What the Fuck is Wrong With San Francisco? Severe Mental Illness and Drug Addiction

Every day I walk by people in pain. Sores fester on their legs and feet as they scream obscenities at the top of their lungs to people only they can see. At night I hear screaming outside my window. My friend recently had to move WeWork locations because someone tried to take his lunch from him and he can’t concentrate for homeless people arguing loudly outside. An acquaintance had to have surgery on her knee after a mentally ill homeless person shoved her to the sidewalk. 

Meth is certainly part of the problem. Half of deaths of homeless persons in SF involve meth. Nearly half of the unhoused people who ended up at San Francisco General Hospital’s Psychiatric Emergency Services unit between 2016 and 2017 suffered from a substance abuse disorder, according to a recent op-ed by Supervisor Rafael Mandelman.

But the bigger problem is our conservatorship system.

California’s current conservatorship laws are three years older than the federal law banning meth. Conservatorship means a court has deemed a person unable to care for themselves and assigned them a “conservator” to make decisions for them around health, lodging, and finances. The conservator is responsible for making sure the conservatee has adequate housing, nutrition, and medical care. 

Homelessness is exploding in San Francisco. It’s victims are likely to suffer from substance abuse disorders and mental illness as a result of the stress of homelessness. 

ER visits due to meth use have increased 600 percent and hospital admissions 400 percent since 2011. People high on meth make up 47 percent of the Psychiatric Emergency Services unit’s visits at SF General. Between 2016 and 2017, more than half of unhoused patients at San Francisco General Hospital’s Psychiatric Emergency Services suffered from a substance abuse disorder, according to a recent op-ed by Supervisor Rafael Mandelman.

And yet between 2012-13 and 2018-19 San Francisco referred 50% fewer people for conservatorship. Right now in SF it’s very hard to get people with severe mental illnesses into conservatorship. The SF Board of Supervisors recently decided to implement Senate Bill 1045, which allows cities to consider conservatorship for people who have a professional diagnosis of both a serious mental illness and a substance use disorder, have been subject to an involuntary psychiatric hold at least eight times in the prior year, and have received less restrictive care alternatives from the county. After all that, a judge must decide that conservatorship offers the “least restrictive” and “most clinically appropriate” care. 

“I do not agree with Senator Wiener about everything,” Mandelman said at a recent hearing for the proposal, referring to his frequent sparring partner and SB 1045 Sponsor. “But he is fearless and relentless and I am grateful for his fearlessness and relentlessness on this issue.”

“It’s completely inhumane,” Mandelman said. “If you have known a friend or a loved one and seen that person in psychosis and seen how far that psychotic individual is from their true self, you cannot believe keeping that person in that state is somehow honoring their autonomy.”

Under this legislation, every person who is referred to court is appointed a public defender and has the right to a court or jury trial. It should only impact between 10 and 50 people. While around 200 SF residents are what EMTs call “frequent fliers,” only about 50 average eight 5150s per year. Under SB 1045 all conservatorships are set to last one year by default. At any point a conservatee can petition the court to end the conservatorship early. 

The Dept of Public Health works with the Office of Public Conservator, which operates within the Dept of Aging and Adult Services. The largest non-family conservator is the Public Guardian, an agency of the City and County of San Francisco. Certain non-profit agencies can also be appointed to serve as conservators. 

As a civil libertarian I’m obviously not a huge fan of conservatorship. But as a SF resident, the alternative is worse. People in extreme mental distress, still wearing their hospital gowns and bracelets, wander around the Mission. I explored the tension between autonomy and care in 2015. I think far fewer people would need conservatorship if we had affordable housing and a functional safety net. 

Speaking of, it’s nearly impossible to avail yourself of mental healthcare in this city. 

“The current system is disconnected, it’s disjointed and there isn’t a treatment plan that follows someone through the system,” Supervisor Haney recently said. “The result is that people enter the system in some way … and then fall through the cracks.”

But in the meantime, I just don’t think letting people loudly and violently self-destruct on the streets should be an acceptable option.

This is part 2 of a series. See part one and three.

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