One Fell Through the Cuckoo’s Nest

From Willamette Week, September 3, 1997

Howard Bethea killed Monica Cuenca, but many say Oregon’s mental-health system is the real culprit.

He liked to brag about his time in prison for armed robbery and assault, as if to prove he was tougher than his pudgy 5-foot-6-inch frame would indicate. He assured his Washington County parole officer that he would one day have his 15 minutes. He threatened, repeatedly, to decapitate those who made him angry.

In the waning days of 1994, when he was being held in the psychiatric ward of Portland Adventist Medical Center, he babbled about serial killers to doctors and nurses and pounded on the windows when he didn’t get his way.

Then the mental-health experts released him to the streets.

Two and a half weeks later, Howard Bethea committed murder. It was an act, according to a wrongful-death lawsuit scheduled for trial this month in Multnomah County, spurred not only by Bethea’s madness but by the twisted priorities of Oregon’s mental-health system.

On Dec. 20, 1994, fueled by quarts of coffee and running on almost no sleep, Bethea took the bus from his Hillsboro boarding house to his step-aunt’s apartment in Portland. After downing two cans of Hamm’s beer, he stole the Smith & Wesson handgun she kept in her dresser drawer. Then he hopped a bus back toward Aloha.
“I knew just what I wanted to do,” he later told police. “Get a rat back who ratted on me for nothing.”

Around 6:45 pm, Bethea barged into the Hughey House, a group home for people with mental illnesses where he had lived for two weeks prior to his stay at Portland Adventist. He marched straight toward Monica Cuenca, a 28-year-old staffer who was playing Canasta with one of her charges. He pulled the .22 revolver out of his waistband and, without a word, fired at her head. She looked up, “right inside my eyes,” Bethea later told the police, whereupon he fired once more: “Let me be honest with you,” he later told Det. Roger Mussler. “I fired a second time because I wanted to make sure I got her.”

Two days later, Cuenca died. Eighteen months after that, Bethea began serving a life sentence for murder.
That, however, isn’t the end of the story. Bethea was a “walking time bomb,” according to the lawsuit filed by Cuenca’s family and scheduled for trial Sept. 22. The family is seeking $9 million and alleging that the state Mental Health and Developmental Disability Services Division, Portland Adventist Medical Center and treating psychiatrist Dr. Glenn Ruminson failed to learn enough about Bethea’s history to assess his danger to society; failed to treat him adequately before discharge; and failed to develop a safe plan for Bethea’s release. Portland Adventist, the suit adds, was “willful and wanton” in its disregard for the best interests of the public, including Cuenca.

It’s too early to tell if a Multnomah County jury will agree. But it’s clear that Bethea’s story is just one of many tragedies that some say could have been prevented if it weren’t for the powerful forces that fuel the flawed mental-health system.

Most obvious, of course, is the inherent difficulty of dealing with people whose behavior defies logic. Then there is the matter of simple math–there are 66,000 people in Oregon who suffer from serious and persistent mental illnesses, but only 198 long-term hospital beds to help them through periods of crisis. Adding to this bleak equation is another economic truism: It’s far more expensive to keep people in the hospital than to push them into community treatment.

Perhaps most significant of these forces, though, is the principle that guides those who make daily decisions on the fate of mentally ill Oregonians–the classic liberal notion that liberty is inherently better than detention.

In short? No matter how bizarre your behavior, how untreatable your illness and how horrific your threats, it’s much easier to get out of the psychiatric ward than it is to get in.

For as long as anyone can remember, Howard Bethea didn’t get along very well in this world.

At school in Hillsboro, Bethea was a loner and a misfit. He had a normal IQ, but his teachers were puzzled when his test answers bore no relation to the questions. He graduated from Hillsboro High School in 1982, and around the same time, a psychologist said he had a “paranoid personality structure,” the first of many labels of mental illness that would follow Bethea throughout his life.

One of his diagnoses was paranoid schizophrenia, a lifelong debilitating disease exacerbated by his drug and alcohol abuse. His anti-social personality disorder also made him difficult, if not impossible, to get along with.
“Everyone in [Washington County] mental health and corrections knew Howard,” said Pat Johnson, one of his parole officers. “He was loud, demanding and narcissistic.” Steven E. Berger, another parole officer, testified in depositions that “nobody in our office has ever received a higher level of supervision than Howard Bethea.”

As documented by police and parole officers, Bethea’s mind made him do things both bizarre and criminal.

In 1984, at age 21, he threatened a couple with a knife and was sentenced to three years of probation for the crime of menacing. In 1985, he used a padlock stuffed in a sock to attack a man and was sanctioned for a probation violation. In 1986 his probation was extended after he slashed the walls of his apartment with a knife.

All told, between 1985 and 1987, he was arrested 10 times, five of them for crimes against other people.
In 1987, Bethea received his first prison term, a 10-year sentence for first-degree robbery. He had tried to steal gum, aspirin and Sominex from a convenience store and threatened the clerk with a knife. Then, while serving time at Oregon State Correctional Institution, he assaulted another inmate.

Between 1988 and 1992, he was transferred eight times from prison to the Oregon State Hospital for psychiatric treatment.

“His overall prognosis is quite guarded and probability of reoffense high,” a report from the state hospital noted.

The prison system, however, could only keep him for so long. In March 1992, he was paroled after serving five years of his 10-year sentence, as was normal at the time.

At this point in his life, Bethea straddled two bureaucracies, each with different ideas of what he needed in order to navigate his future. On one side was the justice system, which in the past decade has come under increasing voter pressure to operate with a “lock ’em up” attitude. On the other side was the mental-health system. This sprawling hodgepodge of state and county bureaucrats and public and private treatment providers operates under another principle entirely: that of helping people with mental illnesses fit into society.

Accordingly, Bethea’s first stop out of prison was Twin Cedars, a boarding home for up to 25 mentally ill men in Washington County, where he would live and take his meals. Bethea wouldn’t behave, however, and wound up spending the next two years bouncing from one group home to the next, and sometimes to jail on parole violations in between. He paid his expenses with checks from the federal government, including Social Security and Medicaid.

Several times during his parole, he checked himself into the psychiatric ward of a local hospital for medication and stabilization. In 1994, he wound up hospitalized at least three times–in March,July and November. “It was a regular thing for Howard to turn himself in to the hospital or call the police and say he was having fantasies and he was going to act out,” explained parole officer Berger.

In November 1994, after spending two weeks in the Washington County jail on a parole violation (for drinking), Bethea moved into Hughey House. That’s where he met Monica Cuenca.

Cuenca was the eldest daughter of devoutly Catholic parents who had emigrated from the Philippines in 1971 with “three suitcases and three kids,” according to Cuenca’s sister, Aimee. Cuenca had known since high school that she wanted to care for people with mental handicaps. “I don’t think many people have that kind of calling,” Aimee said.

For reasons that only make sense in one troubled mind, Bethea did not like Cuenca. He saw her as an “oppressor of the mentally ill” who treated him like “a stepchild.”

Around midnight on Nov. 15, Cuenca called Berger to report that Bethea had been threatening to decapitate other group-home residents. Berger said in court documents that Bethea made specific threats against Cuenca as well.

“I knew I should get there real quick,” Berger said. “Prior to that, Howard’s threats had never been directed specifically…so I wanted to respond.”

The police came early the next morning and took Bethea to a hospital on what’s known as a “hospital hold.”
Under Oregon law, hospitals can keep someone like Bethea for a short period for observation and stabilization. During that time, mental-health experts determine whether the person is appropriate for a longer stay. If he is, the county can ask for a civil commitment hearing in front of a judge. Few people make it this far in the system (most of the time, the person either stabilizes or agrees to forgo the hearing and stay in the hospital voluntarily). Once in the courtroom, however, the person enters what is perhaps the most structured part of the mental-health system.

The civil commitment judge’s task is twofold: First to determine whether the person has a mental disorder; then to decide whether the person is dangerous to himself or others or unable to care for his basic needs.
On Nov. 18, Washington County Circuit Court Judge Hollie M. Pihl decided that Bethea was in fact suffering from a mental disorder and was a danger to others. He committed Bethea to the care of the state mental health division for up to six months.

Bethea was immediately whisked off to Portland Adventist, one of the four metro-area facilities that accepts civilly committed patients; these have become sort of a safety valve for the public and for mentally ill people since Dammasch State Hospital closed in 1995.

Bethea was placed in a secure section of Portland Adventist. He repeatedly complained about his medication. He was “chemically restrained”–sedated–eight out of the next 15 days, the last time four days before his release. He was acting out, and staff repeatedly ordered him to behave. He suffered delusions or exhibited grandiose behavior on and off until two days before his release.

But as with nearly all patients in Oregon’s psychiatric hospitals, there was no question that one day he would be released.

If the front end of the mental-health system, the civil commitment hearing, is the epitome of order, what goes on at the other end is more like chaos.

While a small number of judges have the power to commit someone to a hospital, potentially thousands of mental-health workers across the state, each with his or her own beliefs, have the power to decide how long it will be before the committed person is released.

The task is difficult and often emotionally grueling. In Howard Bethea’s case, it fell to Dr. Glenn Ruminson.
A psychiatrist for more than two decades, Ruminson had the experience to make tough decisions. In addition to running his own private practice since 1975, Ruminson served on the quality management and credentials committees at Portland Adventist in 1994.

Ruminson’s discharge notes and his deposition testimony give some clue as to his reasoning in releasing Bethea.

“It was my judgment at the time of the discharge that the risk factors had been addressed adequately, that [Bethea] had a good treatment program,” Ruminson testified in depositions. “His psychosis, which I considered a major factor in his threats, was improving to a point where he was recognizing that he had a disorder, that he was willing to take medication.”

Since Nov. 30, “he made no threatening comments,” Ruminson wrote in the discharge summary. “He never said that he was going to go out and kill anyone.He never indicated that he had any plans for harming anyone…. During last five days of his hospitalization, he made no references to wanting to be a serial killer.”
On Dec. 2, just four days after he was last administered a sedative, and two days after suffering his most recent delusions, Bethea was released with little more than a bus ticket and a plan: He would live once again at Twin Cedars, a sprawling boarding home without any on-staff clinical supervision. A Washington County mental-health worker would receive a report on Bethea’s progress once a month.

When he boarded the bus from Portland to Hillsboro, Bethea had been in the hospital just two weeks, a stay 51?2 months shorter than the judge’s order would have allowed. This is not unusual. Although the standard period for commitment is up to six months, most patients spend only about two weeks in the psychiatric unit of a local hospital before being discharged, according to state and county figures.

Bethea immediately began acting bizarrely, according to reports from his parole officer, but mental health workers didn’t try to put him back in the hospital. “There was an obvious conflict between Washington County mental health and community corrections,” noted Keith Walker, who defended Bethea at his murder trial. “The parole department was extremely concerned about him. They were convinced he had serious mental problems. They couldn’t get mental health to recognize that.”

By Dec. 20, when Bethea killed Monica Cuenca, it was too late.

For those who don’t know the mental health system, releasing someone like Bethea after 14 days in the hospital might seem like putting a Mack truck on the road with no brakes and no steering wheel–of course it’s going to do some damage.

So why was Bethea released so soon?

The answer is not simple. “I don’t know if you’ll find a smoking gun,” says Dr. David Pollack, medical directorof Mental Health Services West. “It’s kind of a systemic issue.”

Financial considerations may have had something to do with it. Although there is no proof that bean counters put direct pressure on Ruminson, it is clear that keeping Bethea in the hospital was an expensive proposition.

In general, under a state contract with Portland Adventist, it cost taxpayers about $600 per day in 1994 to hold people who were committed. The rooming house to which Bethea was released, however, cost the state nothing; Bethea paid for it with his federal government checks. National experts have argued that when the federal government introduced Medicare and Medicaid–which covered care of mentally ill people in the community, but not in hospitals–states began releasing mental patients from state-funded hospitals in vast numbers.

Depending on the particular circumstances at the time of Bethea’s stay, the state contract could also have given the hospital a financial incentive to release him: Under most circumstances, the state contract paid the hospital a lump sum to reserve a certain number of beds each month for committed patients, whether those beds were filled or not.

Another pressure has to do with philosophy. Like the child welfare system, which operates on the notion that children belong with their birth families, the mental-health system also has a guiding principle. According to Bob Nikkel, an assistant administrator with the state mental health department, Oregon mental-health workers are under a mandate to put clients into the “least restrictive care” possible. In most cases, this means that people with mental illnesses must live in the community.

It wasn’t always this way.

“In the old days,” explains Bob Joondeph, executive director of the Oregon Advocacy Center, “if somebody had a mental break you just sent them away and they were gone…. You went to a hospital where you would stay for the rest of your life.”

As Oregon novelist Ken Kesey vividly portrayed in One Flew Over the Cuckoo’s Nest, mental hospitals were in effect prisons for the innocent, where men like Randle Patrick McMurphy were tortured instead of treated. “It was just a trash bin,” Joondeph says.

Several developments drastically changed that landscape. Thorazine, the first anti-psychotic drug, was developed in the 1950s and made it possible for thousands of previously institutionalized people to live relatively normal lives. Moreover, a consensus began to develop in the early ’60s that lives were being wasted. A continuing series of lawsuits by civil libertarians has fueled the movement well into the 1990s.

In the Bethea lawsuit, lawyers from the attorney general’s office even draw on the civil-liberties argument in the state’s defense: “It is fundamental as we close the 20th century in the Western world that people are not hospitalized against their will as mental patients when the hospital knows that there is no treatment it can provide for them and that they would simply be warehoused as unadjudicated convicts.”

The argument is appealing. Locking people up in the asylums of old is wrong when their only “crime” is being mentally ill. Freedom is inherently preferable to incarceration. Communities should care for their own.
Unfortunately, it doesn’t always work. And as Bethea’s case demonstrates, the pendulum may have swung too far–even with all the danger signs, he was still sent into the streets.

Today, there are only 198 secure long-term psychiatric beds in the entire state, down from 515 in 1988. The weight of some of that decrease has been borne by other institutions. About 190 mentally ill people sit in Multnomah County jails every day, mostly on minor charges. A Department of Corrections spokesman says that 10 percent of the state prison population is also mentally ill.

“There is a growing and seemingly intractable problem with persons…already having a diagnosis of mental illness who are in jail,” a 1997 Multnomah County report said.

Anyone in the system will tell you the promise of a community-based mental-health Utopia hasn’t materialized. The reality is that community beds are scarce, treatment is sometimes lacking and miracle drugs don’t work if you can’t make someone take them. As a result, says Bill Toomey, an administrator in the Multnomah County Community and Family Services Department, people like Howard Bethea are the least likely to receive proper treatment. “I think at this time it’s difficult to get care for people on the extreme end of the spectrum,” he says.

Judging by notes taken by the mental health and the parole departments, there was no question that Bethea was crying out for care in the days leading up to the murder. The help never arrived, making Bethea’s words to Judge Hollie Pihl at his civil commitment hearing even more haunting:

“You will never see me on death row or behind bars,” Bethea argued in his defense. “Do you know why? I was taught to use interventions…. If I have trouble, I’ll go to somebody else…. [I’ll] seek help with the people that the system set up around me–my support system through the community, through mental health and through corrections. If I get in a tough jam, I’ll seek help.”