Oregon’s many mental health crises, OPB.org March 2023

OPB talked to experts throughout the state to learn about several of the most pressing elements of the crisis — and about promising strategies to address the many problems

For too many Oregonians, having a mental illness or substance use problem means repeated failed attempts to get help, then a crisis: an emergency department visit, isolation in a jail cell, or an involuntary stay at the state’s overwhelmed psychiatric hospital.

“You have to fail up in our system in order to get the care you need,” said Dr. Robin Henderson, the chief executive for behavioral health for the Providence health system in Oregon.

High quality data on the prevalence of mental illness and substance use disorders is hard to come by, but several key indicators the Oregon Health Authority tracks are headed in the wrong direction.

In 2011, 38% of Oregonians reported having poor mental health in the past month. By 2021, that proportion climbed to 46%. In 2011, 16% of high school juniors reported having unmet mental health needs in the past year. In 2020, that climbed to 23%. And during that same 10-year period, deaths related to alcohol in Oregon rose from 39 per 100,000 people to nearly 51 per 100,000.

To complicate matters, there isn’t one mental health crisis in Oregon — there are several. Which one seems most pressing depends on who you are and where in Oregon you live.

OPB talked to experts throughout the state to learn about the multi-part crisis. We heard about a lack of youth services, rising substance abuse, an overwhelmed state psychiatric hospital system, a lack of long-term care and housing options for people with serious mental illness and the specific issues faced by Oregon’s rural residents. We also explored promising strategies that could help solve these problems. OPB’s reporting on mental health will be published in four parts over the next several days.

The common element behind all of the crises is that the system is itself in crisis.

Prosecutors and some politicians have argued that the difficulty of having people committed to psychiatric care has contributed to the state’s homelessness rates, perhaps the most visible sign of the mental health challenges facing Oregonians. But some of the top thinkers in the state’s behavioral health system say the problems start long before civil commitment might be necessary. Health care and supportive housing for people with serious mental illness and substance use disorders have not kept pace with Oregon’s growing population and have even been cut in some cases.

“Our system is having a hard time staying in business,” said Chris Bouneff, the executive director of the Oregon chapter of the National Alliance on Mental Illness.

Bouneff and other experts say decisions made by insurance companies, coordinated care organizations or the politicians who control the state’s Medicaid program have led to too little treatment available in virtually every community in the state. Then the pandemic hit, triggering an exodus of health care professionals from some of the most stressful front-line positions in health care, including behavioral health.

“We’ve lost capacity,” Bouneff said.

At this point, the mental health system in Oregon does not provide mental health and addiction care at the same level it covers a problem with the heart, lungs or liver, he said.

This examination of Oregon’s failing mental health system was written and reported by Amelia Templeton, edited by Lillian Mongeau Hughes, produced for the web by Meagan Cuthill, with photos by Kristyna Wentz-Graff. This series exploring both the biggest problems facing Oregon and potential solutions is sponsored by the Oregon Community Foundation. And none of OPB’s journalism happens without you. Help us tell more stories like this one – and ensure stories like this reach as many people as possible – by joining as a Sustainer now.
Requiring parity with medical and surgical care is a recent idea. Until 2005, it was legal in Oregon for health insurance plans to arbitrarily limit the number of hospital days or outpatient visits they would cover for mental health, and to require higher copays for mental health visits than for other types of care.

“We haven’t been trying to do this for very, long or cared for very long,” Bouneff said.

Bouneff also points to the bargain Oregon struck with the federal government in 2012 as it prepared for about 200,000 more people to enroll in the Oregon Health Plan through federal medicaid expansion. In exchange for more federal dollars and flexibility, the state promised to cap the growth of Medicaid spending at 3.4% a year. But the cost growth cap has meant there is limited funding available for Oregon to build a community treatment system for mental health to replace the big, locked psychiatric institutions that were the standard of care in Oregon until the 1990s.

There are some changes coming to the system. In 2021, the legislature pumped $1.35 billion dollars into behavioral health services. And the state asked the federal government for – and got – an exception to that 3.4% Medicaid growth limit, to allow it to increase reimbursements to behavioral health care providers by 30%.

READ – Key Behavioral Health Investments (21-23 biennium) Expected to Increase Resources and Improve Outcomes for the Population Needing Intensive Services

READ – OHA will amend the Medicaid State Plan to increase fee-for-service behavioral health rates and establish payment model for integrated treatment of co-occurring disorders

The problems explained in this series are significant, and the promising solutions would be expensive to scale up statewide. Systemic fixes would require a significant ongoing investment in the public mental health system, likely beyond what’s already planned.

“One of the most promising things right now is we have a new governor whose top three priorities are housing, substance abuse treatment, and mental health treatment,” said Emily Cooper, Legal Director at Disability Rights Oregon.

“If someone has a place to live and get treatment, they have a chance to recover, and no longer go through this revolving locked door of jails and the state hospital.”

Read each mental health challenge researched in OPB’s 4-part series below.

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Oregon kids in crisis are not getting the help they need, OPB.org March 2023

PROBLEM: There are not enough beds – or therapists – in the state for children with the most intense needs.

Many teens experience depression and anxiety and might go through a brief period of crisis, like a bad break-up or an episode of bullying. The pandemic turned up the volume on all of those problems, worsening already long wait lists for child and adolescent therapists.

The state must shore up services to keep these real, but manageable, problems from becoming critical. Increasing school counseling services, running the 988 youth line and investing in the behavioral health workforce are all likely to help.

But a subset of young people face much more serious headwinds and need much more help. These are kids and teens who are growing up while dealing with profound pain and stress: Homelessness, a serious mental illness, a developmental disability, experiences of abuse and neglect or some combination of all of it.

And kids are falling through some of the worst gaps in Oregon’s mental health care system. Those gaps were created in the past 20 years, in part, by the state’s efforts to save money and increase the efficiency of the Medicaid program.

Since 2003, the state has lost more than 200 residential beds as facilities that used to work with youth have closed, said Dr. Ajit Jetmalani, who directs the division of child psychiatry at OHSU and is a consultant to the Oregon Health Authority. Statewide, just four programs remain that serve youth with the most acute mental health needs: Trillium Family Services and Albertina Kerr in Portland, and Looking Glass and Jasper Mountain in Lane County.

“Everybody else has left the field,” Jetmalani said.

Before 2003, the state health authority had contracted directly with companies to make sure youth mental health beds were available whether or not they were in use.

“That allowed for a stability of staffing and predictability of services” Jetmalani said.

Now, facilities have to negotiate separate payment contracts with 15 different Coordinated Care Agencies, groups that administer the Oregon Health Plan and reimburse providers, with a focus on preventative care and containing costs for the state. Those contracts generally mean facilities are only paid if their beds are in use.

That may sound like a good cost-saving strategy. But Jetmalani likens it to only paying firefighters while they’re out fighting a fire. The unpredictable funding has made it much harder for the industry to pay fair wages and retain quality, experienced staff and that means that at times, when the number of youth in crisis is high, the state runs out of places for them to go.

There are now 100-150 residential beds available statewide for youth with acute psychiatric needs, according to Jetmalani. “And our estimated need is 240,” he said.

PROMISING STRATEGY: Staffing and expanding residential treatment facilities for youth could give Oregon the baseline number of beds and professionals needed to serve our children in crisis. Simultaneously, bringing more services into homes for kids who need urgent, but less acute care, will allow more young patients to stay with their families during treatment.

To avoid losing any more beds and to add capacity in its remaining residential treatment programs, the state needs to stabilize funding. Jetmalani believes OHA and private insurers should be paying a base rate to maintain some minimum number of staffed beds year-round, in addition to facilities billing Medicaid for the services they provide.

And though having sufficient residential beds is critical, Dr. Robin Henderson, the chief executive for behavioral health for the Providence health system in Oregon, says the state’s focus should be on supporting family caregivers to keep children in their homes if at all possible.

“The longer they stay in a facility outside their home, the less likely they are to ever go home,” said Henderson, who started her career more than 30 years ago working in the secure child and adolescent treatment unit at the Oregon State Hospital.

Oregon has some models for doing this. The nonprofit Youth Villages runs a program called Intercept for kids up to age 18 who have emotional or behavioral problems or who are at risk of entering foster care.

Andrew Grover, the executive director of Youth Villages, says it’s easy as a parent to be overwhelmed by the needs of a child who is suicidal or aggressive. Parents may feel like the only way to keep their family safe is to go to the emergency room or call the police.

“The problem is that it only resolves the crisis for that particular moment,” he said of using emergency services. “We can find a safe place for a day; we can de-escalate the aggression for a few hours.”

Instead of focusing on moments of crisis, Intercept staff focus on the long term. They work on making home a safe place and on teaching families how to communicate with their kids and how to build a network of supportive adults and peers around a struggling child.

Safety planning is the first step. For a child having thoughts of suicide, that could mean bringing lockboxes to secure any unsafe items in the home, installing a door alarm, and making a supervision plan with family members, teachers, and friends. The team helps the child identify things that might trigger them to feel badly – and makes a list of steps they can take, like playing music or talking to a friend, to help themselves manage their emotions.

And then there’s a lot of counseling.

“We see these families at least three times a week face to face,” Grover said. Staff also provide 24/7 crisis intervention. Therapists in the program carry no more than five families at any given time so they can provide that level of support. “That enables them to work at that level of intensity,” Grover said.

About 80 percent of the children who’ve been through the Intercept program are still living with their families a year later, according to Grover. Intercept typically enrolls around 200 families a year through referrals from doctors, teachers and child welfare workers.

At any given time, there are 60 to 70 families on a waitlist. The program could grow if Grover could hire more staff, but the intensity of the work and the demanding schedule have made it difficult to fill positions. “Like everyone, we’re having challenges getting enough people to do this work,” Grover said.

In 2020, Oregon made a big structural change that could unlock a lot more funding for programs like Intercept. It began formally recognizing this type of in-home care as a treatment for mental illness that qualifies for Medicaid reimbursement. The official name is “Intensive In-Home Behavioral Health Treatment.”

Private insurance plans, however, do not typically recognize and cover in-home treatment for behavioral health, meaning Intercept only works with kids on the Oregon Health Plan.

Grover says the commercial insurance world tends to consider just two levels of care when it comes to behavioral health: outpatient services, where a person meets with their therapist at a doctors office for a few hours each week, and hospitalization. Commercial insurance companies need to re-think that standard and start recognizing other treatment options for youth, “if we’re talking about getting this to every kid who needs it,” Grover said.

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Illegal substances are part of addiction problem in Oregon, but alcohol is biggest killer, OPB.org March 2023

PROBLEM: Roughly one in five Oregonians has a substance use disorder.

Headlines in 2022 declared Oregon to be the “worst in the nation” for addiction. But many local experts in behavioral health say state rankings should be taken with a grain of salt. The most often quoted rankings, created by the advocacy group Mental Health America, rely heavily on the responses to an annual survey conducted by the federal Substance Abuse and Mental Health Services Administration. But since the survey collects information about people’s self-reported drug use, it is likely capturing a combination of different things – regional differences in rates of use, yes, but also regional differences in openness to talking about it.

Still, addiction to substances, a sharp increase in overdose deaths and a lack of public resources dedicated to detox and treatment programs are real problems in Oregon.

Oregon’s substance use disorder treatment system is about half the size it should be, according to a recent study and survey of providers done by the OHSU-PSU School of Public Health.

“My son was ready for help multiple times. We couldn’t find it. We couldn’t get it into any treatment,” says Pam Connelly of Deer Island, Ore., left. Connelly is part of Oregon Moms for Addiction Recovery, who asked legislators to increase funding for addiction recovery in February. Her son has been in and out of addiction and sobriety for about 14 years and was unable to get in to treatment and detox programs.

Detox programs provide medical support while people go through the painful — and potentially life threatening — symptoms of drug withdrawal. In Oregon, such programs are notoriously difficult to get into.

“I laid on my son for three days while he shook uncontrollably — detoxing at home because he just was ready to be done and couldn’t get into any facilities,” said Pam Connelly, who said she wasn’t able to find a detox program to help her 37-year-old son when he was ready to quit using substances. Connelly is a member of the group Oregon Moms for Addiction Recovery who traveled to Salem in February to ask legislators for more funding for addiction recovery.

Illicit drug use has – understandably – captured the most public attention and generated alarming headlines. Fentanyl can take people’s lives the first time they try it and is responsible for a rapidly increasing share of overdose deaths. Meth too, is a deadly habit that claims far too many Oregonian’s lives each year and, because it can trigger psychosis, causes a particular strain on the state’s mental health system.

The death rate from drug overdoses has doubled in just four years. In 2017, 13 people per 100,000 in Oregon died of a drug overdose. In 2021, there were 23 overdose deaths for every 100,000.

But it’s a legal drug that arguably hurts – and kills – the most people.

“Alcohol is the great dirty little secret of the pandemic,” said Dr. Robin Henderson, the chief executive for behavioral health for the Providence health system in Oregon.

She said alcohol is a significant cause of visits to Providence emergency departments. “We put a lot of effort into the opioid crisis and I don’t mean to diminish that at all, but we’re not having those same conversations about alcohol,” Henderson said.

On average, six people die each day in Oregon from alcohol related causes, according to the Oregon Health Authority. Drunk driving crashes and acute alcohol poisoning make up a relatively small fraction of those deaths; the majority are due to the long term effects of alcohol, including alcoholic liver disease, heart disease and cancer, according to state epidemiologists.

In 2021, alcohol was responsible for far more emergency department visits than any other substance nationally, according to the federal Substance Abuse and Mental Health Services Administration. In a survey of medical records from a sample of hospitals nationwide, it was involved in 42% of all drug-related visits, compared to 15% for opioids, 11% for methamphetamine, 11% for marijuana, and 5% for cocaine.

Even before the pandemic, alcohol was the third leading cause of preventable death in Oregon, behind tobacco and obesity but ahead of overdose deaths. Most people know alcohol use can cause liver disease, but it also significantly increases a person’s risk of many cancers, including head and neck, esophageal, liver, breast and colorectal cancer, among others.

Illicit drug use likely rose during the pandemic as well, and overdose deaths are climbing quickly. On average, three Oregonians die each day from unintentional drug overdose. But while Oregon’s drug overdose death rate is below the national average, its alcohol induced death rate is above it.

PROMISING STRATEGY: Tax alcohol and use the revenue to fund detox and treatment programs that the state hasn’t been able to stand up with Measure 110 funding.

Last year, OHA launched “Rethink the Drink,” a public health campaign aiming to increase awareness of the risks of excessive drinking — the kind of drinking a lot of people do that may not meet the definition of alcohol use disorder, but still raises your risk of cancer and other health problems. According to the site, four to five drinks on a single occasion or more than one to two drinks a night, every night, count as excessive drinking.

The group Oregon Recovers is pushing state legislators to do more to curb excessive drinking. They point to Oregon’s beer and wine taxes, which haven’t changed in 45 years and are among the lowest in the nation.

Raising the tax rate on alcohol would likely lower the amount people consume. In 2007, a scientific workgroup that assesses public health prevention strategies for the federal government evaluated the research on alcohol taxes. The group found strong evidence taxes work to curb drinking. For example, it estimated that beer consumption can be expected to decrease 5% for every 10% increase in price.

Advocates also point to Maryland, where researchers found alcohol sales – a proxy measure for drinking – dropped after the state increased its alcohol tax in 2011.

Advocates say teens and binge drinkers are particularly price-sensitive, so the tax is a good way to reduce some of the most harmful alcohol consumption taking place.

Oregon’s beer and wine industry successfully defeated an attempt to pass a tax increase in 2021, but Rep. Tawna Sanchez, D-Portland, who is in long-term recovery herself, is reportedly planning to re-introduce a new version of the measure.

Sanchez declined an interview request, and so far only a placeholder version of the bill, HB 3312, is available on the state legislature’s website.

Oregon Recovers and the Oregon Alcohol Policy Alliance say revenue from the proposed alcohol tax would go to fund treatment programs, including detox spots, and prevention and education campaigns, among other things.

Any funding generated by an alcohol tax would be more flexible than the state’s marijuana tax dollars, which can’t be used to pay for services (including detox) that are also paid for with federal Medicaid funding.

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Oregon doesn’t have enough treatment or housing for people with mental illness – OPB.org, March 2023

Oregon’s system for people with profound mental illness is broken. Below, we explain the roots of two major problems and explore two promising strategies that could address these issues.

PROBLEM ONE: Some people with the most serious mental illnesses cycle between Oregon’s public psychiatric hospital, county jails and homelessness.

People with serious mental illnesses often receive treatment for a time and then drop out or discontinue it.

Here’s what too frequently happens next: Without treatment, some mentally ill people deteriorate and end up homeless. An arrest – easy to come by when living on the streets – can land them in county jail. Unable to stand trial due to psychosis, they’re sent to the Oregon State Hospital on a court order to be treated.

While they’re at the Oregon State Hospital, they get medication, therapy and a safe environment. Most people staying in the Salem psychiatric hospital are also isolated from friends and family. It’s an hour drive for visitors from Portland and much further for people from the east side of the Cascade Mountains or the southern part of the state. Patients are also often cut off from any therapists or health care providers they had been seeing before because of a rule in the federal Medicaid statute. And in any case, the majority of patients can only stay until they’re well enough to understand the charges against them and stand trial.

Though some have to leave before they have hit even that relatively low bar for wellness. As of September 2022, people accused of felonies can be held for treatment for a maximum of one year. For misdemeanors, the maximum stay is 90 days.

Some people are eventually able to stand trial. Others are found to be never able to understand the charges against them. Prosecutors pursue “guilty but for insanity” verdicts in the most serious cases. Less serious charges are dropped, and a person is discharged to a hospital, to the street or to the oversight of a county mental health department. Often, they end up homeless. Then the cycle repeats.

“We’ve become very dependent on the criminal punishment system as our de facto mental health system,” said Jesse Merrithew, a civil rights attorney who is part of a high-profile lawsuit over delays admitting patients to the state hospital. “It doesn’t make sense clinically. Doesn’t make sense morally.”

PROMISING STRATEGY: A statewide program to assess and assist people ages 12 to 25 who are in their first year of experiencing psychosis could result in early and more successful treatment for people with the most serious mental illnesses.

One statewide program aims to intervene far upstream of the revolving door cycle by helping people maintain their sense of identity, family and agency through the initial onset of a mental illness.

Caruso worked with the Early Assessment and Support Alliance Center for Excellence (EASA), a two-year state-wide program that supports people ages 12 to 25 who are in their first year of experiencing psychosis. Early intervention could result in more successful treatments for people with the most serious mental illness, avoiding a lifetime of disability.

The Early Assessment and Support Alliance focuses on people with schizophrenia and bipolar disorder with psychosis.

For many who have these disorders, symptoms begin in their late teens or twenties. Without early intervention, young people first developing a mental illness that involves psychosis will often spend one to two years after their symptoms start before getting any treatment. That delay can upset the course of their lives, disrupting their chance of finishing school, finding a job and maintaining family ties.

“These conditions can lead to the dissolution of a family pretty rapidly,” said Tamara Sale, who runs the Early Assessment and Support Alliance Center for Excellence at the OHSU-PSU School of Public Health. ”It can lead to them being kicked out in the street because their families [are] trying to draw boundaries.”

When people do finally receive treatment, it’s sometimes in the form of involuntary civil commitment, which is difficult to obtain, controversial and increasingly rare. But people have a better shot at recovering if they get early treatment and support, experts say. That’s because most people who experience psychosis due to a mental illness like schizophrenia or bipolar disorder have initial symptoms that are milder, Sale said.

“There’s a window where we can identify and interact with the person before it’s gotten to that really acute level,” Sale said.

In the early stage, people start to experience changes in their sensory perceptions and new ideas that don’t make sense to other people. They are also more likely to consider suicide during the early onset phase.

“They are met with a lot of misunderstanding,” Sale said.

Crucially, during this early period, people are often relatively motivated to figure out what’s happening to them and receive treatment.

But for many people, navigating the rules of the health care system and insurance feels impossible. It requires people to show up on time to appointments and be organized at a time when they are losing those abilities.

“If you think about a program for people in wheelchairs being placed on the second story of the building with no elevator and no ramp and no outreach,” Sale said. “That’s kind of how the mental health system has been set up.”

Sale says it’s easy for a person experiencing the first onset of a mental illness to be mislabeled as lazy or pressured to perform.

“Other people don’t understand how hard they’re working,” Sale said.

This is where the Early Assessment and Support Alliance, EASA for short, comes in. The program is set up to accommodate the needs of people who have experienced psychosis, and to show them that the mental health system can be a friend, not the enemy.

Similarly to the Intercept program for children experiencing mental illness, EASA program staff come to people’s homes and work with their families to figure out how to connect with a person and engage them in treatment.

Skinner marches into the Columbia River at Marina Park. She says, “there’s a huge stigma on mental health care and especially psychosis. You don’t seek the care you need because it’s a stigma and you don’t want to look like a crazy person.”

Skinner is a graduate of EASA’s program, serves on the Young Adult Leadership Council, Southern Oregon Chapter, and is a co-chair for the Healthy Transition State steering committee.

She says EASA’s peer support program was as valuable as clinicians. “What they’re doing is very similar but [its] even more vulnerable, they’re putting even more of themselves out there and sharing their own personal story in the healing process. So it’s really, really important work.”

Program staff will spend time getting to know the person, and will communicate with them in whatever way feels safe. For someone experiencing paranoia, that might mean speaking on either side of a closed door, or exchanging handwritten notes. In the short term, the goal is to get each participant to the point where they can put their thoughts together well enough to participate in decisions about their course of treatment.

Another distinguishing feature of the program is its approach to antipsychotic medication. Taking medication isn’t a requirement of the program, and when meds are used, clinicians focus on getting the dosing right for each participant.

“If we identify people a little earlier, it’s easier to focus on a start low, go slow approach.”

Some people, Sale said, do need medication and may need help working through the grief associated with that decision. While many antipsychotic drugs are effective for most people, they are controversial because they can be sedating and cause heart problems, among other issues.

The program uses strategies to help people who want to minimize the dose that they’re on. A person might opt for a dose that’s just enough to stop scary hallucinations, but that doesn’t completely eliminate the voices in a person’s head, if those voices are friendly.

The program teaches skills that can reduce the symptoms of psychosis, like getting adequate sleep and regulating stress. And it helps people understand the often predictable pattern of their illness.

“If they can understand what their personal pattern is, they can often prevent it from progressing,” Sale said.

While struggling with her mental health in 2018, Nguyen received support from the Early Assessment and Support Alliance Center for Excellence (EASA). She graduated from the two year program, and now works for EASA as a service coordinator and part of the young adult leadership council.

“Everyone deals with their own mental health and if they are not, then they are denying it,” says Nguyen. “It’s a journey and it’s nothing we should be ashamed of.”

Nguyen compares her lived experience of mental illness to learning to skate. “It’s a journey, it’s a process. You have these little spurts of hitting a rock or a wall, or falling, and you keep getting back up.”

People typically stay enrolled in EASA for about two years. Sale says the program is still figuring out which metrics to use to measure success, but some numbers suggest it has a stabilizing effect. The likelihood of a person being hospitalized drops while they are in the EASA program. About 60% of participants are in school or are working when they start EASA, and roughly the same percentage are still enrolled or employed at the end.

Sale says genuine recovery from psychosis is possible, and EASA graduates have gone on to careers in college admissions, law and medicine.

“I think our society really needs them,” she said, “and it’s a huge loss for them not to be able to participate.”

Sale says the metric that matters the most to her is that graduates are able to live full lives.

PROBLEM TWO: There are nowhere near enough group homes, residential care facilities or supportive housing options for people living with mental illness or addiction.

READ – FIVE DEATHS AT DAMMASCH HOSPITAL A Question of Responsibility – OAC December 1993, Oregon Advocacy Center December 1993

In 1995, Oregon closed the Dammasch State Hospital after Disability Rights Oregon publicized the deaths of five patients and the inhumane living conditions there. For years, Oregonians with mental illnesses had lived at the psychiatric institution heavily sedated and in the dark. Eager to find a better way to treat people with mental illnesses, advocates urged the state to replace the Wilsonville hospital with smaller-scale housing and community treatment programs across the state so that people could remain integrated in their communities while receiving the care they needed.

An aerial view of Dammasch State Hospital in Wilsonville, 1960. The facility had 460 beds and accepted patients in March of 1961.

Flash forward 28 years: That promised community treatment system still barely exists.

Instead, legislators spent $311 million remodeling the state psychiatric hospital in Salem in 2013 and $83 million building a new satellite campus in Junction City in 2015. Those expansions were made over the objections of many people working in mental health care.

“We were so frustrated with all this focus over in the valley on the state hospital remodel,” Dr. Robin Henderson, the chief executive for behavioral health for the Providence health system in Oregon, said of that effort. “What we want is the rest of the system.”

As housing costs rose during the last 20 years, it became harder for people struggling with mental illness to afford housing, especially for those on a disability income. That made the need for subsidized or free housing more urgent. But it also made finding affordable housing for people with serious mental illnesses even harder.

And then the pandemic struck. That too exacerbated the housing problem. COVID-19 outbreaks and staffing shortages led a number of adult foster care homes and skilled nursing homes to close or cut back the number of patients they worked with.

For example, in one of the state’s earliest COVID-19 outbreaks, more than 30 people died at a Southeast Portland nursing home, Health Care at Foster Creek. Facing lawsuits and the loss of its state license, the 115 bed facility closed in May 2020.

Health Care at Foster Creek had been one of the places Oregon’s Department of Human Services had placed seniors with serious mental illness, using funding from Multnomah county’s community mental health program.

The Healthcare at Foster Creek long-term care facility is pictured Thursday, April 16, 2020, in Portland, Ore. As of May 1, the number of people living at the facility who have died in the COVID-19 pandemic stands at 21.
Many facilities that housed people with serious mental illness, such as Foster Creek in Southeast Portland, have closed. Foster Creek was the scene of a deadly outbreak of COVID-19, and the 115 bed facility closed in May 2020.

“Many of the places that we sent people in 2019 aren’t here anymore,” Henderson said.

Residential care facilities can choose who they admit, and can turn people away for having the wrong health insurance, for being “too acute,” or for particular behavioral issues.

The current situation is akin to a buyers market, where “the people who have the housing options can be pickier,” Henderson said. That means some patients are frequently rejected and struggle even more to find a stable place in the community.

PROMISING STRATEGY: More small facilities statewide would allow more people to live stably in their communities.

Emily Cooper, with Disability Rights Oregon, says the state’s north star should be providing in- home support and hands-on outpatient treatment so that people with mental illness can live as independently as possible.

“We need more services in the community, period, the end,” Cooper said.

Henderson said the state also needs more “step-down” residential facilities that can treat people with serious mental illnesses after an acute illness and hospitalization, and provide them with a safe environment for long enough to allow them to get stable.

“Ninety-seven percent of people who enter into some type of facility like that, should be able to go back out and reintegrate into the community,” she said.

There’s a distinct advantage to scaling down any new residential care facilities for psychiatric patients. A federal rule that dates back to the 1960s means the state could only use federal Medicaid match dollars for inpatient psychiatric patients in facilities of 16 people or fewer, though the state health authority recently received a waiver from Medicaid that allows for some exceptions for facilities that treat substance use disorders.

At a hearing in December, lawmakers asked then director of the Oregon Health Authority, Patrick Allen, what would alleviate the admissions crisis at the Oregon State Hospital. Allen’s answer was that the state needed to invest more in community services.

“More of everything,” is how Allen described what was needed.

In the last session, the legislature made a down payment on solving the housing and residential care problem.

It allocated $130 million for the acquisition, renovation and start-up expenses of supportive housing and licensed residential treatment facilities, and for “community-based residential settings for individuals with a serious and persistent mental illness requiring a higher level of care.”

Another $100 million in one-time funding went to help county mental health programs pay for short-term housing support, including funding for shelter beds and rental assistance.

The Oregon Health Authority completed its review of proposals this month, and has awarded grants for 16 residential treatment homes adding 122 beds and nine supportive housing projects adding 160 new units.

The health authority wasn’t able to share a list of the projects that have been funded.

The health authority spokesperson said they prioritized rural areas where the need for housing is the greatest. The projects “will help relieve the bottleneck of individuals waiting to be released from the Oregon State Hospital,” said health authority spokesperson Timothy Heider.

The legislature’s one-time investment may help stand-up new residential facilities, but it won’t cover their annual operating budgets, or ensure they can keep their doors open. The recent changes to the state’s Medicaid program that increase reimbursement rates for behavioral health and allow some larger facilities to bill Medicaid for substance use disorder treatment may help sustain these places in the long run.

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In rural Oregon, there’s a higher need for mental health care, but few options, OPB.org March 2023

PROBLEM: People living in rural areas of Oregon have higher rates of depression, anxiety and suicidality.
Oregon’s coastal and rural communities face a heightened version of the state’s mental health care system crisis. Rural communities have higher rates of so-called “deaths of despair,” like overdoses, alcohol related deaths and suicides, than the more urban parts of the state.

And the risk of suicide is elevated for people, and in particular men, working in some of the industries that are central to rural lives and identities: fisheries, farming and ranching. The impact of suicide in rural communities was the subject of a recent video conversation between Todd Nash, the president of the Oregon Cattlemen’s Association, and Allison Myers, who directs the OSU Extension Family and Community Health Program.

They discussed the isolation and the unique economic stressors people live with in rural Oregon.

“When you combine the economic environment with how challenging it is to earn a living producing food, it’s stressful,” said Myers. “You have this combination where folks are feeling alone, or where it’s not OK to talk about the stuff underneath.”

Minnix tried to kill himself in October 2013. He was later diagnosed with post-traumatic stress disorder related to the sexual trauma he experienced in 1973. He got his dog, Elsa, as part of his suicide prevention plan.

Bill Minnix of La Pine has had regular mental health support following a suicide attempt in October 2013. Minnix says a big challenge for veterans, including himself, “will see a therapist for a year then the therapist moves on and us survivors must relive our trauma over and over. This has happened to me six times in the last four years and right now I don’t have a therapist.”

Rural communities also have even more limited behavioral health providers and treatment options, and longer waitlists, than Oregonians living in the Portland-Salem-Eugene corridor.

And some services, like psychiatric care for children, are virtually non-existent outside the Portland metro area.

In testimony this week before the state House Committee on Behavioral Health and Health Care, Dr. Beech Burns, a pediatric emergency medicine specialist, described what that lack of services means for families in rural Oregon who have a kid struggling with thoughts of self-harm. Children may end up being transported hundreds of miles away, by ambulance, just to be evaluated at a pediatric emergency department in the Portland metro area. If doctors decide the child doesn’t need to be hospitalized “they are discharged the same day back to their community, with the family left to determine how to arrange transportation home and how they will pay for the ambulance fee and cost of the emergency department visit,” Burns said.

PROMISING STRATEGIES: A first aid mental health course offered through the extension service at Oregon State University could help train people to recognize signs of mental illness and connect them with resources to provide support. And a bill before the state legislatures would create children’s psychiatric units in three hospitals outside of the Portland metro area.

Many of the strategies OPB has explored elsewhere in this series – like the EASA program and new investments in residential care – are being deployed statewide, including in rural areas, but there are also initiatives tailored to the needs of people living in the rural parts of the state.

Oregon State University’s Coast to Forest initiative is taking advantage of its deep reach into rural Oregon to train people in mental health first aid. It’s a short course that helps people learn how to recognize signs and symptoms of mental health distress and how to respond.

The course prepares people to have conversations that may not come naturally, but can be helpful in a crisis. For example, many people fear that if they ask someone if they are considering suicide, it can plant the idea. That’s a myth. But people who are considering suicide are often relieved to find out they can talk to someone about those scary thoughts. Mental health first aid can teach how to ask the question and how to receive the answer.

Oregon State also includes county resource guides in the training.

They’re giving the training to experts who work in rural and coastal communities across the state, including the staff of 4-H, outdoor school program leaders and extension experts working with people in forestry, agriculture and marine sciences.

The idea is that people experiencing a mental health crisis might be more likely to talk to someone they already know and trust rather than reaching out to a professional, particularly in parts of the state where professionals are few and far between.

“People who work in forestry and youth development might have connections that behavioral health professionals don’t,” said Dusti Linnell, an associate professor with Extension Family & Community Health.

Another project seeking to improve mental health care in rural Oregon would build connections between small, rural hospitals that can’t offer much specialty care for mental illnesses and larger hospitals that would share their staff and expertise.

A bill in this legislative session, HB 3126, would pilot this approach by designating three hospitals in three separate parts of the state as “Regional Child Psychiatric Centers.” Each of these hospitals would have a small psychiatric emergency unit for children, overseen by at least one child psychiatrist and a behavioral health clinician. The units would provide 24-7 care and observation for children in crisis, for up to three days at a time.

Dr. Ajit Jetmalani, who directs the division of child psychiatry at Oregon Health & Science University and is a consultant to the Oregon Health Authority, helped develop the proposal.

He says the Regional Child Psychiatric Centers would operate in much the same way the state’s regional trauma system does, triaging patients so that children with less intense needs can stay in their community, while those with more complex needs are admitted for specialty care. Jetmalani says the proposal is one of several big system changes, including the rollout of the 988 suicide and mental health crisis helpline, meant to create a more cohesive statewide response for people in crisis.

“People feel like things are completely chaotic and there’s no plan, but there really is a plan,” he said.

Hospitals would work together to decide which should serve as the regional center, and would sign agreements so that when a child in crisis shows up in their emergency department, they could get consultations over video from the team at the regional center.

Proponents of the bill say if the pilot is successful, they’d like to expand it to create seven such centers statewide. And, they say the same strategy could be applied to strengthen emergency psychiatric care for adults in rural Oregon too.