Trapping the mentally ill

By Robert Landauer – editorial columnist for The Oregonian, part of the series – “Rescuing the mentally ill,” March 19, 2000. Not available elsewhere online.

Over the past three months, Robert M. Landauer, The Oregonian’s editorial columnist, has examined the efforts of public agencies in Multnomah County to treat the indigent mentally ill. His research found a broken system seriously in need of rethinking. This series written for the editorial board recounts that research and offers recommendations on how to fix the system.

“The state, cities, school systems and private service providers share responsibility for a system that can’t reliably tell you how much it spends, how many people it serves and what the outcomes are for those who are enrolled.”

Public agencies in Multnomah County have created a cruel and dangerous obstacle course for the mentally ill.

More than 10,000 county residents who receive public assistance to deal with their severe, persistent mental illnesses are as likely to encounter hurdles as help in a treatment and service system that is in appalling disarray.

Over three months The Oregonian has identified five areas where our local governments could remove or lower barriers that trip the mentally ill’s progress toward rehabilitation and recovery. The most conspicuous hazards are:

  1. A crippling shortage of affordable housing for Multnomah County’s low-income mentally ill. Their inability to quickly find what little housing is available compounds the difficulties.  Without stable, long-term, affordable housing for the seriously mentally ill, treatment unravels and usually fails.
  2. Criminalization of mental illness. Police, sheriff’s deputies and the Multnomah County Jail are being vastly overused to deal with the county’s chronically mentally ill. Money could better be spent on services to keep the mentally ill out of jail.
  3. Sentencing the mentally ill without knowing which punishments or treatments are most likely to stop them from repeating their offenses. Information on which sanctions are effective and which are unproductive are buried, unused, in justice system records.
  4. Failing to operate an adequate early warning system geared to prevention and treatment of mental illness in children who show profoundly troubling symptoms. Early intervention consistently offers the best prospect for good results.
  5. Organizational meltdown that obstructs delivery of help to the mentally ill. Topheavy layers of administrative staff at public agencies and contractors materially reduce the number of people who directly help clients regain and sustain mental health.

A complicating factor: The information systems that mental -health workers use typically fail to give them the detailed clinical information they need to be effective with clients.

The county is the primary service coordinator. But the state, cities, school systems and private service providers share responsibility for a system that can’t reliably tell you how much it spends, how many people it serves and what the outcomes are for those who are enrolled.

What problems are most pressing?

  • No one is in charge, so no one is finally accountable for results. The buck of responsibility has nowhere to stop.
  • The system is so broken into unconnected parts that even workers who toil in it struggle to identify who can give assistance that clients require.
  • The fragmentation baffles, frustrates and defeats patients. Only the most persistent are likely to navigate the many agencies and complex procedures to find all the help they need.
  • The first tasks of all medical systems are to prevent illness when that is possible and to improve the well-being of patients when it is not. Yet the information produced by agencies that serve the mentally ill is not designed to accomplish these core missions.
  • Instead, the data that the public agencies and contractors churn out — statistics, for example, about costs and patient visits — produce an audit trail for billing and to prevent fraud.
  • The clinical information that is available is so incomplete, inexact or irrelevant that it reveals little about what aids or blocks mentally ill clients’ progress. This intelligence on the needs of clients is as vital for results-oriented budgeting as it is for individualized treatment of the clients.
  • Those who deal with the mentally ill get to share little of the information that anyone else produces. The data systems aren’t linked.
  • So physicians, psychologists and social workers, housing agencies and public employment services, police, judges and jailers make decisions about patients while blind to vital intelligence about them.
  • Parents, nursery school staff and Head Start instructors regularly spot children whose extreme behavior patterns might signal mental illness or be precursors to it.
  • Very conservative estimates indicate that at least 18 percent to 20 percent of local children ages 0-6 who should be getting specialized mental health attention fail to get it — with consequences that upset their success in school, personal relationships and the work force.
  • Many severely and persistently mentally ill adults, probably a majority of 70 percent or more, also have drug or alcohol addictions. The co-occurring illnesses need to be treated together. Separate fiefdoms at local and state levels make that a rarity.
  • Caseloads for those who coordinate services for the mentally ill have grown dangerously larger in the Portland area than nationally recommended standards. Social workers with unreasonably high caseloads constantly chase mental health emergencies. Their time dwindles, even disappears, for contact with clients who are not conspicuously in crisis but who require consistent, caring attention to remain stable.

All of this conspires to complicate, and often defeat, public-agency clients’ chances to regain mental stability.

These defects in mental -health system organization, administration and information are correctable.

By fixing those flaws, we could help most of our neighbors enrolled in the system to live useful, happy and, yes, normal lives in our community. And many others, candidates for mental illnesses in the future, could be diverted from that sad personal and publicly costly fate.

The failure to provide that help — available at our fingertips — indicts us as co-conspirators in the theft of much of what makes life worth living for these victims of brain disorders that can be remedied by a combination of medical and support services.