Locking up the problems isn’t the solution

By Robert Landauer – editorial columnist for The Oregonian, September 8, 1996. Not available elsewhere online.

Review these recent Portland scenes:

1. During Rose Festival, a woman was disrupting traffic, holding a baby doll, sucking her thumb and beating her head against trees, injuring herself.

2. He really thought he was Superman and would not stop lifting way too much weight for his safety at the Nautilus fitness club.

3. The turbaned woman, blessing everyone, released pigeons during mass at the Downtown Chapel. She was about to be evicted from her apartment, because she believed God called her to invite all of Portland’s homeless to live with her.

4. A man, filthy and shoeless, was found sleeping on a Parks Block bench. His toenails, 1 1/2 inches long and overlapped, had fused. He didn’t speak, only grunted. Eventually he hit someone and was jailed.

The episodes feed the perception that downsizing or closing state hospitals has few if any positive trade-offs and is causing the quality of life in our communities to drop.

Many want these unsavory people locked up in mental hospitals, out of sight.

Well, not so fast.

Another way to look at this is this: Could you solve these problems simply by reopening mothballed state hospitals or building new ones? No indeed.

If Oregon operated as it did 30 years ago, with the same ratio of people in mental hospitals as then, the state budget for the mentally ill would be close to $1 billion per biennium for 10,000 beds rather than $100 million for 760 beds statewide, says Barry Kast, administrator of Oregon’s Mental Health and Developmental Disability Services Division.

The patients then and now are the people with schizophrenia, major depression and bipolor disorder (formerly called manic depression), dementias and alcohol- and drug-induced psychoses.

The policy puzzle is easier to understand at Fairview Training Center in Salem. It has about 350 residents. That is 3 percent of Oregon’s 10,000 developmentally disabled. Yet Fairview gobbles dollars like an insatiable Pacman, consuming 37 percent of the budget for the entire developmentally disabled population as opposed to the mentally ill.

It doesn’t take long to calculate that the more people you serve in this institutionalized way, the fewer you serve in all.

Consider another piece of the mental-health puzzle. If you have a limited budget and treat people only in an acute phase, you will see fewer people who are more seriously ill, and they will be much more expensive to treat. So if you want to be both cost-effective and humane in preventing personal crises, you have to divert much of your attention and funds to intervening early.

The issue, then, is not just the number of state mental hospitals, but whether Oregon’s 50,000-60,000 mentally ill people are treated adequately in the communities.

A big difficulty is that the public sees treatment as incompatible with living on the street, says Kast, but budgets and how the mentally ill behave make street-level treatment inescapable.

The transition is happening, slowly. In Portland, for example, Project Respond operated like 9-1-1 and answered this column’s four mental -health emergencies right at the street level of crisis.

These mobile professionals, operating out of a van, work for the private, nonprofit Mental Health Services West. They give their own DNA — dogged nonjudgmental attention — to the mentally ill. This builds trust in people who hear the walls breathe and buttons talk. It helped the pigeon-releasing madonna of the Downtown Chapel to agree to move to the Bridgeview Community, a Mental Health Services West facility that offers services and safety to the chronically mentally ill.

The Parks Block derelict responded over months to Project Respond’s assertive outreach. Caseworkers say you can chat with him at the Broadway Deli “where he sits looking clean and dapper drinking tea with his pinkies up and his toenails clipped and inside a new pair of shoes.” He will eventually be able to maintain an apartment on his own.

Life is better than it was for the Superman weightlifter with manic bipolar disorder and for the woman who was so distraught during Rose Festival. The outreach workers carried them through their crises and out of emergency services’ revolving door by reconnecting them to treatment, housing, transportation, food and other social services.

Project Respond, helping to keep the clients stable, can assist a person to live in the community for $4,000. Institutionalized, the same person typically costs the public $75,000 to $100,000 a year.

Oregon tries to treat the mentally ill in the least restrictive setting possible. That is legally required, ethically proper and financially necessary. It is also far from perfect.

It is getting better, though, as acclaimed efforts like Project Respond help the chronically mentally ill to stay stable — and free.