From Asylum to Community – Mental Health Care in Oregon from the 1950s to 2000
By David Cutler MD, Barry Kast MSW, Zeb Larson PhD, and Jason Renaud
Published in the Oregon Historical Quarterly, October 2022

READ – formatted PDF of this article

The question of how to provide mental health services for people with severe mental illnesses predates the founding of the United States. In modern times, debate often focuses on failures and setbacks related to post–World War II deinstitutionalization (moving from long-stay hospital care to community care), a strategy prompted by mental hospital reforms and a variety of new treatments becoming available as alternatives to long-term institutional care. During the 1950s, states began re-thinking the strategy of long-stay hospitalization, noting false assumptions about its benefits. But the lessons learned from the early years of deinstitutionalization foresaw better care.1 In a 1979 article, noted psychiatrist and academic J.A. Talbott pointed out that just leaving the state hospitals was not enough to ensure former patients had adequate instrumental social and financial skills to survive in the community.2 Talbott’s assessment remains to some degree the same today: deinstitutionalization, in the words of professors David Mechanic and David Rochefort, is an “unfulfilled promise.”3 It is often demonized in popular media, with one recent article hyperbolically describing it as one of the greatest policy failures of the twentieth century.4 By examining the history and context behind deinstitutionalization and mental health care in Oregon from the 1950s to 2000, we hope to better understand and perhaps learn from this radical but flawed process.

PHOTO

DOCTORS DEAN BROOKS AND J. DONALD BRAY were instrumental in forming Oregon’s unique state and county partnerships during the move toward deinstitutionalization of those needing mental health care during the last half of the twentieth century. Brooks, who is seated in the center background, was superintendent of the Oregon State Hospital from 1955 to 1981. Bray, in profile in the left foreground, became head of the Oregon Mental Health Division in 1971 and was a visionary leader in his work with the families of people with mental illnesses and with county governments.

In his trilogy of books documenting the history and treatment of mental illnesses in the United States, historian Gerald Grob offers a narrative overview of the changing relationship between government and mental health care. Grob adds a critical political dimension to our understanding of how mental health care is offered in the United States, separating it from purely medical histories that otherwise dominate the field.5 Grob’s history shows moments of crisis followed by reform, inattention, and neglect that have led to repeated crises and disputes over how to fix a broken system. In Oregon, the historiography of mental health treatment has numerous gaps. While some psychiatrists and care providers have written about their experiences in the mental health system, an overarching account of the community system is conspicuously absent. Olaf Larsell is the most recent author to offer an overview of the history of mental health care and recovery in Oregon in the “History of Care of Insane in the State of Oregon,” but it was published in December 1945.6 Between that article’s publication and today, the context of treatment and the understand- ing of mental illness has changed tremendously. Diane L. Goeres-Gardner’s Inside Oregon State Hospital: A History of Tragedy and Triumph offers a history of the Oregon State Hospital through the recent past, but it does not focus in-depth on the community mental health care system.7 In addition to modern psychopharmacology, neuroscience, new psychological methods, and skepticism about medical treatment of mental illness, practitioners must now deliver mental health care with far more regulation from the state and federal government, and review from private insurance corporations. The evolution of organized mental health care in Oregon during the latter half of the twentieth century — a shift from hospitalization to community care — has provided hopeful and creative approaches to the complex problems faced by the state’s residents. At times for many, however, that same care system has failed, and those failures can be instructive.

This article focuses mainly on the history of mental health care in Oregon between the 1950s and 2000, encompassing both state institutions and community settings. Oregon’s mental health system has had a different trajectory than the national systems in many respects, but mental health care in the United States has evolved differently, not just in states but also in local communities. Because of these differences, when politicians suggest that the mental health “system” is broken, it usually means they lack an understanding of the details about how such so-called systems function. What emerges from a historical assessment of the transition from hospital to community care is a trend toward greater focus on patient rights and, when that community care is properly funded and supported, better outcomes for the people in the system. To make these lessons clear, we begin with an overview of the development of asylum-based care in Oregon during the nineteenth century.

LATE-NINETEENTH AND EARLY-TWENTIETH-CENTURY MENTAL HEALTH CARE IN OREGON

Systematic mental health care came to Oregon with the arrival of doctors James Hawthorne and A.M. Loryea, who both moved to Portland from California by 1859. Together, they became Oregon’s first psychiatrists. By that time, there were a sufficient number of cases of mental illness in the state to justify their opening of the first mental hospital in the Pacific Northwest, originally located on Taylor Street in downtown Portland. Hawthorne and Loryea ran the hospital privately for two years, beginning in 1859. They moved to Southeast Twelfth Avenue and Salmon Street in 1861 and opened the renamed Oregon Insane Hospital. The Greek Revival–style facility had a bell tower and a lagoon in front of it and, in August 1868, had a census of ninety-one patients. The majority of patients Hawthorne worked with were, in nineteenth-century parlance, “acute,” meaning that their symptoms appeared abruptly and were judged to be curable; other patients likely had developmental disorders, or in some cases, elderly dementia. Treatment at that time was referred to as “moral treatment” and was based on the philosophies of Philippe Pinel, a French physician who called for humane treatment of people with mental illnesses. According to moral treatment principles, placing individuals in a well-regimented institution would enable them to replicate and eventually relearn the behavior of mainstream society.8 Nineteenth-century treatments included a healthy environment with a mix of kind behavior, firm discipline, rest, and light therapeutic work. By most accounts, Hawthorne’s hospital was consistent with the concept of warm, empathic, moral treatments. Evidence of Hawthorne’s concern for his patients is found in a report he gave to the Oregon Legislature in 1872:

To turn these people away without money, employment or any way of reaching their homes is to expose them to the danger of relapse to their former mental condition. To many of this class I have given out of my own means, the full amount required to take them home.9

PHOTO

THE HAWTHORNE ASYLUM, located at Southeast Twelfth Avenue in Portland, Oregon, opened in 1861 and was the first institution in the Pacific Northwest dedicated to the treatment of mental illnesses. Established by James Hawthorne and A.M. Loryea, the hospital staff provided “moral treatment,” based on a philosophy of treating patients humanely with the goal of returning them to mainstream society.

In 1869, Dorothea Dix, an activist who led reform movements for the treat- ment of people with mental illnesses, visited the hospital and declared: “I very earnestly wish every measure taken for sustaining Dr Hawthorne in his charge.” Between 1862 and 1883, the Oregon Insane Hospital humanely cared for about 200 people per year.10

During the late nineteeth and early twentieth centuries, asylums were the primary places for caring for people with mental illnesses. This approach led to rapid population growth in state hospitals, and overcrowding in the Oregon State Hospital in Salem required the construction of Eastern Oregon State Hospital in Pendleton, which opened in 1913.

In 1883, Oregon opened its first state hospital in Salem, and in 1913, a second one in Pendleton. During this time of state hospital expansion, patient demographics were also changing. Throughout most of the nineteenth century, the majority of those admitted to asylums were patients suffering from “acute” symptoms, but as time went on, practitioners judged an increasing number of patients to be “chronic.” Many individuals who were considered chronic cases had been ill for an extended period of time and were largely cared for through local charities or in jails; some chronic cases resulted from neurosyphilis, a condition that required custodial care. A large portion of the population included elderly people as well, and as life spans extended, an increasing number of people with dementia or Alzheimer’s were sent to hospitals rather than almshouses (local public institutions for poor and aged people).11 This was especially true at the local level, where county officials transferred to the state individuals who were a burden on county finances, a trend that grew stronger through the twentieth century.12

Between 1883 and 1957, asylum care was the predominant means of care for people with severe mental illnesses. During those seventy-four years, by and large, patients were not expected to recover, and asylums provided a total community of food, shelter, companionship, and as relevant knowledge increased, state-of-the-art treatment. In Oregon, as elsewhere, this caretaker approach led to rapid population growth in state hospitals; in 1888, the Oregon State Hospital population was 526 patients, and by 1898, it had grown to nearly 1,200.13 Overcrowding eventually required construction of two more state hospitals, Eastern Oregon State Hospital (EOSH) in Pendleton in 1913 and Dammasch Hospital in Wilsonville in 1961.

The 1930s and early 1940s were an especially difficult period for state hospitals nationwide as well as in Oregon. In absolute terms, the Great Depression worsened the situation; cash-strapped county governments in Oregon sent whomever might be a financial burden to the state at the same time as the state’s tax revenues were declining. Relative to the national average spending, Oregon fared poorly. For comparison, in 1931, New York spent $392 dollars per capita on hospital maintenance and Massachusetts $366, whereas Oregon spent only $201. In 1938, the superintendent in Salem reported that “our present overcrowding forces us to place beds in our exercise courts.”14 By 1940, per capita maintenance expenditures had declined to $179, and the superintendent of the Oregon State Hospital noted that the appropriation for patient growth accounted for only 28 patients annually, when in reality, the growth rate was nearing 50 patients per year.15 This placed Oregon forty-fourth out of forty-eight states in the United States.16 To make ends meet, the hospital system relied on patient labor for many maintenance functions.

The combination of overcrowding, reliance on patient labor, and poor employment practices may have been partially responsible for a mass poi- soning at Oregon State Hospital. On November 19, 1942, the head cook sent one of the patients helping in the kitchen to fetch powdered milk. While in the stockroom, the patient confused the powdered milk with sodium fluoride, a form of insecticide, which was mixed in with scrambled eggs. Forty-seven people died and more than four hundred were sickened.17 Larsell acknowledged this was due to the hospital lacking “adequate funds with which to hire competent help, making it necessary to depend too much on the assistance of . . . patients.”18

C.L. Brown, a patient at Oregon State Hospital, interviewed her doctor, Joseph Treleaven, decades after admission in 1965. The interview shed light on patient treatment in the hospitals during that time:

At one time, I had occasion to review the charts of a lot of patients who had been at Eastern Oregon State Hospital for twenty years or more, and the thing that struck me was that the person was admitted to the hospital and they had a severe mental disorder, [but] you could see from the notes — which were very sparse — that they gradually improved but nobody paid any attention. Nobody worked to get them out. Nobody worked to set up a situation where they could leave the hospital. Nobody worked with the family to find an alternative place to live, so they just became institutionalized. They lost — through illness and through being incarcerated — the necessary skills to live in the community or in their own home, so they became chronic that way.19

PHOTO

JOSEPH TRELEAVEN was a doctor at Oregon State Hospital and was appointed as the first Executive Director of the Mental Health Division in Oregon. This portrait was taken in 1966, when Treleaven became clinical director of Oregon State Hospital.

As Treleaven notes, the hospital’s role was largely custodial during the 1940s and 1950s, but that role would change through federal reform policies in the following decades.

FROM HOSPITAL CARE TO MENTAL HEALTH CARE

Scandals alone did not bring systematic changes to the asylum system. Beginning in the 1950s, reforms meant to address poor conditions in state institutions permit- ted many patients to move to a variety of community settings. This effort, commonly referred to as “deinstitutionalization,” aimed to dramatically reduce state hospital populations and improve inpatient and outpatient care. To a significant extent, newly discovered medications made deinstitutionalization possible. In 1952, French psychiatrists Jean Delay and Pierre Deniker published findings that a chemical compound known as chlorpromazine (Thorazine) was effective in reducing the symptoms of psychosis in humans.20 This was the first time any medication ever showed a measurable effect on psychosis, and it gave hope that psychotic illness could be sufficiently managed without long-term hospitalization.21

The federal government began to play a role in deinstitutionalization when it passed the Mental Health Study Act in 1955, which authorized President Dwight D. Eisenhower’s administration to appoint the Joint Commission on Mental Illness and Health. The commission published its final report in 1961, Action for Mental Health, which called for the establishment of community-based mental health care.22 The report prompted the U.S. Congress to pass The Community Mental Health Centers Act of 1963, which provided grant funding to catchment areas within states to build community-based and community-operated mental health centers.23 Congress intended the act to avoid hospitalizations due to mental illnesses and hoped the new centers would also provide prevention services. Under the act, the country was divided into catchment areas consisting of 100,000 to 200,000 people, and grantees would receive federal funds for several years before turning to local third-party funding.24 In 1965, amendments to the act provided eight years of federal staffing grants to help pay for the centers’ personnel.

Although the act was intended to create continuity of care between hospitals and community centers, the planning process that it required did not specify how to accomplish transitions from hospitals to Community Mental Health Centers (CMHCs). As a result, the move from hospitals to community living turned out to be destabilizing for many people. Because the act’s language loosely defined the population that CMHCs would serve, newly discharged patients often competed for treatment with those in the broader public who may not have needed as immediate services. Hospitals had provided for the most basic needs that people with severe mental illness faced, such as shelter and food, but now patients in many CMHCs would have to find those resources on their own.25

During the early 1960s, most states and mental health professionals were not prepared to take on such a complex challenge. At the time, very little was known about how to help people with psychiatric disabilities function independently in the community or what skills a workforce might need to be able to accomplish such a goal. What followed for mental health workers across the nation was a period of learning by trial and a lot of error.26 Eventually, the need to adapt new skills and programs led to effective deinstitutionalization of people with mental illnesses in Oregon and elsewhere. The national growth of and adoption of CMHCs, however, was slow. The federal government had hoped for 1,500 CMHCs nationally by 1980, but fewer than half that number were ever fully funded.27

At first, Oregon was reluctant to apply for these new federal community mental health centers due to their temporary nature, ending after only eight years and requiring increasing local match money each year. This was a concern for many other states as well. Although the grants began with a 90 percent federal match in the first year, by the eighth year, the match decreased to 10 percent, with 90 percent funding required on the local level. The expectation that local governments would provide the necessary additional funding was a problem for local taxing authorities. The federal mental health centers also bypassed the state governments, giving management authority directly to local community boards and groups, not necessarily elected officials.28

OREGON’S NOVEL STATE AND COUNTY PARTNERSHIPS

Around the same time that Action for Mental Health was published in 1961, Oregon was developing its own Mental Health Division, which began to make funds available to local counties to set up their own clinics for inpatient, outpatient, and crisis intervention services.29 Before 1962, Oregon did not have a statewide mental health authority that provided leadership on how to care for people with mental illnesses. Dean Brooks, a doctor and superintendent of Oregon State Hospital from 1955 to 1981, reported directly to Gov. Mark O. Hatfield, and was deeply concerned with the dehumanization of patients that he believed was caused by long-term hospitalization. In his 1969, article “A Bushel of Shoes,” he noted that a patient once asked him why there were no towel racks in the bathrooms at the Oregon State Hospital. Towel racks were easy items to install, it led him to wonder “how many elements of dehumanization are present in our hospital?”30 Due to his thoughtful kindness toward his patients, Brooks, although not a trained psychiatrist, was a role model and powerful inspiration to many of Oregon’s mental health leaders.31

In 1962, Hatfield appointed Treleaven, who had worked under Brooks at the Oregon State Hospital, as the first Commissioner of Mental Health for the State of Oregon. Before coming to Oregon, Treleaven worked at a hospital in Washington State that had attempted to treat schizophrenia with psychotherapy, which he determined was not effective. Later, when working at a child guidance clinic in Tacoma and Olympia, Washington, he took a one-week seminar from Gerald Caplan, a Harvard professor and community mental health expert, who opened his eyes to there being “something more to mental health than a one-to-one relationship with the patient who is ill.”32 Treleaven, Brooks, and others were interested in understanding community approaches to treatment for people suffering from mental illness. Hatfield charged Treleaven with implementing the new ORS Section 5 chapter 706 and a plan for community mental health care that gave state grants to counties to develop mental health programs with a menu of services that were written into the law. Before 1961, the Board of Control, a small executive body consisting of the governor, secretary of state, and treasurer, oversaw the Oregon State Hospital, the prison system, the Oregon State School for the Blind, and a host of other institutions. While the Board of Control continued to operate until 1969, its responsibilities for mental health were transferred to the Oregon Mental Health Division.33 Prior to the new law, anyone discharged from the state hospital would need to be seen for outpatient care at the hospital for follow-up care. The law’s newly required services would allow people to receive aftercare and medications, such as chlorpromazine, from local providers instead of state hospital-based physicians. This unique and early law represented a substantial change in how Oregon administered mental health services.34

J. Donald Bray became head of the Oregon Mental Health Division in 1971 and turned out to be an exceptionally talented and visionary leader.35 Born in Kansas in 1930, Bray went to medical school at the University of Kansas. He came to Oregon State Hospital in 1962 as a resident in psychiatry, where he was supervised by Brooks and social psychiatrist Maxwell Jones, was an internationally known expert in milieu therapy, also known as “therapeutic community.”36 Applied in a hospital context, therapeutic communities were supposed to bring patients and therapists together to work cooperatively in groups. After training and working at the state hospital, Bray moved to the Mental Health Division, where he applied his expertise to the newly developing state system of care. During the early 1970s, Bray conducted retraining conferences for the entire state mental health workforce following changes in civil commitment laws compelled by the U.S. Supreme Court. Beginning in the 1960s, activists challenged the ease with which civil commitment had been applied against individuals. The standard for commitment in most states, including Oregon, became whether the person was an imminent danger to themselves or others. The Supreme Court supported this standard in O’Connor v. Donaldson, which upheld dangerousness as a standard and required institutions to provide treatment.37

MAXWELL JONES (foreground) sits next to Narain Jetmalani in 1978. Jones was a social psychiatrist who was internationally renowned as an expert in milieu therapy, or therapeutic community, a structured, group-treatment method for people with mental health issues. This treatment was an important component of Oregon’s developing state system of care during the 1960s and 1970s.

The trainings were conducted at the Northwest School of Law mock courtrooms, where Bray taught classes wearing odd, roughed-out cowboy boots. His easygoing style also enabled him to work collaboratively with other stakeholder groups, such as the University of Oregon Medical School, the families of people with mental illnesses, and county governments. In 1973, he collaborated with professor George Saslow, Chair of Psychiatry at the University of Oregon, to design and fund the Community Psychiatry Training Program at the University of Oregon Health Sciences Center (OHSU today).38 Bray was highly regarded for his patience and empathy. In 1982, he met with frustrated and angry family members who objected to the lack of appropriate and effective services available for discharged patients with mental illnesses. The patients’ relatives organized a task force for the mentally and emotionally disturbed in Portland to advocate for better community services. Bray agreed that something needed to be done. He worked with the state legislature to strengthen partnerships with counties by offering a 50 percent match in funding from the state for county-based outpatient mental health services that were tailored to the needs of consumers and families. This plan worked well for counties that were granted substantial federal replacement funds for taxes and timber revenues no longer collectible from lands that reverted to the federal government when the Oregon & California Railroad Company failed. Counties not eligible for those revenues were less able to participate.39

Bray’s pioneering efforts to establish genuine collaboration with the county programs and the state mental health division, along with his great warmth and genuine interest in patients and families became known and appreciated nationally. He was elected to two terms as president of the National Association for State Mental Health Program Directors during the 1970s. Brooks, Treleaven, and Bray’s leadership during the 1960s and 1970s was informed by their collective work at the Oregon State Hospital. Without their vision of community support, the state and county partnerships for county-based outpatient mental health services would have failed.40

For many patients who spent long periods of time living in state hospitals in Oregon, deinstitutionalization was difficult because of the lack of support when moving into the community. At first, group homes and foster homes, often run by former hospital staff, sprung up in Salem around Oregon State Hospital. Resources for discharge were otherwise minimal, and patients faced conditions that varied widely from county to county. Multnomah and Washington counties, for example, did not have group homes or other housing resources during much of the 1960s and early 1970s, and many patients discharged from state hospitals were sent to single room occupancy (SRO) hotels or boarding houses. To address the missing services, Ed Sandvig, a local pastor, established a group home in his own house to accommodate twelve people in 1977, using a volunteer board of directors and operating without any direct supervision from the state for close to a year.41 Sandvig called the group home Luke-Dorf, which became “New Narratives” in 2020 and is now a large agency with mental health services and both transitional and long-term housing for people with mental illness. Projects such as this served as models for and provided a wider variety of structured housing alternatives for patients returning to the community.42

LIVING IN THE COMMUNITY (LINC)

Oregon was one of several states during the early 1970s that began to organize innovative deinstitutionalization projects. In 1969, EOSH obtained a five-year federal Hospital Improvement Grant that funded staff training on new strategies for treating and discharging long-stay patients. By 1974, although many patients had been discharged, there was a 24.2 percent readmission rate, and some long-stay patients remained hospitalized. So, EOSH applied for and received a second federal grant that year to provide the social and survival skills training necessary for long-stay patients living outside the hospital in small rental houses in Pendleton. Hospital staff moved their work and work location directly into the community to assist their discharged patients in new, shared five-people homes and conducted trainings on skills such as how to enroll in social security benefits and find part-time employment in town. Wes Terwilliger, an EOSH psychologist, led the project and called it “Living In the Community” or LINC.43 This project had begun during Bray’s tenure as com- missioner of the Oregon Mental Health Division (1971–1979).

The innovative LINC approach to gradually transitioning patients from the hospital to the community in Pendleton was so successful that state leaders tried to implement its principles throughout Oregon by way of small grants to county programs. They also intended the grants to reduce stress for people with psychiatric disabilities who had not been admitted to the state hospitals. The EOSH project was similar to a program run by Leonard Stein and Mary Ann Test in Wisconsin, which moved experienced staff and patients together from the state hospital to community care.44 This continuity with known caregivers enabled patients to make the difficult transition without losing relationships with the people who had been providing their daily support. Other successful examples of community living models during the 1970s include a group of discharged patients living in a Herald Square hotel in New York City, who over time developed natural supportive social networks on their own by sharing skills and duties associated with daily living, such as shopping, cooking, and cleaning.45

Although the LINC model was successful, it was not applied consistently throughout the state. In Marion County, for example, several group homes, operated by entrepreneurial former state hospital employees, had opened around Oregon State Hospital and continued to receive state hospital patients, rather than transitioning them to community living programs. While the staff at the group homes had worked with hospitalized populations, their experience was caring for dependent people rather than individuals in recovery, resulting in former patients not receiving the transitional care and training they needed. Additionally, the State of Oregon’s payment mechanisms covering staff, room, and board enabled the group homes to fill quickly but did not incentivize moving people out to more independent living. Once the homes filled, they were no longer open for referrals unless patients left or died.46 Although this achieved the initial goal of getting people out of the hospitals, it did not help transition them to living independently. Mental health care providers began to develop more sophisticated living arrangements, called “housing first” programs, in the 1980s.47 They were designed to fit housing arrangements to the needs of individuals through tailored support. Creators of programs such as the Hawthorne Apartments in Eugene, Oregon (now part of ShelterCare), and Central City Concern in Portland, designed them to provide supportive, transitional, and permanent housing with living-skill training.48 Such services replaced the total-care environments of the state hospitals with flexible care that encouraged independence. These programs, however, relied on skilled staff and are expensive, requiring special federal funding for subsidized housing that, despite ongoing concerns about homelessness, Congress and many states continue to under- fund.49 Although deinstitutionalization on the surface may seem uncomplicated, without comprehensive, equivalent, long-stay support services with familiar staff, many people with mental illnesses and disabilities cannot manage the stress of living outside hospitals or structured care facilities. Adding to the stress on the system was the persistent incidence of new cases despite primary prevention programs intended to avoid the onset of mental illness.

FEDERAL COMMUNITY MENTAL HEALTH CENTERS COME LATE TO OREGON

As mentioned previously, the federal government began providing federal staffing grants in 1965 to local catchment areas of up to 200,000 people. Although other jurisdictions throughout the country applied for federal money, throughout the late 1960s and early 1970s, Oregon resisted doing so. Gov. Tom McCall refused to accept federal money and went so far as to offer Oregon’s eligibility for federal CMHC funds to Washington State, out of wariness over taking on the potential financial burden after the temporary federal funds were no longer available.50 At the same time, however, Oregon continued to develop county partnerships, and in 1973 began offering 100 percent funding for emergency mental health services. But, as the weight of deinstitutionalization became clear, the state’s government acceded to the reality that it would have to begin paying for more services.51

In the mid-1970s, more Oregon communities began applying for federally funded centers. At that time, a federal CMHC grant had funded a unique center in Pendleton that served most of eastern Oregon. The eastern counties had experience working together as a region centered around their shared use of EOSH. Smaller county governments made it easier for individuals involved in the process to know and trust each other, compared to the rivalries and complexities of multiple agencies and stakeholders in, for example, Multnomah County.52 The Eastern Oregon Community Mental Health Center was said to cover the largest land mass covered of any federal community mental health center in the lower forty-eight states, and it offered a successful model for rural areas, despite challenges presented by its enormous land area.53 Until the late 1970s, no grants were submitted for the four large federal catchment areas in Multnomah County, Oregon’s most populous county. Although federal grant money to build and staff community mental health centers had been available for ten years, the county hesitated to go after those funds almost until the end of the program, out of concern over taking on the additional financial burden.54

But, in response to demands from Black community members in North and Northeast Portland, led by Edna Mae Pittman, the county hired James Shore, Chair of the Psychiatry Department at OHSU, in 1975 as a consultant on efforts to establish a federal mental health center in the area.55 The grant-writing process required extensive neighborhood input and ultimately took three attempts over the next four years to produce an acceptable proposal, with support from the State Mental Health Division and OHSU Department of Psychiatry grant writers. The proposal included all the existing mental health agencies in North and Northeast Portland, absorbing the Multnomah County–operated mental health aftercare clinic, Delaunay Mental Health Center in North Portland, and the Center for Community Mental Health in Northeast Portland.56

The National Institute of Mental Health (NIMH) regional office agreed to review the third proposal in 1979, and a group of North-Northeast (NNE) Portland neighbors and state and county grant writers presented their case in person in Seattle, Washington. The grant was approved at that meeting, ultimately creating the NNE CMHC (now known as The Garlington Center, named for Rev. Dr. John W. Garlington, Jr., who was a champion for social justice in North and Northeast Portland). The group returned to Portland exuberant with the knowledge that they had funded the first federal mental health center in Multnomah County.57 It was an important victory for Portland’s Black community, but there were also many challenges and much to learn by trial and error. Pittman, who had participated in the grant-writing process, became the center’s first chairperson of the board of directors but faced a challenge finding and recruiting a Black mental health director. Out of over 100 applicants, the only Black person who applied for the job was Michael Benjamin of Washington, D.C., who was not a psychiatrist. But he was a highly qualified professional who held a master of public health degree and had worked for several years at NIMH. He became the first CEO. Edward Colbach, a prominent White, local forensic psychiatrist, became the first medical director.58 Gene Taylor, another well-respected child psychiatrist, who had been the psychiatrist at the Multnomah County Northeast multi-service health center, moved to the day-treatment program at the contract agency, Center for Community Mental Health. Taylor was described by Black staff member Richard Jones as a kind, dedicated, and much-loved practitioner, who, for decades (well into his nineties), along with a small staff of psychologists, social workers, and nurses, looked after hundreds of patients at the day-treatment program. Taylor was also a talented amateur violinist and led a lunchtime string quartet of musician patients and staff.59

In 1980, after the success of the NNE CMHC proposal, Multnomah County hired Betty Brunette, a Harvard-trained clinical psychologist and former director of the Eastern Oregon Federal Community Medical Center, to lead its mental health programs. She and her staff wrote three more grants, two of which were funded, for the remaining catchment areas in Portland. The two grants funded Mental Health Services West, Southeast Mental Health Network, and Mt. Hood Mental Health Center in Gresham. Brunette was also responsible for starting the so-called “Quadrant System,” connecting each of the four mental health centers with a local hospital psychiatric inpatient unit.60 The coordination between the local hospital psychiatry units and mental health centers was important because patients could access outpatient care and medications in the community immediately after discharge, avoiding the risk of re-institutionalization. Although most Oregon county mental health programs did not apply for federal mental health center grants, many of them worked out similar arrangements either with the nearest local hospital psychiatric inpatient units or the state hospitals. By the 1980s, a more organized community care system was taking shape in Portland, but its development had been slow.

EDNA MAE PITTMAN participated in the grant-writing process to establish the North-Northeast County Mental Health Center in Northeast Portland and became the center’s first permanent chairperson of the board of directors. She is pictured here on July 1, 1985, in an image published in the Oregonian.

CHANGES IN LAW AND POLICY

Parallel to the national growth of the mental health service system, states also passed legislation that determined how to care for people who were civilly adjudicated, dangerous themselves or others, or unable to care for them- selves. California helped pioneer legislation that changed civil commitment laws in its Lanterman-Petris-Short Act of 1972, and subsequent U.S. Supreme Court decisions limited what circumstances allowed a person to be legally detained and hospitalized.61 In 1977, landmark legislation in Oregon created the Psychiatric Security Review Board (PSRB) to oversee cases of people convicted of crimes who are determined insane at the time of the crime or unable to assist in their defense. Under the new legislation, these people were sent to forensic wards at the Oregon State Hospital and kept either until they were able to assist in defending themselves in court or for the duration of the maximum sentence they might have received if found guilty but insane. If they responded to treatment in the hospital, they could be discharged but were still required to remain under the jurisdiction of the PSRB.62

George Saslow, the former chair of psychiatry at OHSU, was the psychiatrist for the PSRB from the time it was created through 2003, when he was ninety-nine. The question of when and how to deprive people of their liberty for safety reasons became a popular issue of discussion around the new commitment laws. On the one hand, the medical establishment wanted to treat patients and protect those around them, while on the other, the legal and civil rights movement had become concerned about the unnecessary deprivation of individual rights and the right to refuse treatment. These trends occurred nationwide as hospitals were being downsized, making it more difficult for some people to access needed inpatient care.63

The passage of the Americans with Disabilities Act (ADA) of 1990 and the update of the Civil Rights of Institutionalized Persons Act in 1997 required states to provide services to disabled people in settings appropriate to their needs. The acts considered state hospitals to be the highest level of care, and as part of the acts’ mandates, states had to continuously evaluate patients’ readiness for discharge to less restrictive settings. In 1988, the Governor’s Task Force in Oregon found serious deficiencies in how the state hospitals were run. Combined with negative press attention that hospitals had received at that time, and because state hospitals are expensive and are unable to bill federal Medicare and Medicaid, in 1995, the Mental Health Division made the decision to close Dammasch hospital’s 345 beds and replace them by buying 90 beds at Holladay Park Medical Center in Portland.64 Constraints on bed availability forced Oregon to reduce or stop admitting voluntary patients to state hospitals, essentially converting them to civil commitment and forensic facilities. As a result, hospitals went from “therapeutic communities,” where people could slowly recover in a more supportive, protective environment, to involuntary institutions. Dangerousness was required for admission. The legal definition of dangerousness also changed to imminent danger, which made it more difficult to hold suicidal patients who claimed they were no longer considering suicide even though they had made recent attempts.65 These changing standards made community care the primary form of mental health care in the state, and indeed nationally.

CHANGES IN FUNDING STREAMS

In the late 1970s, the Mental Health Division had received a federal Community Support Project grant to train staff on strengthening its programming and developing community support systems for disabled and mentally ill people. During the following decade, it became clear that the only way to continue to expand access to community-based care was through Medicaid funding. Because Medicaid is federal medical coverage for people with low incomes and disabilities, reimbursable services have to comply with and be billed as medical services. Medication monitoring and psychotherapy obviously fit within Medicaid reimbursable services, but important services such as social clubs, supported employment, and residential care did not. Housing and social services — essential non-medical services that promote positive outcomes for people with serious mental illnesses — therefore were not adequately reimbursed. Squeezing support services into billable hours set up another crisis for a vulnerable community members who needed a variety of services to sustain them beyond Thorazine and other medications. This trend worsened during the 1990s as Medicaid services were converted from fee-for-service to managed-care capitated schemes, which paid agencies flat rates per numbers of registered consumers per month, regardless of the level of care they required, and thereby further limited the services individuals were likely to receive.66

In 1981, CMHC grant funding came to an end under President Ronald Reagan’s administration, which canceled the eight-year grant program and distributed the remainder of the federal money in block grants to the states in the program, based simply on what they were receiving at that time.67 Many states that either never applied or already finished their CMHC grants got none of that federal money. This further restricted the kinds of programs that could be developed and funded by the states and created a greater reliance on Medicaid dollars.68

To provide funding for social support services, agencies had to find ways to define them as Medicaid-eligible. Although services such as case management were eligible, leaders were largely unable to use Medicaid to fund non-medical social support.69 Eventually, the idea that people are better off living outside of hospitals with social support eroded into the notion that since community living was less expensive it was therefore better than hospital care.70 Community living could be more effective, and potentially more cost effective, than hospital care, but it also required the development of a new interdisciplinary work force, and those professional workers needed to be paid for their work, as opposed to relying on families and volunteer support. Consequently, managing funding streams became a goal for program survival, rather than creating positive outcomes for people with mental illnesses and disabilities living in the community. Oregon leaders’ initial doubts about accepting federal funds were perhaps justified.

REACTIONS TO “INNOVATIONS” IN MENTAL HEALTH CARE

During the 1970s and 1980s, resistance to the grief and negative outcomes of deinstitutionalization — compounded by the shift toward funding-stream restrictions — flourished in Oregon. Organizations and individuals set out to challenge these “innovations” in mental health care in Oregon. They were motivated by different concerns: larger numbers of unhoused individuals with mental illness, ongoing reports of poor conditions in the state’s hospitals, and the experience of abuse that many consumers endured. The National Alliance on Mental Illness organized in 1979, and its Oregon branch organized shortly after that, growing out of the Task Force for the Mentally and Emotionally Disturbed. The group advocated locally for better hospital, medical, and social supports for family members.71 For over twenty-five years, from about 1986 to 2005, David Oaks of Eugene, Oregon, was executive director of the non-profit newsletter known as Dendron that ultimately became the organization MindFreedom International. The organization advocated in Oregon for people with psychiatric disabilities, including for their right to self-determination in treatment. Oaks met Judi Chamberlain in 1976 and recruited her to join the board of MindFreedom International, where she became a powerful advocate for people labeled as “mentally ill” by society. During the 1970s and 1980s, Oaks and members of his organization appeared at Oregon Psychiatric Association meetings demanding to be heard. Later, they peacefully protested at the annual American Psychiatric Association meetings nationwide.72
Changes in funding streams also meant that community mental health care became increasingly medicalized over time. Services had to fit into bill- able hours, as mentioned earlier, which prioritized medical interventions first and foremost. The result was that treatment in many cases was exclusively medical, usually meaning medications.73 Medications offered inconsistent benefits for consumers, and often with side-effects that affected their quality of life.74 This fed into a growing anti-psychiatry movement at that time.

People with mental illnesses began to join others in the disability rights movement and became advocates on their own behalf. Howard Geld, known as Howie the Harp, established the Insane Liberation Front in Oregon in 1970.75 It was the first group of its kind in the country. Although the group survived for less than a year, its demands for an end to involuntary commitments, protests against electroconvulsive treatment, and advocacy for better patient treatment inspired similar groups. In 1971, Geld moved to New York and three years later founded the Mental Patients Liberation Project and Project Release, which still exist in New York City. He was also active in California during the 1980s. Those who knew him remembered him as a charming and effective leader, and to this day, Community Access in New York operates a housing, crisis respite, health and wellness, and advocacy center known as Howie the Harp.76 The reaction to deinstitutionalization and to the excessive medicalization of survivors of mental health treatment yielded some important research and changes in mental health services staffing for people experiencing severe mental illnesses and psychiatric disabilities. In the 1980s, for example, Portland-based Garrett Smith, who had worked as a housing coordinator at Mental Health Services West and identified himself as someone who had recovered from a mental illness, became the director of The Mind Empowered, a new state-funded assertive community treatment program staffed by people recovering from mental illness.77 The Portland State University School of Social Work Regional Research Institute received a grant in 1984 to study and compare two teams of social workers, those who had experienced a mental illness and those not so diagnosed.78 The study actually included some people who had experienced mental illness in both groups, and the two cohorts produced relatively similar outcomes in terms of medical and social results, including reduced emergency room visits and homelessness in the communities they served. These innovative studies were some of the earliest to measure the effects of consumers functioning as staff in the mental health workforce nationwide.79

CONCLUSION

Much changed from the mid-twentieth century to the latter half of the twentieth century. In 1950, mental health care essentially occurred in a few large state institutions. But by the end of the century, care and treatment had spread all over the state, managed through diverse county, state, and federal funding streams and organizations. People with mental illnesses toward the end of the twentieth century experienced less stigmatization and were much more likely to live independently, but while they certainly had more freedom, the question of depth of integration into social support systems remained. When Dammasch State Hospital in
Wilsonville closed in 1995 and Eastern Oregon State Hospital closed in 2014, the loss of accessible beds for patients experiencing mental-health disabilities created life-changing problems.80 As of March 2022, Oregon State Hospital in Salem and in Junction City (built in 2014) employ about 2,240 people and care for about 650 patients, most of whom are people with mental illnesses and are accused of committing crimes. The migration from long-stay hospital care to community treatment, for many, enabled extraordinary growth and achievement. For others, it meant despair, homelessness, and perhaps a greater risk of early death. Oregon has a long history of strong leaders in mental health care who came along at crucial times throughout the latter half of the twentieth century to overcome obstacles and build a new system of care. In addition to leadership, however, better outcomes for consumers often depend not so much on what is the latest new fad in treatment but understanding and coping with prevailing political and economic conditions necessary to support continuing services for vulnerable populations in communities where they live.

DAVID OAKS, an activist in Oregon, was featured in the Winter 1983 edition of Profiles magazine. Oaks advocated for people with psychiatric disabilities and for their right to self-determination.

The twenty-first century has brought new social, biological, and politicized solutions to stressors such as the effects of climate change and the COVID pandemic, which will require new treatments, new housing and social sup- ports, and new leadership focused on overcoming these obstacles. Creating new solutions will certainly require awareness of the historical context and adaptations that built our current system of care.

FOOTNOTES

1. Linda Chafetz, Howard Goldman, and Carl Taube, “Deinstitutionalization in the United States,” International Journal of Mental Health, 11:4 (1982): 48–63.
2. A. Talbott, “Deinstitutionalization: Avoiding the Disasters of the Past,” Hospital and Community Psychiatry 30:9 (September 1979): 621–24.
3. David Mechanic and David Rochefort, “Deinstitutionalization: An Appraisal of Reform.” Annual Review of Sociology, 16 (August 1990): 301–27.
4. Samuel Goldman, “A Murder in New York and the Dilemma of Deinstitutionalization,” The Week, January 19, 2022, https://theweek.com/public-health/1009111/a-murder-in-new-york-and-the-dilemma-of-deinstitutionalization (accessed April 24, 2022).
5. Gerald Grob, The Mad Among Us: A History of the Care of America’s Mentally Ill (New York, NY: Maxwell Macmillan), 27.
6. Olaf Larsell, “History of Care of Insane in the State of Oregon,” Oregon Historical Quarterly 46:4 (Winter 1945): 295–326.

7. Diane L. Goeres-Gardner, Inside Oregon State Hospital: A History of Tragedy and Triumph (Mount Pleasant, SC: Arcadia Publishing, 2013).
8. Tim Askin, “James Hawthorne (1819–1881),” The Oregon Encyclopedia, https://www.oregonencyclopedia.org/articles/hawthorne_j.c/ (accessed August 15, 2022); Report of the Physicians of the Oregon Hospital for the Insane for the Years 1867–8 (Salem, Ore.: W.A. McPherson, State Printer, 1868).

9. Report of the Superintendent of the Oregon Hospital for the Insane Asylum, Oregon, Oregon Legislative Assembly, Seventh Regular Session, September 1872 (Salem: Eugene Semple State Printer, 1872), 10, https://digital.osl.state.or.us/islandora/object/ osl%3A76042/datastream/OBJ/view (accessed August 15, 2022).
10. “Miss Dix on the Insane” Daily Tribune, November 11, 1869, 2; David L. Cutler, “Moral treatment at the End of the Oregon Trail: Dr. James C. Hawthorne, 1819–1881,” American Journal of Psychiatry 158:6 (2001): 871.
11. Grob, Mad Among Us, 121.
12. Larsell, “History of Care of Insane in Oregon,” 313.
13. , 312–13. For an administrative history of Oregon State Hospital and the care of people with severe mental illnesses, see Department of Human Services, Addictions and Mental Health Division, Oregon State Hospital, “Administrative Overview,” November 2009, (accessed August 15, 2022).
14. Board of Control, Thirteenth Biennial Report of the Oregon State Board of Control for the Biennial Period Ending June 30, 1938 (Salem, Ore: State Printing Office, 1939), 30.
15. Board of Control, Fourteenth Biennial Report of the Oregon State Board of Control, 41.

16. Gerald Grob, Mental Illness and American Society, 1875–1940 (Princeton, NJ: Princeton University Press, 1983), 218–19.
17. “Poisoned Show Improvement,” Oregonian, November 22, 1942, 1, 21.

18. Larsell, “History of Care of Insane in Oregon,” 319.
19. L. Brown, “Oregon State Hospital during the 1960s: A Patient’s Memories and Re- cent Interview of Her Doctor,” Oregon Historical Quarterly 109:2 (Summer 2008): 291.
20. Delay and P. Deniker, “Le traitments de psychoses par une méthode neurolytique dérivée de l’hibernothérapie; le 4560 RP utilisée seul en cure prolongée et continue,” CR Congr Méd Alién Neurol (France) 50 (1952a): 497–502.
21. Zeb Larson, “America’s Long-Suffering Mental Health System,” Origins, (accessed August 1, 2021).
22. Ewalt, Action for Mental Health: The final report of the joint commission on mental Illness and health (New York, NY: Basic Books, 1961).
23. L. Cutler, “A Historical Overview of Community Mental Health Centers in the USA,” in Innovations in Mental Health, eds. S. Cooper and T. Lentner, Sarasota, Florida, Professional Resource Exchange, Inc., 1992.

24. Steven S. Sharfstein, “Whatever Happened to Community Mental Health?” Psychiatric Services 51 (May 2000): 5, 617.
25. Larson, “America’s Long-Suffering Mental Health ”
26. Gerald Grob, From Asylum to Community: Mental Health Policy in Modern America, (Princeton, N.J.: Princeton University Press, 2016) 237.
27. Blake Erickson, “Deinstitutionalization Through Optimism: The Community Mental Health Act of 1963,” Psychiatry Online, June 11, 2021, (accessed April 26, 2022).
    28. David Cutler, “A Historical Overview of Community Mental Health Centers in the USA,” in Innovations in Mental Health, eds.
    29. Cooper and T. Lentner (Sarasota, Florida: Professional Resource Exchange, Inc., 1992).
    30. E. Appel and L.H. Bartemeier, Action For Mental Health: Final Report of the Joint Commission on Mental Health and Mental Illness (New York, NY: Basic Books, 1961).
    31. Dean Brooks, “A Bushel of Shoes”, Journal of Hospital and Community Psychiatry, 20 (1969): 371–75.
    31. Robert Nikkel, “A Tribute to Dean K. Brooks: The Fire Still Burns,” Mad in America, April 23, 2022, (accessed July 25, 2022).
    32. Karen Unger, interview with Joe Treleaven, March 9 1999, (accessed August 15, 2022).
    33. Department of Human Services, Addictions and Mental Health Division, Oregon State Hospital, “Administrative Overview”; Gary Halvorson, “Oregon State Board of Control Agency History,” Oregon State Archives, (accessed August 16, 2022).
    34. Bob Nikkel, “https://www.oregonarchive.org/a-short-history-of-the-public-mental-health-system-of-oregon/,” Oregon Mental Health Archive, February 7, 2020, (accessed July 2022).
    35. Karen Unger, interview with Don Bray MD, April 8, 1999, (accessed August 15, 2022).
    36. Fuller Torrey, American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System (New York, NY: Oxford University Press, 2013), 73.
    37. Megan Testa, Sara West, “Civil Commitment in the United States,” Psychiatry (Edgmont), 7:10 (October 2010): 30–40.
    38. L. Cutler, J.D. Bloom, J.H. Shore, “Training psychiatrists to work with community support systems for chronically mentally ill persons.” American Journal of Psychiatry, 138:1 (1981): 98–101.
    39. Donald Bray’s work with the state legislature is based on personal recollections by David Cutler. See also, “The Oregon and California Land Acts,” The Oregon Encyclopedia, https://www.oregonencyclopedia.org/ articles/oregon_and_california_lands_act/#. YSf2KY5KhPZ (accessed August 15, 2021).
    40. Personal reflections of David Cutler, June 1990.
    41. Mona Knapp, interview, February 7, 2013. For more on the history of halfway houses and their early connections to religious institutions, see Cyrus J. O’Brien, “‘A Prison in Your Community’: Halfway Houses and the Melding of Treatment and Control,” Journal of American History 108:1 (June 2021): 93–117.
    42. David Cutler, “Clinical Care Update Community Residential Options for the Chronically Mentally Ill,” Community Mental Health Journal 22:1 (Spring 1986); New Narrative, “Learn Who We Are,” https://newnarrativepdx. org/learn-who-we-are (accessed August 15, 2022).
    43. L. Cutler, M.A. Terwilliger, L. Faulkner,
    44. Field, D. Bray “Disseminating the Principles of a Community Support System,” Hospital & Community Psychiatry 35:1 (January 1984): 51–55.
    45. I. Stein and M.A. Test, “Retraining Hospital Staff for Work in a Community Program in Wisconsin,” Journal of Hospital and Community Psychiatry, 27:4 (1976): 266–68.
    46. Carl Cohen and Jay Sokolovsky, “Schizophrenia and social networks: ex- patients in the inner city,” Schizophrenia Bulletin 4:4 (February 1978): 546–60.
    47. David Cutler, “Community Residential Options for the Chronically Mentally Ill,” Community Mental Health Journal 22:1 (Spring 1986).
    48. Cutler, “Community Residential Options for the Chronically Mentally ”
    49. Cutler, “Community Residential Options for the Chronically Mentally ”
    50. Globally, governments underfund mental health See Faraaz Mahomed, “Addressing the Problem of Severe Under- investment in Mental Health and Well-Being from a Human Rights Perspective,” Health Human Rights 22:1 (June 2020): 35–49. For a U.S. perspective, see the American Hospital Association’s statement on behavioral health from 2022, https://www.aha.org/news/perspective/2022-02-18-perspective-we-must- address-americas-behavioral-health-crisis-now (accessed April 29, 2022).
    51. Oregon State Letter from Kenneth Gaver to Robert L. Prairie, July 22, 1968.
    52. Department of Health, Education, and Welfare and other Federal Agencies, “Deinstitutionalization of the Mentally Disabled in Oregon,” United States General Accounting Office, July 16, 1976, http://archive.gao.gov/f0302/092275.pdf (August 16, 2022).
    52. Cutler, et al., “Disseminating the Principles of a Community Support System,” 51–55.
    53. Tom Brubaker, David Emmons, and John Meade, “A descriptive study of demography & transportation issues of chronically mentally ill in the eastern Oregon comprehensive community mental health catchment area,” https://pdxscholar.library.pdx.edu/cgi/ viewcontent.cgi?article=3821&context=open_ access_etds (Accessed May 26, 2022).
    54. David L Cutler, Joseph Bevilaqua, and Bentson H. McFarland, “Four Decades of Community Mental Health: A Symphony in Four Movements,” Community Mental Health Journal 39:5 (October 2003), 381–98.
    55. Personal recollection of David Cutler, May 1976.
    56. , August 1977.
    57. , July 1979.
    58. , October 1980.
    59. , June 1981.
    60. , September 1981
    61. Gerald Grob, “Public Policy and Mental Illnesses: Jimmy Carter’s Presidential Commission on Mental Health,” The Milbank Quarterly 83:3 (2005): 447–48. The Lanterman-Petris-Short Act attempted to “end the inapproporiate, indefinite, and involuntary commitment of persons with mental health ” Quote is from Disability Rights California, “Understanding the Lanterman-Petris-Short (LPS) Act,” https://www.disabilityrightsca.org/ publications/understanding-the-lanterman-petris-short-lps-act#:~:text=Petris%20and%20 Alan%20Short%2C%20the,protections%20 for%20mental%20health%20clients (accessed August 15, 2022). For a historical overview of the origins and current status of civil commitment laws, see SAMHSA, Civil Commitment and Mental Health Care Continuum: Historical Trends and Principles for Law and Practice, p. 11.
    62. D. Bloom and M.H. Williams, Management and Treatment of Insanity Acquittees: A Model for the 1990s (Progress in Psychiatry) (Washington, D.C.: American Psychiatric Press, 1993).
    63. D. Bloom, “Thirty-Five Years of Working with Civil Commitment Statutes,” The Journal of the American Academy of Psychiatry and the Law 32:4 (2004): 430–39.
    64. Bob Nikkel, “A Short History of the Public Mental Health System in Oregon,” February 2000; Oregon State Hospital Museum of Mental Health, “Oregon State Hospital,” https://oshmuseum.org/hospital-2/ (accessed August 15, 2022).
    65. Department of Human Services, Addictions and Mental Health Division, Oregon State Hospital, “Administrative Overview,” 7–8.
    66. L. Cutler, McFarland B, Winthrop
    67. “Mental Health in the Oregon Health Plan Integration or Fragmentation?” Administration and Policy in Mental Health 4:25 (March 1998): 361–86.
    68. Daniel Yohanna, “Deinstitutionalization of People with Mental Illness: Causes and Consequences,” AMA Journal of Ethics, October 2013, https://journalofethics.ama-assn. org/article/deinstitutionalization-people-mental-illness-causes-and-consequences/2013-10 (accessed May 25, 2022).
    69. L. Cutler, McFarland B, Winthrop
    70. “Mental Health in the Oregon Health Plan Integration or Fragmentation?” Administration and Policy in Mental Health 4:25 (March 1998): 361–86.
    71. David Cutler, Douglas Bigelow, and Bentson McFarland, “The Cost of Fragmented Mental Health Financing, Is It Worth It?” Community Mental Health Journal, 28:2 (April 1992): p. 121–33.
    72. J. Tanenbaum, “Medicaid eligibility policy in the 1980s: medical utilitarianism and the ‘deserving’ poor,” Health Political Policy Law 20:4 (Winter 1995): 933–54.
    73. Carol Howe and James Howe. “The National Alliance for the Mentally Ill: History and Ideology,” New Directions for Student Leadership (Summer 1987): 23–33.
    74. Mind Freedom, “Timeline,” https:// org/kb/mf-timeline (accessed May 2, 2022).
    75. PLoS Magazine Editors, “The Paradox of Mental Health: Over-Treatment and Under-Recognition,” PLoS 10 10:5 (May 2013).
    76. The debate around the benefits and drawbacks of medications remains ongoing, but to learn from one perspective on the issue, see Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (New York City: Crown Publishing Group, 2010).
    75. Geoffrey Reaume, “Lunatic to patient to person: Nomenclature in psychiatric history and the influence of patients’ activism in North America,” International Journal of Law and Psychiatry 25 (2002): 415.
    76. Community Access, “Howie the Harp,” https://www.org/ index.php?option=com_content&view=arti- cle&id=489&Itemid=106 (accessed August 15, 2021).
    77. Clarke, H. Herinkx, R. Kinney, R. Paulson, D. Cutler, K. Lewis, and E. Oxman, “Psychiatric Hospitalizations, Arrests, Emergency Room visits, and Homelessness of Clients with Serious and Persistent Mental Illness: Findings from a Randomized Trial of Two ACT Programs Vs Usual Care,” Mental Health Services Re- search 2:3 (September 2000): 155–64.
    78. “Howie the Harp,” Community Accessed August 2, 2021:
    79. Paulson R., H.A. Herinkx, J. Demmler, G.N. Clarke, D.L. Cutler, E. Birecree,“Comparing Practice Patterns of Consumer and Non-Consumer Mental Health Service Providers,”Community Mental Health Journal 35:3 (June 1999);
    64. Clarke, et al., “Psychiatric Hospitalizations, Arrests, Emergency Room visits, and Homelessness of Clients with Serious and Persistent Mental Illness,” 155–64. 46 C.T. Dickel, H.A. Dickel, Dickel’s History of Psychiatry in Oregon; A monograph prepared for the H. A. Dickel Memorial Lectureship, Dept. of Psychiatry Oregon Health Sciences Center, 1977.
    65. E. Nikkel, “A Short History of the Public Mental health System in Oregon,” February 2000, http://www.localcommunities.org/ lc/225/FSLO-1203990289-183225.pdf; https:// www.bendbulletin.com/nation/century-old-pendleton-mental-health-hospital-prepares-to- shut-down/article_572961ac-2a7a-59d8-a3cc- 9915d47d7ad5.html5d47d7ad5.html (accessed July 1, 2022; Kathy Aney, “Century-old Pendle- ton Mental Health Hospital Prepares to Shut Down,” Bend Bulletin, February 18, 2014; Lynne Terry, “Oregon State Hospital on a Hiring Spree with $10 Million Appropriation,” Oregon Capital Chronicle, March 22, 2022.
    Health Care, Mental Health