2018- Homelessness is Not Just a Housing Problem

2018- Homelessness is Not Just a Housing Problem

Hardly a day goes by that there isn’t an article in the Chronicle about the homeless “mentally ill.” As one that worked in adult, inpatient psychiatry much of my adult life, I want to point out that this was not always the case that we read articles about homelessness almost every week.

When I first started working in adult psychiatry in 1974, we didn’t have encampments of mentally ill living in tents throughout the City. Before the 1980’s, Ronald Reagan and “managed care,” we still cared for our mentally ill. There were six California State facilities for the mentally ill, including Napa State Hospital. Ronald Reagan signed the California Community Mental Health Act when he was governor in 1969 and by 1975, many psychiatric patients were being transferred to “community placement” facilities or just discharged into the streets.

My job as a nurse during the 70’s & 80’s entailed evaluating patients for admission to a private. Adult, inpatient psychiatric facility in San Francisco. In the 70’s, patients could be involuntarily admitted to the locked unit if they were a danger to themselves, a danger to others or “gravely disabled.” The definition of “gravely disabled” changed dramatically in the 1980’s when profits began taking priority over patient care. Up until the 80’s, “gravely disabled” meant that a patient could not provide food, clothing & shelter for themselves & “shelter” meant an actual roof over your head. During the 80’s, when the emphasis changed to profits over patient care, the term “gravely disabled” conveniently changed too. As Republicans set about transferring the wealth from the working poor to the country’s idle rich, we started hearing the term “managed care” which was really more about managing costs and emphasizing profits than having anything to do with “care.” In fact, “custodial care” from the 1950’s made a comeback. Actual “therapy” became too expensive as nurse to patient ratios increased dramatically in search of more profits. More emphasis was placed on chemically restraining patients & just warehousing them if they were admitted to inpatient care at all.

During the 80’s, as I was going to the emergency room to evaluate a patient for admission, I remember a manager telling me, “unless the patient has a bullet in their head, do not bring them to the unit.” Medi-Cal” didn’t pay very well. The economic solution was to just quit admitting these patients.

In 1997, the SF Chronicle did a series of articles titled, “Retarded Pay Price as State Shuts Asylums / Death rate rises in shift toward community care.” This series thoroughly covered the tragedy that ensued from emptying out developmentally disabled patients from the State Hospitals like Agnews and Sonoma State into community hospitals which were ill equipped to handle them and chronically underfunded. Many died in the process. The State hospital system was always imperfect and an alternative to closing beds would have been to modernize them but that would have cost money that Republican politicians chose to give to the idle rich instead.

When we look at homelessness before Reagan and post Reagan, we see the numbers of mentally ill homeless skyrocket. By the late eighties, no longer is a patient considered “gravely disabled” if they are eating out of garbage cans and living on the sidewalk, defecating and urinating in the streets. Patient care took a back seat to profits. Treating the mentally ill and housing them was more expensive than letting them die on our streets. The courts essentially colluded with the politicians in changing the rules to accommodate profits over patients, in the name of “patient rights,” re-defining the term “gravely disabled” to be meaningless.

Napa State Hospital went from 4991 patients in 1960 to 1255 patients today. Where are the other 3736 patients? Just look around the streets of San Francisco. They are living in tents and self-medicating with alcohol, crack, meth and opiates in the shadows of luxury high rises where Russian oligarchs, the Chinese and other foreign investors launder or park their money. Many of those luxury high rise condos sit empty during a housing shortage and the mentally ill sleep in tents just outside their doors.

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