Thomas Jefferson's voice echoed through the San Francisco Board of Supervisors' vaulted Chambers as he stood at the podium on Thursday, February 25, addressing a Joint Hearing of the San Francisco Mental Health Board and The National Alliance on Mental Illness.

Jefferson, 51, speculated intelligently about the limitations schizophrenia placed on his life. “Had my mental health been treated early on, I might have been President. Most seriously!” He smiled with confidence. The audience smiled back.

Jennifer Johnson, Deputy Public Defender, is Jefferson's attorney at Behavioral Health Court where he is one of 100 seriously mentally ill clients she represents. If not for BHC's dual diagnosis program which treated his mental health problems and drug addiction, Thomas fears he would have been “pushed out into the streets” or ended up “in prison somewhere.”

A client with San Francisco's Citywide Case Management, Mr. Jefferson, participates in a long-term treatment program where he remains stabilized on medications and has been able to “better myself...and hold a job.”

Both Jefferson and Annette Robinson suffered severe psychiatric illnesses that remained undiagnosed until well into adulthood. Incarceration finally brought both the help they needed.

Soft-spoken Robinson's sweet voice touched attentive listeners. “When I was arrested in San Francisco, when I went to jail, I don't think anybody knew how to help me.” She recalled that her mind, “was totally gone. Diagnosed with bipolar disorder, “It was a shock to me. I have never seen myself as someone who could not control her own mind.”

Annette lavishes appreciation on staff and caseworkers at the Behavioral Health Court and Citywide. “They've all shown me an unconditional care about how my life turns out.

“I do need help still. They have allowed me to get to a place where I can do things on my own. I can start to go back to work. I am going to school now.”

NAMI's Gifford Boyce-Smith, M.D. acknowledged their courage. “I'm not sure I could [undergo] all that they've gone through in their life, then stand in a public session as intimidating as this venue, and talk about how they got through Behavioral Health Court, are now pursuing education, holding down a full-time job, maintaining a residence completely on their own, and thanking the City of San Francisco for the services they received along the way.”

The hearing was organized through the coordinated efforts of the San Francisco Mental Health Board, the National Alliance on Mental Illness, and the Physicians Organizing Committee --- doctors and grassroots supporters advocating for public health in San Francisco and statewide.

James Shaye Keys, Mental Health Board Chair, and Helynna Brooke, Executive Director, conducted and recorded the Joint Hearing to facilitate consumers,' citizens,' and stakeholders' testimony and data regarding budget cut impacts on the mental health system. Gifford Boyce-Smith, M.D., President, represented the San Francisco affiliate of the National Alliance On Mental Illness [NAMI].

Eleven Board Members sat in attendance --- Vice Chair Susan McIntyre, Del Milfay, Pat Fischer, Fred Martin, Mary Ann Jones, Ph.D., Lara Siazon Arguelles, Officer Kelly Dunn, Tom Purvis, Lisa Williams, Errol Wishom and Virginia Wright.

Chair Keys plans to compile a report for the Mayor and Supervisors presenting testimony and figures from participants ---- the “people on the ground ---- basically saying 'Stop The Cuts. Put More Services Back Into Mental Health.'”

Gifford Boyce-Smith, M.D. summarized this hearing's aggregate testimony of “front line, dedicated professionals” --- physicians, an SFPD Lieutenant, jail staff, a homeless expert, public defenders and district attorneys, normally in opposition but on this issue, agreeing --- “all of them describing the fallout of inadequate options, (and) inadequate services for people... struggling with mental illness” in San Francisco.

“They paint a very stark picture. Instead of treating mental illness, we are criminalizing mental illness. It really doesn't have to be that way.”

Jennifer Friedenbach, Executive Director, San Francisco Coalition on Homelessness, described analyzing the budget for cuts, impacts, savings, harmful or wasteful expenditures, or to stave off major cuts --- trying to shift funds to poor and homeless services.

Friedenbach reported that this year DPH cannot yet predict its Federal FMAP revenues, hospital fees, and extended Medi-Cal waivers, so hasn't presented its budget. However, for the past 15 years--- whether surplus or deficit --- DPH has “highly targeted” substance abuse and mental health services for cuts.

Human Services is substantially cutting supportive housing services almost exclusively serving people with severe psychiatric illnesses. “Therefore, the chance ... individuals without the support services (could) become homeless again --- is pretty high,” she stated.

Multiple participants cited lack of early prevention and treatment which would keep the mentally ill out of jail. At public comment, Piers McKenzie, concerned about bed cuts, related his daughter's psychotic episode a few years ago. Early intervention at SFGH, when beds were available, restored her normal life, including marriage.

Lieutenant Mark Solomon, SFPD Field Operations, and Dr. Cameron Quanbeck, Psychiatric Emergency Services Forensic Psychiatrist, reported a “Front End Bottleneck” in “acute service utilization.”

Lieutenant Solomon works with the 6,500-strong SF homeless population. He sees drug / alcohol-related incidents masking “the real problem” --- untreated mental illness. Bumped up ER 5150 admissions are discharged before the officer finishes the paperwork. Patients too disorganized to seek followup treatment return to the street, repeat the activity and end up back in the ER. One recidivist with numerous 5150s turned criminal, got violent, and hurt an officer. “ I feel if he had received longer term treatment, he wouldn't be criminalized for this. These budget cuts have exacerbated this problem.”

Dr. Cameron Quanbeck painstakingly detailed a similar “Revolving Door Pattern” caused by an underfunding-generated lack of beds. The client is admitted, receives stop-gap treatment. Discharged to the community, the unresolved psychiatric problem inevitably brings him back.

The worst outcomes are the enormous cost of failure and the criminalization of the mentally ill. Dr. Quanbeck described “Jason,” a 24-year-old African-American male paranoid schizophrenic. On medications, he is “pleasant, engageable, enthusiastic, self-motivated.” Off meds, he suffers paranoid delusions. Fearing poisoning, “Jason” refused food and assaulted a nurse. He was jailed for felony battery --- a quarter million dollar price. At the podium mike, Dr. Quanbeck simulated a “whooshing” sound. “More money going down the drain,” he said.

Mary Kate Connor, Caduceus Psychiatric Services Director, testified it costs $34,000 to incarcerate a mentally ill inmate in the San Francisco County Jail. County Jail's Behavioral Health Court releases people only to programs. Underfunding reduced program beds, so, “People spend more time in jail, and more money is spent incarcerating them.”

Physicians spoke of inadequate, underfunded Inpatient Services. Loss of funding reduced numbers of beds. Dr. Quanbeck sourced the Treatment Advocacy Center's official count of the minimum bed number National average as 37. John Ross, M.D. cited local numbers, reporting that “5 or 6 yrs ago, SFGH had 84 non-forensic beds; now has 40 acute beds.” March 16, 2010 cuts could reduce the number further. When stabilizing a patient with medications, even one week can make a “night and day difference.”

Attendees reported a “Back End Bottleneck” as well, with inadequate or closed board and care facilities. Board member, Lara Arguelles was forced to move her emotionally challenged daughter out-of-county to a Sacramento Board and Care when none could be found in San Francisco. The alternative was arduous home care or losing her to the street.

Dr. Ralph Fenn, Psychiatrist at Family Service Agency, Chronically Mentally Ill in Board and Care Homes, who is Co-President with Nancy Brand to The Residential Care Association of San Francisco, testified in public comment, “There used to be 1,200 beds in the system. Now it is 500 and going down rapidly.” These include 65 facilities --- family homes with six to eight clients. He likened this situation to the bottleneck on the back end, constituting a loss to a massive savings in high end care dollars.

Other funding cuts deficiencies included loss of Step-Down Acute Diversion Units, inadequate discharge followup, lack of case managers, no full continuum of care or vital full-spectrum psychiatric services --- acute, subacute, and community based treatment programs

For Dr. Quanbeck, the “Take-Home Message” is simple. The entire mental health system is broken. It is not modernized or structured appropriately to give the best care. Policymakers should improve it.

“Does it need to be that way?” asked Dr. Boyce-Smith. “Both Ms Robinson and Mr. Jefferson told us, 'No! Get me the services. Get them early before my life is in and out of revolving doors of prison or jail, and I can become a stable and productive citizen.'”

All opinions marched lockstep with Attorney, Jennifer Johnson. “Treatment is more efficient and cheaper than incarceration. There is no other way to say it.”

During public comment, business person, Daniel Gelgardo, characterized his brother-in-law with bipolar disease as “one of the kindest (most normal) persons I know.” He witnessed no episodes until a recent manic event. It was “one of the saddest moments of my life.” He guessed politicians and decision-makers without personal experience could “grasp” neither human cost nor the pragmatic side. “If we spend a little bit more today, we can save a whole lot more tomorrow.”

Mary Kate Connor reported she started her own nonprofit, Caduceus Psychiatric Services, because she was tired of what the public system and the Department of Public Health was not doing --- “legislating illness based on 'financial whimsy.'” Caduceus provides volunteer psychiatric services to 100 people yearly for as long as they need it. She stated flatly, “You can't tell us there is no money in this City. There is a lot of money in this City.”

With smarter care, stated Boyce-Smith, the City could save lives and make budget dollars work by implementing three suggestions:

Not-For-Profit hospitals, commensurate with tax breaks they receive, should return benefits to the community as increased services.

As a matter of City and County policy, hold the Public Health Department accountable to provide psychiatric services --- acute, subacute, community-based treatment programs --- the full continuum of care recommended by medical physicians.
Everyone testified to current inadequate services. “We should demand the City commission a gap analysis, (comparing actual performance with potential performance) and an investment plan to get us there,” advised Boyce-Smith.

Dr. Boyce-Smith quoted President Barack Obama this same day proclaiming he would like to see “at least adequate health care” for all United States citizens. Boyce-Smith wants the “best --- or at least adequate” --- care for mentally ill San Franciscans as well.