation of recommendations to the state review panel for approval and implementation. Given the recent local, state and federal budget crises concerning cuts to Mckinney, HUD and Section 8 it is imperative that MHSA funds are not seen as a remedy for these inexcusable reductions to homeless services.
Contact the Coalition on Homelessness for more information on how to become involved in the community process of insuring that consumers’ voices are heard. It is only with assertive, consumer inclusive program design that the Mental Health Services Act can be made into an effective tool for providing services to those who need them most.