Radical Shrink

From the Willamette Week, May 15, 2002

It’s loud. It’s messy. It’s nasty. But psychiatrist Peter Davidson is determined to rescue Portland’s mentally ill–whether they like it or not.

There’s something about Dr. Peter Davidson that drives certain people–well, crazy.

Most won’t say so in public. In public, they are unfailingly respectful to the maverick psychiatrist with a windsurfer’s tan and a hint of Harvard in his voice who has, in less than a year, elbowed his way to the top of the Multnomah County Division of Mental Health and Addictions Services–the agency that oversees the savage vortex known as the mental-health system.

But when the tape recorder is turned off and the reporter’s pen is capped, they let go. Arrogant. Hateful. Dangerous. They compare him to Rasputin, Richard III, even Frankenstein. The stories are legendary. Like the staff meeting where he criticized another therapist so harshly she broke down in tears. Or the time he made a point to a subordinate by s-l-o-w-i-n-g d-o-w-n his words, the way you’d talk to a 6-year-old.

In December, a group of Davidson’s own employees at the county lodged a formal complaint accusing him of discrimination for, among other things, referring to minorities as “mud people.” (An internal investigation dismissed the complaint, but rapped Davidson for behaviors that were “not conducive to a good work environment.”) In January, Davidson’s predecessor, psychiatrist Larry Marx, filed a notice of tort claim against the county–the first step in a lawsuit–alleging that Davidson defamed him in a meeting with a dozen local psychiatrists. (Davidson denies having done so.)

“Peter Davidson is a smart doctor, but a horrible manager,” says County Commissioner Serena Cruz, one of the few critics willing to speak on the record. “All I get are complaints.”

Even Davidson’s supporters–and there are many–concede that he can be abrasive. “Peter does not suffer fools gladly,” says Irv Smith, who was Davidson’s boss for five years at a private Oregon mental-health provider.

“He’s not a diplomat,” agrees his current boss, County Chair Diane Linn.

In a town where civility is regarded as a cardinal virtue, why hasn’t Davidson been fired? In part, because he has the thankless job of overseeing the desperate effort to tame an $87-million monster: the chaotic patchwork of services and facilities for the county’s 10,000 severely mentally ill residents–a system that, as recently as a year ago, teetered at the brink of catastrophic failure.

And in part because, despite the groans of dozens of influential critics, he appears to be succeeding.

The statistics are persuasive.

Since July, the number of days patients have spent in local psych wards has dropped 28 percent. The number of times that Portland police officers have transported psychotic or suicidal mental patients to local ERs has fallen 35 percent. The number of calls to the crisis line has plunged 43 percent.

“The floodwaters are now around our waist, instead of around our neck,” says Linn.

“I’m seeing a huge improvement,” says Sheriff Dan Noelle, who, as the county’s chief jailer, locks up thousands of mentally ill people every year. “He’s getting stuff done–that’s more than I’ve seen the whole time I’ve been here.”

Davidson emphasizes that these trends are still in their infancy. “I don’t want to declare victory,” he cautions. “We have a long way to go.” Nonetheless, the numbers suggest Multnomah County is turning the corner on a crisis of gargantuan proportions.

To understand the significance of these numbers, you have to understand their context. The deinstitutionalization of the ’60s and ’70s, followed by the massive social-service cuts of the Reagan era, sent thousands of Oregon’s mental patients flooding into the community. Some of them stabilized. Others landed on the streets of Portland, bouncing in and out of mental hospitals, homeless shelters, group homes and jails.

The result was a long-running series of psychiatric tragedies: Janet Marilyn Smith, 28, who in August 1994 wandered into a Gresham Fred Meyer clutching her cat and a 12-inch kitchen knife, and was shot and killed by police; Peter Klarquist, 20, a manic depressive who gouged out his eyes in the Multnomah County jail in January 1998; schizophrenic Elise John, 29, who talked her way out of the psych ward at Good Samaritan Hospital in March 1999, then hanged herself from the Morrison Bridge.

In different ways, each of these incidents illustrated the yawning gaps in the safety net. “It was a completely fragmented system,” Davidson says. “It was overloaded. It’s not a case of someone falling through the cracks–it’s like on a flow chart, the lines just stopped.”

Attempts at reform invariably bogged down in turf battles and finger-pointing. Task forces issued reports and begat more task forces, which issued more reports. “In Multnomah County, it has been a history of planning by standoff,” says Oregon Health & Science University psychologist Doug Bigelow. “It just went on and on and on.”

By 2001, the system was dangerously unstable. Faced with a sharp jump in hospital costs (the price tag for a night in a psychiatric bed leapt from $430 to $700), county administrators turned to their only source of ready cash. They cannibalized funding for clinics, nurses, housing and outreach workers in order to pay for psychiatric beds at local hospitals.

Unfortunately, this fed a vicious cycle. Cut off from their support systems–those very same nurses and outreach workers–people with mental illness deteriorated to the point where they had to be hospitalized, triggering more budget shortfalls and putting more pressure on the system.

“It was an unmitigated disaster heading for total breakdown,” says Linn.

Then, one morning in March 2001, a 29-year-old Mexican immigrant named Jose Mejia Poot boarded a Tri-Met bus at Northeast 72nd Avenue and Killingsworth Street. He was 20 cents short on his fare.

The driver flagged down a police officer, who told Mejia to pay the full fare or get off the bus. Mejia did not respond–possibly because he did not understand English, or possibly because he was having an epileptic seizure. Whatever the reason, a scuffle ensued. Mejia was subdued, hogtied and ultimately taken to Pacific Gateway Hospital, a psychiatric facility in Southeast Portland that had a contract with the county. Two days later, Mejia somehow broke out of seclusion and threatened staff with a steel “safety rod” he tore loose from a security door. Panicked hospital workers called 911. Police officers ordered Mejia to drop the rod. When he refused, they opened fire, shooting him in the head and chest. He died on the spot.

The death of Jose Mejia seemed to crystallize everything that was wrong with the mental-health system: overworked staff, shoddy facilities, indifferent regulation and an overreliance on the police, plus a liberal sprinkling of linguistic barriers, cultural insensitivity and plain old incompetence.

The tragedy sparked street demonstrations and prompted Linn, the newly elected Multnomah County chair, to make mental-health reform her top priority. The county hired an outside administrator named Jim Gaynor to spearhead the redesign. There followed a chaotic power struggle as competing factions vied for dominance. When the dust finally settled, a slew of influential players–including Department of Community and Family Services chief Lolenzo Poe, veteran administrator Jim McConnell and Gaynor himself–had been pushed aside. Standing amid the wreckage, like Achilles prowling the ruins of Troy, was an obscure consultant named Peter Davidson.

Davidson is not your average policy wonk. He rides around town on a Mongoose dirt bike with purple handgrips and a bell shaped like a hamburger. When he’s not sweating over psychiatric budgets, he spends his time windsurfing, wakeboarding, rafting, snowboarding, ice climbing and piloting his helicopter–a Robinson R-22. His house, perched on a cliff outside Lyle, Wash., overlooks eight miles of the Columbia Gorge.

He can reel off obscure mental-health statistics by the dozen, but has to consult with his 28-year-old wife, Lia, whom he met on a surfing trip, before he can remember his own age (he’s 45).

Davidson comes from a family of head-shrinkers–his father was a psychiatrist, his mother a psychologist–but his career was hardly conventional. After graduating from a Cambridge prep school, he bummed around Germany for a couple of years, with shoulder-length hair and a pair of earrings, soaking up the decadence of mid-’70s Hamburg. “It was a great time to be 19,” he says.

Returning to the U.S., he obtained a degree in oceanography from the University of Washington in 1981, just as President Reagan decimated federal spending on oceanographic research. Suddenly, Davidson’s intended career–the study of amphipods, or marine insects–held all the promise of TV repair. He went back to UW, this time to medical school, and completed his psychiatric residency at Harvard. In 1996, he became the medical director of Greater Oregon Behavioral Health Inc., a far-flung managed-care organization serving Oregon residents east of the Cascades, before joining Multnomah County as a consultant last year.

Davidson brought a high-octane mix of passionate intensity to the job, plus a knack for rubbing people the wrong way. More important, however, he brought a new approach to a dilemma that has bedeviled his profession for 30 years: Why don’t people take their meds? “This is the paradox of human existence,” he says. “With all this intelligence, with these huge brains, why do we still do the wrong thing?”

In fact, there are two main reasons. “These drugs are poisonous,” Davidson says. “They have ‘side effects’–which is a euphemism for negative effects. There’s also a stigma. It really twists your mind up to think that you have to take a pill every day just to feel normal.”

For many years, standard psychiatric practice was to lock patients up until they were willing to undergo the treatment of the day–be it Haldol, shock therapy or psychoanalysis. Usually, however, this accomplished little: Clients quickly abandoned their medication as soon as they were released. In addition, it spawned a civil-rights movement of “psychiatric survivors” implacably opposed to doing anything the doctor tells them.

“Coercion doesn’t work,” Davidson says.

Once he was hired, Davidson applied a ruthless form of shock therapy to the county mental-health system itself. With Linn’s strong backing, he turned the bureaucracy inside-out. Overnight, job descriptions were rewritten, then rewritten again. “It’s just insane,” says one county employee. “Some people don’t even know what their job is. They just sit in their cubes all day.”

The chaotic environment in the division became the backdrop for several complaints against Davidson of racial discrimination and harassment. In accordance with county rules, Davidson declined to comment on the specific allegations. But he vehemently denies being a racist, pointing out that his wife is an Indonesian Muslim and that his mother wrote a book on the origins of bigotry. “It’s preposterous,” he exclaims.

In addition to the bureaucratic reshuffling, Davidson pursued an unconventional, three-pronged strategy. First, despite a deafening clamor for more psychiatric beds, he reduced funding for psychiatric wards by 20 percent, or $3 million, pumping the money back into mobile crisis teams, walk-in centers, outpatient clinics and peer counseling. His logic was simple: With better access to treatment that works, fewer clients would need to be hospitalized in the first place.

The newly revived “mobile crisis teams”–a kind of citywide karma patrol–are now making 400 house calls a month, helping to defuse problems before they go nuclear. And four new walk-in clinics, which didn’t even exist a year ago, are now seeing almost 600 clients a month, the majority of whom had no access to services before.

Second, Davidson focused on the “high utilizers”–the 300-odd clients who together consume 46 percent of the county’s scarce mental-health treatment dollars (see graph, above). These are the clients nobody wants. Because they suffer from devastating illness, typically combined with drug or alcohol addiction, they often pinball from jail cell to psychiatric hospital to street corner to courtroom. “These are the people we’re going to find,” Davidson says. “I don’t mean finding them physically–we know where they are. I mean finding them emotionally and making contact so they choose to use us.”

This approach–based on Davidson’s own experience knocking on the doors of the severely mentally ill–requires therapists to visit recalcitrant clients almost daily. “I had one client who fired me every time I saw him,” Davidson says. “But after four months, he decided not to drink again.”

“No one is beyond help,” he says. “You have to maintain that attitude. Otherwise, you’re playing God.”

To encourage treatment providers–the private clinics and centers that take care of the vast majority of the county’s mentally ill residents–to lavish attention on the high utilizers, Davidson crafted a strong incentive: The county now sends bills to providers whenever their clients land in the emergency room. “We don’t cream off the easy clients any more,” explains Jason Renaud, a spokesman for Cascadia Behavioral Healthcare. “We went from booting the difficult clients out the door to grabbing hold of them with both hands.”

Finally, Davidson expanded funding for “client-oriented” programs such as the Renaissance Center, a sort of social club on Southeast Division Street that is run for, and by, clients with mental illness.

Over the crack of the cue ball and the smell of buttered popcorn, patrons gather on a Monday afternoon to get out of the cold, surf the Net, and try their hand at Yahtzee. The center includes support groups, peer counseling, a cafe, laundry services and showers. “Twenty years ago, all these people would have been hospitalized,” says Renaud. “Including the staff.”

The idea behind the Renaissance Center is to provide a safe place where clients can socialize, get a bite to eat and–over time–build enough trust that they are willing to take their medication. “It’s like a 12-step meeting,” explains Cliff Smithers, a 40-year-old real-estate broker turned peer counselor, who came to the Renaissance Center suffering profound depression and panic disorder triggered by a divorce and the stresses in caring for a son with Down syndrome. “I could see people who had a tougher diagnosis than I did–and who worked through it.”

Taken together, these three ideas–reducing psychiatric hospitalizations, working with the high utilizers and emphasizing client-oriented therapy–constitute a frontal assault on the psychiatric establishment. “He’s really challenging a lot of ideas,” says Renaud. “He’s asking people to flip their whole paradigms around. This is a sweeping indictment of people’s entire careers. They worked long hours to make the old system work, and they’re frustrated by this carpetbagger waltzing in and ordering them to ‘Do it my way.'”

Critics say he’s a snake-oil salesman. “Brilliant but crazy,” is the diagnosis of one mental-health professional who worked on the redesign.

But advocates for the mentally ill find Davidson’s approach inspiring. “He’s an amazing thinker with amazing ideas,” says activist Kevin Fitts. “Davidson believes you’ve got to bring the person back through crisis into a support system. He’s like the talented and gifted kid in the classroom–and he knows it.”

Has Davidson’s progress so far been achieved because of his blunt management style, or in spite of it? As awkward as it may be to acknowledge, the truth is that reforming a system as dysfunctional as the one Davidson inherited requires a willingness to make enemies. “When you stab the sacred cows, you offend the people who worship those cows,” says Irv Smith, his former boss at GOBHI.

Davidson is unrepentant–and even a little defiant–when asked about the style issue. “A lot of do-gooders fold their tent when the going gets tough,” Davidson says. “But to fix a system that’s broken requires overcoming what I’ll politely call inertial forces.”