Multnomah County mental health leaders agree that some patients need voluntary treatment, but where?

As Oregon grapples with how best to treat patients with severe mental illness, a group of Portland mental health leaders said involuntary treatment is an important piece of the puzzle, but it’s unclear what the best place for those patients is.

At a wide-ranging panel discussion held Wednesday by the Oregon Health Forum, five community leaders spoke about the need for stabilization centers, increasing the supply of behavioral health housing and providing social services for the mentally ill.

The speakers, who included a county commissioner, a judge and the interim director of Portland’s Mental Health Crisis Services, agreed that the current system of funneling patients through the criminal justice system before they receive mental health treatment is unsustainable.

Oregon lacks places for patients in crisis, panelists said, especially those who cannot advocate for themselves.

Doctors and county health officials can order people who pose a danger to themselves or others to be held involuntarily for up to 72 hours, after which a judge must weigh in. However, in practice there are few facilities to accommodate people detained for treatment.

The Oregon State Hospital in Salem, the state’s largest psychiatric facility, now rarely admits those patients because it is full of patients who have come through the criminal justice system, been found guilty except insanity or incompetent to stand trial.

Instead, patients in acute mental health crisis are often congregated in medical hospitals that are not equipped to care for them.

“Oregon’s largest involuntary treatment system is prisons and jails,” said Robin Henderson, director of Providence Oregon Behavioral Health. “It’s a traumatic place, not a good situation.”

Increasingly privatized psychiatric services have made patient beds more difficult, Henderson said.

“There’s just no compromise in the system,” Henderson said.

Multnomah County Circuit Court Judge Nan Waller presides over the county’s mental health court and also oversees hearings for people accused of crimes but deemed mentally unfit to stand trial.

Waller says that in her years on the bench, she has seen patients in the depths of mental illness or addiction who struggle to stay in treatment. A few have asked to be put in jail, while others are just moaning in the streets.

“I work in the system of mandates,” he said. “There are points where people really don’t have a chance, and to say we’re just going to let people go out and say we’re going to let them make a decision, in my opinion, that’s not humane.”

He urged an alternative to prison, a place where people can be released if they are in crisis and placed elsewhere, whether it be substance abuse treatment or psychiatric care.

Officials from Multnomah County groups, including Waller, spent four years planning the Portland Crisis and Sobriety Center, which would focus on intoxicated people with mental health issues. Once they sobered up, health workers could assess them and connect them with treatment or services.

But that effort fell apart after it was rejected by the board, which allocated funds for treatment under Measure 110 to decriminalize drugs, competing interests between city and county officials, a lack of buy-in from the county and a lack of a strong champion. The county government is now considering a tailored sobering-up center, but has yet to allocate funding for it. The county approved $7 million for a separate 20-bed stabilization center.

Waller said people with mental illness should be able to get treatment, regardless of whether they face criminal charges or the severity of the illness.

“Those in the criminal justice system with behavioral health issues are sometimes literally left out in the cold when housing or programs turn them down,” she said. “The stigma of criminal charges, on top of the stigma of mental illness, really puts people in the criminal justice system at a huge disadvantage.”

Lila Leighton, a licensed clinical social worker and interim director of Portland Street Response, said there is a time and a place for restrictive interventions, such as committing someone who cannot make their own decisions to psychiatric care.

But, he said, many patients may be more inclined to seek treatment if their basic needs, such as housing and physical safety, are addressed.

“I feel that volunteering to care starts you off on the right foot,” Leighton said. “But what’s more interesting to me is being realistic about what we’re asking people to consent to. It may seem like a great idea for us to help them get to the emergency room, but what does that mean for their belongings, their safety? Will they have to come back after dark? Discharge in two hours? Many of their complaints are due to these unmet basic needs.”

Jonathan Mroz, a communications specialist at Central City Concern, says struggling to meet those basic needs is an obstacle to his own recovery.

Several years ago, Mroz says, he started using drugs after a traumatic event in his personal life. He ended up living on a street in the Old City in what he described as a “constant state of hypervigilance.”

“Homelessness is deeply traumatic even without drugs,” she said. “There was an endless cycle. Losing a backpack, losing a cell phone, getting back everything that makes us human, it takes a long time. And that puts the burden on the individual to be sane enough to get help.”

He cited a severe shortage of psychiatric beds and the residential facilities patients need afterward, as well as the need for a place where patients can simply get off the street while they stabilize.

“At that point, we create a never-ending cycle of abandonment,” he said.

As panelists looked at immediate solutions, some emphasized the need for a long-term plan.

“We don’t have a plan or a functioning system,” said Multnomah County Commissioner Sharon Meyran, who also works as an emergency room physician. “Until we have that, we’re just going to throw good money after bad.”

Meiran suggested someone who could coordinate mental health efforts between the state and counties.

“We don’t need any more studies, meetings, task forces or commissions,” he said. “We need someone to pull it together and connect the dots to move us forward.”

— Jayati Ramakrishnan;

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