Decisive action could help Portland’s dysfunctional behavioral health system, experts say

Rather than spend tens of millions in public funds on a new 24-hour dropoff center for people experiencing mental health crisis, why not fix the logjam at the dropoff center Portland already has? 

Rather than spend money on more studies, why not invest it in services?  And why not make administrative changes so that people most likely to benefit from treatment get it in a timely way?

Local and state leaders could be making concrete changes to better help people experiencing psychosis in the Portland region, experts in an online discussion said Wednesday. Instead, the Portland area’s fractured behavioral health system is too frequently leaving people in the depth of psychiatric crises with nowhere to go but jails, emergency rooms or the streets.

“We need to stop the self-inflicted wounds,” said Robin Henderson, chief executive of behavioral health at Providence Health Oregon, during the virtual panel on Wednesday that was moderated by Axios Portland reporter Emily Harris. The solutions-oriented event was organized by the Oregon Health Forum, a sister organization of The Lund Report.

In recent years, Portland’s treatment providers have struggled to respond to the influx of the highly addictive opioid fentanyl and more potent meth that’s driving users to psychosis.  The five panelists described seeing the crisis up close from different angles as clinicians, local government officials and directly experiencing psychosis on the streets of Portland. Each called for better coordination to meet the needs of people in crisis who often have nowhere to go. 

“I think that the longer people stay outside, the more traumatized they become, and the more pain and suffering they have to they have to walk through in order to get out,” said Jonathan Mroz, who overcame drug addiction and homelessness and now works as a communications specialist for nonprofit Central City Concern. 

Mroz told his story of becoming homeless and addicted to drugs and his struggle to recover. 

Recovery is possible

“I lost custody of my daughter in 2018,” he said. “And I had a neighbor in Long Beach that offered me some methamphetamine, and within six months my life completely disintegrated. Two years prior to that, I had a four-bedroom house, two cars, the American dream, career — you know, all the things that we think make us what we are, right? 

“So we can fast forward to like 2021,” he added, “and I was shouting and camping half-naked in the street out in Old Town.”

While on the street, Mroz described having a “warped perception of reality” and “being in a constant state of hypervigilance” that he didn’t understand. He said his condition was “indistinguishable from a schizophrenic or someone who was severely imbalanced.” 

Mroz finally got help after sleeping in front of a treatment center for days. He described himself as fortunate because his psychosis was chemically induced. 

“But I like to balance that by saying, ‘You don’t experience homelessness, without walking away with a mental health diagnosis,’” he said. “It’s a deeply traumatic experience, even without the drugs, and I think we need to hold some space for that.”

Judge Nan Waller, who oversees Multnomah County’s Mental Health Court and Competency dockets, said she’s seen how the justice system “can become a never ending highway of pain” with no offramps for support and treatment. 

She said that jail is not the right place for people with serious mental illness but they’re too often the easiest place to admit someone and she encounters people in crisis who believe it’s their only open door. She recalled how during the height of the pandemic a man on probation came into court despite not having a hearing. 

“He looked horrible,” recalled Waller. “It was a very, very cold day, and he’d been living on the street for several days. He was dehydrated. He was exhausted. He’d been using, hadn’t been on his medication for his serious mental health disorder. And he begged me to take him into jail.”

The man started crying after Waller told him she couldn’t jail him. Waller told her staff to find him some food and water and let him sleep on the floor. Finally, she and her staff had him taken to an emergency room. Waller said he thanked her sweetly, but added that he’d be out soon. He was right, said Waller. Despite being a frequent user of emergency rooms, Waller said they can’t meet his needs. 

Judge: barriers need to be addressed

Waller said Oregon needs “a point of deflection” from the criminal justice system. 

But she said that barriers are keeping people who would benefit from treatment from getting it. For instance, programs and housing often reject people because of the acuity of their symptoms or because of their criminal charges. 

“No program is required to take people into their program from the criminal justice system,” she said, adding that these charge-based exclusions need to be addressed. “There has to be some way of making sure that people in the criminal justice system are getting the treatment that they need. They cannot be excluded simply because of their charges or because they’re seen as ‘too acute’ or fill in the blank, ‘risky,’ whatever.” 

Lielah Leighton, the head of Portland Street Response, a program of the Portland Fire Bureau, said that her program sends trained crews to people who are experiencing low-acuity mental and behavioral health crises.

“Our crews have many of the same challenges that other health care behavioral health social service providers face, which boil down to scarce resources in the community at large,” she said. 

She said that crews have difficulty making referrals to long-term behavioral health and substance use disorder treatment and “restrictive interventions are frequently invoked as a solution” to calls.

Leighton said that involuntary treatment can be life-saving. But without addressing upstream causes, such as poverty, homelessness, substance use and trauma “it only defers dealing with the fundamental issue: The people who are most in need of service and support have nowhere to be and no place to go.”

Henderson said that instead of trying to fix its mental health system, Oregon has been reaching for a “brand new bright shiny object.” She outlined how Oregon leaders over the decades have turned to different ways to address the state’s mental health needs. Those have included Multnomah County’s crisis triage center, rebuilding the state hospital, coordinated care organizations and the Unity Center for Behavioral Health. 

Fix Unity Center

“We need to take a breather,” she said. “Assess what we’ve got based on the data, and let’s fix what we have while we’re building out what we need.”

For instance, Unity Center, which was formed in 2017 by local health systems to serve as a 24-hour dropoff center for police and walk-ins of people in crisis. The vision has not worked, leading to discussion of the need to build a new one, Henderson noted. But, she said, why not fix the one we have?

Unity Center was set up to provide psychiatric emergency services to patients for 24 hours or less, and relies on reimbursements to cover that care. But Henderson said the Unity Center ends up keeping patients there for multiple days “because there’s no place else for them to go.” 

She said she visited a crisis facility in Arizona that Unity was modeled after, and asked staff their ‘secret sauce’ to moving people out within 24 hours.

“And they explained to me, amazingly enough, it had very little to do with their facility and design and had everything to do with their payment mechanism,” she said, adding that it has other facilities nearby with different levels of treatment.

One of those is a 12-bed support center where people manage their own medications with the help of peers, people who’ve had similar experiences. People staying there can also leave to look for jobs or housing, she said. 

“I want 25 of them yesterday,” she said. 

Henderson said the county has “a lot of self-inflicted wounds” that prevent people from getting into housing when they need it. 

And she said leaders both state and locally should work to execute on past initiatives, promises and studies before moving to launch similar or duplicative efforts.

Plans not executed, promises not kept

In 2007, counties and other agencies worked on a plan to flesh out needed improvements to supplement the Oregon State Hospital, and the state hired a consultant, PCG, to put out a report with recommendations. “A great report,” Henderson said. “Highly recommend you read it, because all of those solutions are still relevant today, and were never enacted.”

Then came the Legislature’s Oregon Health Plan reforms a decade ago to set up coordinated care organizations, known as CCOs, to oversee care, she recalled. The initial reforms were aimed at physical health, but mental health was slated to be next, she said.

“I’m still waiting for that,” she said. “I’m really waiting for that CCO point in which we’re going to talk about how we’re going to do mental health differently.”  

Multnomah County Commissioner Sharon Meieran said county government should be responsible for coming up with a plan to coordinate how resources are delivered to people who need them the most. She said that while more money helps, she said the problem is a lack of leadership. 

“We don’t need any more studies,” said Meieran, an emergency room doctor. “We don’t need more meetings, taskforce committees, etc. What we need is actually the opposite: Someone, some group to bring it together and connect the dots and lead us forward.”

She said the county should declare a public health emergency around fentanyl or drug addiction that she said will lift restrictions on funding and streamline efforts. She also called for the county to reopen a sobering center while investing more in recovery-based housing to prevent people from “cycling through the revolving door of detox and treatment back into homelessness.”

Mroz said that Portland leaders need to approach people in the crisis on the streets with compassion.

 “We need to look at them as patients,” he said. 

Behavioral health ‘czar’ to get things done

The panel was generally supportive of a “czar” to oversee behavioral mental health services in Portland, which Gov. Tina Kotek and U.S. Rep. Earl Blumenauer have called for. 

Waller noted that she, like the other panelists, was speaking only for herself, not for her agency. “Yes to the czar idea. Somebody needs to be putting together the plan and then more importantly, making sure that the plan gets implemented.”

“I think a czar would be great. It would increase that sense of accountability and follow through on these common sense solutions,” Leighton said. “You know, something from Dr. Meiran’s opening remarks has just really been hanging with me this whole time, and that is we don’t need studies, we don’t need more task forces. The solutions are actually fairly common sense. The implementation of course, it’s a different discussion. But I just — I really wanted to lift that point up again.

“And I guess the only other thing that I would add to that list of solutions would be to insist and demand that people with lived experience who are most impacted are a part of these conversations. Because at some point, and hopefully very soon, we move beyond strategizing and coordinating care for sick people, and really co-designing what it looks like to be well.”