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About Mental Health

A person is seen sleeping on the ground at Civic Center Plaza in front of City Hall in San Francisco, CA, Thursday, January 9, 2014. (Michael Short/Special to the San Francisco Chronicle)

Fifty years ago, the destitute figures who dotted America’s streets were called winos and hobos, and in San Francisco they mainly stuck to Third Street’s Skid Row.

Then, with the end of the Vietnam War, battle-shocked veterans began filling urban alleyways. The 1980s brought Reaganomics’ decimation of federal social and housing programs, and a cascade of the poor and mentally ill landed on the streets.

By the end of that decade, a new term had entered the lexicon of San Francisco and the rest of the nation: homeless. Considering it’s still the same now it really comes as a surprise as to why San Francisco’s business economy is booming, take a look at San Francisco real estate news for example, no signs of slowing down, yet the number of homeless are increasing?

Today, despite the efforts of six mayoral administrations dating back to Dianne Feinstein, homelessness is stamped into the city so deeply it has become a defining characteristic.

San Francisco initially responded by providing temporary, spartan shelters. Now, it permanently houses thousands of people salvaged from the streets through multimillion-dollar residential and counseling programs. But still, the city remains home to sprawling tent cities, junkies squatting on blankets shooting heroin, and all manner of anguished destitute people and beggars holding out hands.

The city’s last official one-day count, in 2015, put the adult homeless population at 6,686. But another city survey puts the total closer to 10,000, and many officials and advocates for homeless people say the number may be higher.

Whatever the case, homelessness in San Francisco doesn’t look much different than it did 10 years ago. Or 20. There are some individuals are who are trying their best to help save this, with some even looking at the development of shipping container homes as one of the many ways to help.

Money has always been part of the problem — no matter how much the city has spent, it has never been enough. But homelessness has also persisted because of a lack of focus and because good intentions have fallen short.

A homeless woman from the encampment on 5th Street near the Bay Bridge entrance laid in the sidewalk and street Tuesday March 3, 2015. Homeless encampments are still prevalent in San Francisco, Calif. and their locations are becoming more apparent.
A homeless woman from the encampment on 5th Street near the Bay Bridge entrance laid in the sidewalk and street Tuesday March 3, 2015. Homeless encampments are still prevalent in San Francisco, Calif. and their locations are becoming more apparent. (Brant Ward/San Francisco Chronicle)

Shelters Weren’t Answer

In the mid-1980s, as a growing number of street people began living out of shopping carts downtown, Mayor Feinstein joined the rest of the country in adopting the shelter-bed-and-a-sandwich approach. Offer a place of respite, the thought was, and they can turn it around.

It didn’t work.

Cities from San Francisco to New York learned that without dealing with the underlying factors that cause the most acutely troubled people to lose their housing — mental illness, substance abuse, disabilities and joblessness — temporary shelters accomplish little. That realization led to another: Doing more than just providing a cot for the night is incredibly expensive.

San Francisco has been a national leader in getting people off the streets and into housing where they receive the counseling services they need. Since 2004, it has put more than 22,000 people under roofs. But it now spends $241 million a year on homeless programs — more than double the budget for the city Recreation and Park Department.

Such spending can seem like sand shoveled into a tide. Workers at the eight city departments and 76 private and nonprofit organizations who devote themselves to restoring street-ravaged lives say there has been a lot of progress, but no end of frustration and criticism.

“Sometimes I shake my head and think, ‘What are we trying to do here?’” Mayor Ed Lee said one day as he watched a homeless camp being disassembled and its inhabitants moved into the city’s one-stop Navigation Center of homeless housing services.

“We’re trying everything we can,” Lee said. “It takes time. It is not easy.”

‘Why Can’t They Do More?’

Khalid Abdul-Rahim, who works as a security guard along the Embarcadero, regularly has to shoo homeless people away from Justin Herman Plaza.

“They do new shelters like that Navigation Center, but why can’t they do more real housing permanently?” he asked one rainy night last winter as he watched three people shiver under thin blankets in a bus shelter. “I had one guy pull a fork on me to stab me once out here. I see people all the time hungry, sleeping outside, miserable. How can this be in a city this rich? It’s about humanity. Shouldn’t be this way.”

Few understand the misery of homelessness better than Daniel Pledger. Born and raised in San Francisco, he’s been without a roof off and on for many of his 65 years — a notable exception being when he played bass in the locally popular punk band Seizure in the 1970s and ’80s.

Pledger has spent most of the past year sleeping on the streets around Potrero Hill. He kicked heroin five years ago, but his struggles with alcohol have gotten him evicted from one place after another.

“I used to have a wife,” he said recently, sitting on a Tenderloin sidewalk with a Hefty bag full of his clothes. “I had a place to live.

“Now I am the invisible man. People walk right by me. I have to get control of this demon — of the booze — but there are a lot of guys like me out here. Have they given up on us?”

First Innovation

Mayor Art Agnos took the first step in San Francisco to move beyond overnight shelters. In the late 1980s, he created two large complexes with not just beds, but also mental health and substance-abuse counselors on site — what have come to be called supportive services. He envisioned a program that would direct street people from there into permanent housing.

But there wasn’t enough housing available. As Agnos struggled to ramp up his plans, a colony of homeless people in front of City Hall grew into the hundreds and was derisively dubbed “Camp Agnos.”

In July 1990, Agnos finally ordered police to sweep out the Civic Center squatters, abandoning his promise to transition them inside. Yet the stench of civic ineffectiveness had set in. The homelessness issue Agnos had taken on with such hope sank his bid for re-election.

Today, the shelter-counseling complexes that Agnos created are mere shelters — and he remains frustrated.

“We do know what to do, but we haven’t had the conviction or the commitment to make it happen,” Agnos said. “We could end homelessness as a commonplace occurrence in American cities if we adopted the same kind of commitment we did in addressing World War II: if we treat it like we want to win.

“But until the public and the politicians who serve them say we are going to win this, we won’t. There is a bright spot here and there, and bleakness in everything else.”

The man who succeeded Agnos as mayor, former Police Chief Frank Jordan, changed tactics, using police as outreach workers as well as enforcers. Under his Matrix program, their job was to clear the streets of homeless camps and aggressive panhandlers and steer them into housing and counseling programs.

But again, there weren’t enough programs to handle the thousands of indigents on the streets. And enlisting police as social workers drew ceaseless attacks from the city’s progressives, torpedoing Jordan’s re-election bid as well.

Mayor Willie Brown followed with efforts at supportive housing, but ultimately — and famously — declared the homeless problem unsolvable.

His successor, Gavin Newsom, took the most aggressive stance yet toward tackling the issue. In 2004, he announced a 10-year plan to end chronic homelessness.

While it failed to reach that goal, it did result in moving 22,000 homeless people off the streets into either housing or onto buses headed home. And in the past few years, the majority of the city’s destitute military veterans — many suffering post-traumatic stress from as far back as the 1970s — have been moved indoors, thanks in part to a national effort led by the U.S. Department of Veterans Affairs.

And yet the city’s streets look the same today.

“There’s a mythology that you can, quote unquote, end homelessness at any moment,” Newsom said in 2014. “But there are new people coming in, suffering through the cycles of their lives. It’s the manifestation of complete, abject failure as a society. We’ll never solve this at City Hall.”

Former Supervisor Angela Alioto, who was in charge of crafting the 10-year plan, says it failed because it didn’t create enough counseling and engagement, not just for street people, but for those already housed — some of whom still panhandle, making the homeless landscape look even worse than it is.

“You have to do housing, what I call ‘minute clinics’ for health and counseling in every building, and get the homeless involved in things that make them feel good about themselves — volunteer work, charity, whatever,” Alioto said recently as she handed out dollar bills to a couple of panhandlers in North Beach. “It’s about dignity. Housing is not the end, it’s the beginning, if you really want to get everyone off the streets.”

A homeless panhandler plied his trade as traffic came off the freeway near 13th Street Wednesday July 15, 2015. Although San Francisco housed over 3,000 homeless people in the last two years, the overall homeless count stubbornly remains about the same.
A homeless panhandler plied his trade as traffic came off the freeway near 13th Street Wednesday July 15, 2015. Although San Francisco housed over 3,000 homeless people in the last two years, the overall homeless count stubbornly remains about the same. (Brant Ward/San Francisco Chronicle)

Different Types of Homeless

What became clear over all the years is that the city’s homeless population is anything but homogeneous.

Today, there are about 1,300 homeless people in San Francisco in either individual or family shelters, and another 1,500 in jail, transitional housing, hospitals or otherwise indoors. Some 3,500 are estimated to be “unsheltered,” and about half of those make up the hard-core street population — the most obvious, most troubled and most expensive homeless people in the city to care for.

Estimates by San Francisco officials and by the Silicon Valley Economic Roundtable are that each of those chronic cases costs about $80,000 a year in police, jail, ambulance and other tabs. By contrast, it costs about $20,000 a year to keep a person in a supportive environment — the permanent housing where on-site mental therapists, substance abuse counselors and other social workers can help keep a person off the streets.

Many chronically homeless people crowd into the Tenderloin, where soup kitchens, rehab clinics and poverty-aid organizations are centered. Homeless drug addicts have spread into areas where their dealers are easiest to find: heroin in the Mission District, methamphetamine around Division Street, crack in the Tenderloin.

Mental Illness

Perhaps the most heart-rending subpopulation is made up of the mentally ill. Here, good intentions are at the heart of how San Francisco’s streets became an open-air mental ward, with deranged people railing at telephone poles or passersby, or muttering to themselves for hours.

Back in the 1960s and ’70s, state-run mental institutions, where troubled people were once committed against their will, came to be seen by advocates as a means of violating individuals’ rights. Closing them saved money.

With their demise, the plan, supported by both conservatives and liberals, was for community-based centers across the country to help people instead — but those were underfunded. The result: A growing population of mentally ill people were turned loose to fend for themselves.

Today, it’s estimated that a third or more of homeless people in San Francisco and nationally suffer from mental illness. The city would need hundreds of new psychiatric-care beds to get them off the sidewalks — the current inventory of fewer than 1,000 is not nearly enough.

But even if it created those beds, getting people into them is difficult. Unless they are judged a danger to themselves or others, the mentally ill can’t be forced into care.

One example: Tatiana and Oksana, Ukrainian immigrants who speak little English and give no last name. Believed to be mother and daughter, they’ve been on the streets for at least a decade, with brief stints in emergency housing.

The pair pose no threat as they push their heaped shopping cart through downtown and the Mission, sleeping in doorways and glancing suspiciously at everyone who passes by, so they can’t be compelled to leave the streets. Any conversation with them veers quickly, wildly off track.

Two social workers, barred by state privacy rules from being identified, interviewed them several times. They concluded that Tatiana is in her 50s and Oksana is in her 30s, and that they are probably mentally ill or impaired. For three years, social workers have tried to get them to give their required permission for psychiatric care — but the pair won’t commit.

Afraid of the ‘Russkies’

The two women have repeatedly told The Chronicle through Ukrainian interpreters they don’t need help.

“We’re afraid of everyone, afraid we’ll be sent back to the old country,” Tatiana said. “Russians want us to leave the city, they are bad, they are everywhere, but we won’t go. We’re not homeless. We are just on the street. We will not go inside where the Russkies can get us.”

Mental health programs weren’t the only ones bludgeoned by budget cuts. Federal housing aid and social programs were slashed by as much as 80 percent in the 1980s, and state and local governments couldn’t catch up. Many of the people who wound up homeless that decade have never left the street, pushing the average age among the street population to 58.

Millions in Poverty

Today, with the minimum wage supplying about half or less of the buying power it did in 1980 and about 30 percent of Americans living at or near poverty level, there is a continual flow of people becoming homeless, said Peter Edelman, a Georgetown University law professor specializing in poverty.

“We never even replaced the affordable-housing support that was destroyed in the 1980s, so if you want to solve homelessness, you need to not have so much poverty,” Edelman said. “What we’ve got is a problem of homelessness created because we haven’t done what we should have in the first place, so now we have to handle it in the second place — with techniques like supportive housing.”

That’s one area in which San Francisco, with among the highest rents and greatest gulfs between rich and poor in the country, is actually a leader in innovation.

Over the past decade, the city has refined a system of sending outreach counselors into the street to persuade the chronically indigent to accept housing, shelter, employment or medical help — and then move into permanent supportive housing before they can wander off again. In the past 12 years, San Francisco has put about 12,000 people into such housing.

The trouble is that the city is at least 2,500 supportive-housing units short of what it needs to clear the streets of the most expensive and visible chronically homeless people — about 1,500 of them — and to stay ahead of the incoming chronic population every year. But that’s not insurmountable.

The situation could be dramatically improved through new private-public funding models, cheaper forms of modular housing, and streamlining techniques for helping people move out of supportive housing after they’ve been stabilized.

If the city’s shelters were expanded by hundreds of beds, and fashioned more along the lines of the 15-month-old Navigation Center, they could finally become the routing tools into housing that Agnos envisioned a quarter-century ago. The center at Mission and 16th streets takes in street campers with their partners, pets and gear and surrounds them with case managers to help them get their lives together quickly. The city is already heading that way: A second center is scheduled to open at Market and 12th streets this week, and the Board of Supervisors has voted to open five more Navigation Centers over the next two years.

With the city’s establishment of a new Department of Homelessness and Supportive Housing, streamlining city services for street people under one roof into a more direct focus on housing and counseling, San Francisco has its best opportunity in years to clear the streets.

“We know how to do what we need to do,” said Jeff Kositsky, head of the new department. “The approach now is the same — we just have to be creative.”

Bit of Optimism

Jennifer Friedenbach, whose Coalition on Homelessness advocacy group has spent decades pushing the city to create more housing and services for the indigent, is skeptically optimistic.

Even though Matrix is in the trash bin of history and police leaders insist cracking down isn’t the way to solve homelessness, Friedenbach said, the city still puts too much emphasis on breaking up camps whose residents have nowhere good to go and issuing tickets for quality-of-life violations like sitting on sidewalks.

‘Wasting Money’

A city report in May that found taxpayers spend $20 million a year enforcing such laws quantifies the futility of the effort, she said. To Friedenbach, ticketing street people boils down to just two things: “San Francisco is either ruining homeless people’s lives and wasting money, or harassing homeless people and wasting money.

“With little to show for it, it is time for a new approach,” she said. For Friedenbach, “new” actually means ramping up old concepts — more efficiently.

“It’s about money,” she said. “We need a sustained revenue source to double the housing units for homeless people, and to do prevention to keep people in their homes and to not become homeless to begin with.

“It’s not that complicated,” she said. “I think in San Francisco, people are ready to do something different. But then, I’ve seen that before.”

Kevin Fagan is a San Francisco Chronicle staff writer. Email: Twitter: @KevinChron

About this project: This week, the Chronicle will join more than 70 other news organizations to focus San Francisco’s attention on the seemingly intractable problem of homelessness in our city. The S.F. Homeless Project aims to explore possible solutions that might ease, if not end, the suffering of so many thousands of unfortunate people living on our streets, and improve the quality of life for all residents. The project’s primary day of coverage is June 29, but the Chronicle will publish stories and editorials all week. Videos, interactive graphics, and coverage from other media can be found online at and, and on Twitter at @bayareahomeless. Join the online conversation at #sfhomelessproject.