From the Oregonian, July 21, 2002 – not elsewhere online

The community mental health center in North Portland where Michael Sloan works is, on a scorching June morning, a swirl of tumult and decline.

A delusional man curses at a receptionist from beneath a black ski mask. A therapist, sprinting to catch his phone, trips on puckered industrial carpet. A man-sized teddy bear wearing a Christmas sweater fights clients for space on a waiting room sofa that hasn’t been stylish since the Carter administration.

The setting is bleak for the task ahead. An estimated 6,000 to 8,000 Oregonians with mental health disorders spend some time without housing each year.

Sloan is a housing specialist for Cascadia Behavioral Healthcare, the largest public-funded mental health agency in Multnomah County, and it’s his job to help keep them sheltered.

The problem didn’t exist 40 years ago when America locked away the mentally ill. But as state-run psychiatric institutions scaled back or closed, lawmakers didn’t move resources to the community, ignoring why insane asylums were ever built: Many people with chronic mental illnesses can’t survive without support.

Millions wound up in society’s margins, cycling through homeless shelters, jails and a crisis-driven public mental health system. The result is human suffering and a nation that spends billions dealing with the consequences of untreated mental illness.

With medication and social supports, people often can manage their illnesses to the point their symptoms disappear. Not only does stable housing help the mentally ill adjust to community life, it also makes them less reliant –as much as 50 percent less, some studies show — on the public mental health system.

Sloan and his 13 co-workers on Cascadia Behavioral Healthcare’s Housing Outreach Team do everything from splashing Pine-Sol around squalid apartments and schmoozing impatient landlords to signing emergency housing vouchers for the mentally ill to stay in cheap hotels — all on the statistical promise it will save public resources down the line.

The problem is, mental health officials say, systems nationwide are so strapped they don’t have the resources to invest in the supports that could not only save millions, but also lift up lives.

On this day, June 25, Sloan has exactly $898 to do a job that could save taxpayers untold thousands.

He prays aloud for a slow week, the last until a new fiscal year begins and his budget will be replenished. Until then, he has enough money to help four people, maybe five, if he’s thrifty.

Thrifty, like yesterday, when Sloan sent a 43-year-old woman with bipolar disorder to a hostel in Northeast Portland a week after she was released from a psychiatric hospital.

The woman’s family asked her to move out because, after two attempts, they don’t want a suicide to occur in their home.

It didn’t go well at the hostel. This morning, she sits next to a 6-foot stuffed bear in the lobby of Delaunay Family Services, twisting a Kleenex, waiting for Sloan.

A battered copy of the DSM-IV — the Diagnostic and Statistical Manual of Mental Disorders — rests on Sloan’s desk beneath a generic box of two-ply tissues.

Sloan flips to page 352 and reviews the woman’s diagnosis: “Completed suicide occurs in 10% to 15% of individuals with Bipolar I Disorder.”

Sloan slaps the book shut and reaches for his English breakfast tea. After a gulp and a calming breath, he calls the woman into his office.

“I had to sleep in my car,” she whimpers. “There was a pest — a silverfish — that crawled into my bed at the hostel.”

As if barely making enough to cover his own $525-a-month rent wasn’t enough of an occupational letdown, try having to dispatch one of society’s most vulnerable citizens to a fleabag.

Sloan masters the guilt. Tells himself that a bed is better than the street, after all.

“I’m going to ask a favor of you . . .” Sloan says.

“How do I know there’s not lice, too?” she interrupts, hugging a scuffed Louis Vuitton handbag to her chest. “I threw up this morning, this has been so nerve-racking.”

Sloan presses on. Could she please stay there another night?

Nope.

Please.

I won’t sleep with bugs.

As clients stack up in the waiting room, Sloan wants to tell her that beings more terrifying than silverfish lurk in some of the 22 places that accept the county’s emergency housing vouchers. Instead, he tells her another truth.

“I am basically out of money until the first of July,” he says. “That’s why you’re in the hostel this week, as opposed to a hotel. That’s all I could afford.”

Sloan promises that in six days, when his voucher money is refilled, he’ll put her up in a “nice hotel, a clean, decent living situation,” until he can help her find a permanent home. But that, he says with honest regret, is the best he can do today.

In ways greater than he could not have imagined when he took this job six months ago, 32-year-old Sloan, a former waiter who quit college 30 credits short of a psychology degree, is responsible for helping rescue the county’s $87 million mental health system.

But here on Lombard Street, Sloan isn’t basking in his importance. He faces daily what policy-makers have mostly been spared: human agony up close.

Dozens of new referrals chug through the fax machine in Sloan’s office each week: A woman who is about to be evicted because she can’t stop urinating on her carpet. A man with major depression who is living in his van. Someone else who can’t afford an apartment on the $314 a month he receives in federal general assistance.

People with mental health disorders often are among the poorest of the poor. Some of Sloan’s wealthiest clients receive just $545 a month in Supplemental Security Income, or SSI. That leaves even the most modest dwellings beyond reach and contributes to a disheartening national fact: Almost one-third of all homeless people have a serious mental illness, according to Mental Health: A report of the Surgeon General.

A handful of local apartment owners contract for federal housing subsidies, which allow tenants to pay no more than 30 percent of their income for rent and utilities. But the demand is so great that even when Sloan types a priority letter, flourishing it with please’s and thank you’s, his clients still wait a year, frequently cycling between jail, the hospital and the streets in the meantime.

Clients can apply for Section 8 vouchers through the Housing Authority of Portland, which allows them to pay no more than 70 percent of their income for an open market apartment. But the agency is so flooded, it accepts applications one week a year, then chooses recipients by lottery.

It’s a long shot, even for those who sail through the nine-page application. But try penciling in the eye-glazing particulars while voices scream in your head. As a co-worker of Sloan’s put it, handing the paperwork to a psychotic person is “like handing a tax form to an 8-year-old.”

After a 45-minute effort, Sloan’s next client has managed to fill out nothing but his name.

“Do you have a landlord?” Sloan asks gently.

No.

“Professional references?”

No.

“Employers, teachers, case managers, medical staff?”

No.

“The bottom line is they need some references to satisfy the request,” Sloan says, tugging at his scalp in harried frustration.

The man finally mumbles what sounds like the first name of his mental health caseworker.

“There’s one,” Sloan says encouragingly. “Problem is, you’ll need two.”

Another client awaits.

Personal experience

Sloan extracts his compassion from a personal place: He knows what it’s like to need help.

Last fall, a 16-year-old boy fresh out of driving school ran a stop sign and slammed into Sloan’s 6-foot-5 body, shattering his left knee.

After surgery, Sloan couldn’t move, let alone work. He lost his job at an adult foster-care home for men with traumatic brain injuries. He had to hock his bicycle to buy pasta and toilet paper. He would have lost his apartment without his parents’ help.

Sprinkle on a few more disappointments — student loan payments on a degree you didn’t finish, a girlfriend who moves 1,000 miles away to Los Angeles, the approach of your 32nd birthday when you’re not the raging success you thought you’d be — and there was Sloan, flat on his back on a couch he had bought at Fairly Honest Bill’s.

“I was not happy,” he says. “I was depressed and grouchy. I learned that we all have to take life on life’s terms.”

At the same time Sloan struggled to survive, so did Multnomah County’s mental health system.

The cost of a night in a local psychiatric bed skyrocketed from $430 to $700 last year. County administrators were forced to cut clinics, nurses, housing and outreach workers to make up the difference.

Things only got worse when, without those supports, many people with mental illness deteriorated to the point where they had to be hospitalized, digging the system deeper into debt.

Despite the impulse to keep pouring money into psychiatric beds, reformers wanted to get ahead of the money instead of always chasing it. With better support systems, the research-based logic went, fewer people would have to be hospitalized in the first place.

To that end, the county reduced funding for psychiatric wards by 20 percent, or $3 million, and stuck the money back into mobile crisis teams, walk-in centers, outpatient clinics and peer counseling.

Part of that money created Sloan’s position on the housing outreach team, a job he spotted in the classifieds just as his credit card barreled toward its $400 limit.

It turned out to be a good thing Sloan is skilled at surviving on a shoestring. Even with the influx of county cash for support systems, it doesn’t mean there’s enough to erase the need.

The math of reform has become Sloan’s mantra: 30 bucks a night for a hotel, $700 for a hospital bed.

What doesn’t get counted is the personal sacrifice of Sloan and his front-line colleagues: The therapist with a master’s degree who moved a schizophrenic’s belongings — everything from garbage bags brimming with stuffed animals to cat litter — up four flights of stairs after the client flipped off and otherwise ran afoul of her previous landlords.

The housing worker who turned down a higher-paying job because he fears no one else would do what he does: Don hip-waders and gloves to “muck out” the apartments of clients who are too depressed or psychotic to clean.

Sloan, who spent almost all his insurance pay-out to buy a used, $1,500 Honda Civic wagon so he’d have a way to meet clients too paranoid to venture outside their apartments.

The thanks does not come in their paychecks, which range from $22,000 to $28,000 a year for housing workers. For Sloan, who often must charge $4 lunches on his credit card because his checking account is dry, the thanks comes when a client says, “You’re the best guy I ever met, Jerry,” even though his name is Michael.

“Those days are hard,” says Sloan, who got his start in mental health housing doing muck-outs in Seattle. “You talk to landlords until you’re blue in the face, and they still kick your client out because he ran around the complex naked.”

Sometimes, Sloan says, you have to laugh so you won’t cry.

And what else can you do but laugh when, on a hot June morning, a delusional man wearing a ski mask embraces a 6-foot stuffed bear like a lover and waltzes through the waiting room to music that plays only in his mind.

Sloan isn’t laughing today, though.

He has only $648 left in his budget, six faxes in his chair, seven messages blinking on his answering machine and four clients stacked up next to the bear.

To top it off, one of Sloan’s most difficult clients, Ernest Hall, 49, has this morning blown his chance to move into the Delaunay Quads.

Sloan worked for months to get Hall, a schizophrenic whose paranoia leads him to believe everyone, including Sloan, is on illegal drugs, into the subsidized building.

This morning, during his interview with Rebecca, the building manager, Hall pitched a fit when he learned there would be no refrigerator in his room.

“I had to turn them down,” Hall announces when Sloan arrives at the Comet Club, a daytime activity center for the mentally ill in North Portland where Hall spends his weekdays. “What are you going to do for me now?”

For many of Sloan’s clients, cause and effect is an elusive concept. You resist playing your trumpet at midnight and waking up your landlord. You take your medications so you remember to take out the garbage and pay your rent. You try not to freak out in front of the person who holds the keys to your next apartment.

“I’m getting tired of this criminal system,” Hall yells. “I’m telling you, they’re all on drugs!”

“What did you say to Rebecca?” Sloan asks, afraid of the answer.

“Not too much,” Hall says unconvincingly. “I told her I wasn’t on drugs. Then she told me I had to socialize with the others. Do I really have to socialize with them, Jerry?”

“You have to not make any waves,” Sloan says. “You just have to be nice.”

“But you told me I could just stick to myself,” Hall pouts.

“Just be congenial.”

Hall sighs what sounds like a relent. “OK, but I’m going to tell you one thing right now in advance. If I even smell drugs I’m calling 9-1-1.”

“All right,” Sloan says, slumping weakly into a chair and grinding his palms into his forehead.

Sometimes Sloan thinks all that’s holding up the mental health system is creativity and luck. He and his housing co-workers meet twice a week to brainstorm solutions where there appear to be none.

This time, the client comes up with the resourceful idea.

“I’m going to tell Rebecca that I’m sorry for making her explode,” Hall says. “Uh, and, uh, I guess I could stop over there, and I’ll give her a Classic Coke.”

“That’s a good idea,” Sloan says, impressed. “Give her a Classic Coca-Cola, shake her hand and tell her that you’re very sorry.”

“What size?”

“I’d go for the 20 ounce.”

As Friday, June 28, begins, Sloan’s labor is reduced to numbers. A fax he’s waited for all week finally arrives.

“Oh, God,” Sloan says as he reads the new budget number. “This is not good.”

Since last year, the number of days patients have spent in local psychiatric wards has dropped 28 percent. The number of times Portland police have transported psychotic or suicidal people to local emergency rooms has fallen 35 percent. The number of calls to the crisis line has plunged 43 percent.

Somehow, this has not translated into more money in Sloan’s pot.

Multnomah County has granted him exactly $2,000 in rental assistance and $4,424 in emergency vouchers to keep roofs over the heads of whoever walks, stumbles or crawls through his door between now and Oct. 31.

“If we continue to positively impact the hospitalization rate, we will be able to pump the money from the risk pool back into treatment,” promises the agency’s June newsletter buried on Sloan’s desk. “This can mean more staff, increased services and lower caseloads. The light at the end of this tunnel is an increase in wages for those who have worked so long and so hard — fueled more by dedication than compensation . . .We ain’t there yet, but we’re gonna be!”

As two crows peck on a box of rancid potato salad outside his window, Sloan decides to heed his supervisors’ pleas for patience, to buck up and confront the tough choices he’s been hired to face.

He turns bravely to the red light flashing on his answering machine, presses play and hears Hall rambling about the FBI, the CIA and a crack cocaine ring he’s helping them “bust wide open.”

“Don’t leave me hanging, Ernie,” Sloan implores loudly. “I need some good news.”

After what feels like an eternity, Hall finally mentions that the apology to his prospective landlord went well.

Sloan hits the next message. It’s the manager. Yee-ha! She’ll reconsider!

“There may be hope for Ernie,” says Sloan, a broad smile finally crossing his lips. “That Coke may have saved him from the streets.”

Another client awaits.