Millions in taxes buy nightmares for mentally ill

From the Portland Tribune, August 5, 2010

MY VIEW by Jenny Westberg, board member of the Mental Health Association of Portland • Civil commitment laws are a $700-a-day answer to a $20-a-day issue

Peter Korn’s “Suicidal? Psychotic? Dangerous? Who should be committed?” (July 15) jackhammers at soft hearts with story after painful story of people with mental illness who wound up dead. In it, the mother of Keaton Otis claims a civil commitment to a psychiatric hospital would have saved her son.

Confronted with the human tragedy of mental illness, is broadening civil commitment law the answer?

It may be tempting. But soft hearts should not lead to soft heads.

Korn’s examples are Jack Collins, Aaron Campbell, Keaton Otis, James Chasse Jr. and George Grigorieff. His question: if we had an expanded commitment law, would they still be alive?

The answer is no. Of these five men, four died at the hands of police. These men were not shot or beaten by our civil commitment laws. They did not die of their mental illness. The real question is, “Had not police used lethal force, would they still be alive?”

Stipulated: We have a broken mental health system. Greater civil commitment powers might seem like a quick, happy solution, but the cost is unsustainable, and outstanding legal and ethical questions overwhelm any prospect for change. Since commitment law is based on a federal standard, expansion would occur at the Oregon State Hospital.

Run the numbers on inpatient care. It would cost less to stack patients in the London Ritz. A private psychiatric bed, where patients must sometimes queue for weeks, costs $1,000 per day, per patient. For the Oregon State Hospital, a bed is $700 per day, per patient. Meanwhile, the very best, most effective outpatient care is $20 per day, per patient.

As taxpayers and wage-earners in hard times, accepting a $700 solution while a $20 solution is ignored is reckless extravagance. It’s even more foolish when we look at what we get for our money.

In a 2008 investigative report, the U.S. Department of Justice documented abysmal conditions at the Oregon State Hospital. Beyond the mice, scabies outbreaks, injuries and infection-related deaths, there were treatment deficiencies so severe that patients’ illnesses got worse, not better. There were patients confined to a seclusion room for a year or more, and drugs used for behavioral control rather than therapeutic purposes.

We pay millions, and we buy nightmares. While some patients do benefit, often it is despite commitment, not because of it. It’s expensive, it’s brutal, and it doesn’t work.

Further, commitment is open-ended. This should bother us on several counts. Whenever a citizen’s liberties are removed without conviction of a crime, every freedom-loving person should be on full alert; every legal option should be observed; the best defense should be mounted.

It doesn’t happen. On appeal, commitments are often overturned, with the judge, in effect, finding that the person never should have been committed in the first place.

Criminals get the benefit of a release date. But for persons convicted of a mental illness, there is no maximum stay. Every commitment is a potential life sentence.

DOJ investigators discovered patients “months or years after having met the criteria for discharge.” In other words, even those who get better may not go home. And there are those who die inside, like Moises Perez last fall. His body lay unnoticed, for 10 hours, across from the nurses’ station. For patients like Perez, all hope of recovery is lost.

And again, there’s the price. Because commitment is open-ended, it’s not just a matter of throwing thousands of dollars into a hole. It’s that we do it again and again. Each time we commit someone, we commit ourselves as well — to an endless series of blank checks. Now we are thinking about doing it more often.

Changing the law might make sense if the law didn’t work. There is absolutely no evidence of that. Our law already allows commitment for those who are a danger to themselves or others, or who cannot provide for their own needs.

This is a strict standard, as it should be; after all, commitment represents removal of basic human rights. Still, when a person goes before a judge, there is a 70 percent chance it will result in commitment. Where there is a genuine threat, we already have a remedy. We do not need a softer, blurrier law.

Rather than rushing toward an unnecessary and harmful solution at upwards of $700 per day, let’s look at the one that costs $20.

Community-based mental health treatment works. It’s effective in promoting recovery, and it’s effective in preventing crisis. It reduces our need for civil commitment. That’s if you can get it.

If we want to expand an option for mental health treatment, shouldn’t we expand the cheap one that actually helps?

We can go down a road of extravagance, shame and neglect. Or we can choose common sense and compassion, fully funding outpatient mental health treatment as the least expensive, most effective intervention.

We must reject the call to expand civil commitment. We must pursue the better way.


Note from Mental Health Association of Portland: – The $20 per patient per day figure is about 125% of the assertive community treatment model used by Cascadia Behavioral Healthcare in 2001-2002. Those five geographically displaced teams case-found the 700 countywide clients at highest risk of hospitalization / incarceration and started daily contact with all of them providing social work, psychiatric care, housing assistance & employment assistance. Jim Hlava, Sarah Goforth, Kim Burgess, Ginny Robinson, built the teams. Diane Linn defunded it after about 1 year. That was the last serious effort to provide standard of care on a wide basis for public mental health treatment in Multnomah County.