Multnomah County mental health leaders agree that some patients need involuntary treatment, but where?

As Oregon grapples with how best to treat patients with severe mental illness, a group of Portland-area mental health leaders said involuntary treatment is an important piece of the puzzle, but it’s unclear where the best place for those patients is.

In a wide-ranging panel discussion held Wednesday by the Oregon Health Forum, five community leaders talked about the need for stabilization centers, adding behavioral health housing and social services for those with mental illness.

The speakers, who included a county commissioner, a judge and the interim director of Portland’s Mental Health Crisis Services, agreed that the current system of funneling patients through the criminal justice system is unsustainable.

Oregon lacks places for patients in crisis, the panelists said, especially those who cannot advocate for themselves.

Doctors and county health officials can order people who are a danger to themselves or others to be detained for up to 72 hours, after which a judge must make a decision. In practice, however, there are few facilities to accommodate people being held for treatment.

The Oregon State Hospital in Salem, the state’s largest psychiatric facility, now rarely sees those patients because it is filled with patients who came through the criminal justice system, found guilty except by insanity or unable to assist in their own trials.

Instead, patients in the midst of an acute mental health crisis often find themselves in medical hospitals, which are not equipped to care for them.

Oregon’s largest involuntary treatment system is prisons and jails, said Robin Henderson, executive director of Providence Oregon Behavioral Health. It’s a traumatic place, not a good situation.

Increasingly privatized psychiatric services, Henderson said, have made patient beds harder to find.

There is simply no slack in the system, Henderson said.

Multnomah County District Court Judge Nan Waller presides over the county’s mental health court, and also oversees hearings for people who are accused of crimes but deemed mentally incompetent to defend themselves in court.

Waller said in her years on the bench, she has seen patients deep in the throes of mental illness or addiction struggling to keep up with treatment. A few asked to be jailed, while others simply languished on the streets.

I work in the mandate system, she said. There are points where people really don’t have the ability, and we’re going to just let people out on the street and say well let them make a decision, in my opinion that’s not humane.

She called for an alternative to prison, a place where people can be dropped off if they’re in crisis and then placed elsewhere, whether it’s addiction treatment or psychiatric care.

Officials from groups in Multnomah County, including Waller, spent four years planning the Portland Crisis and Sobriety Center, which would focus on drunk people with shared mental health issues. As they sobered up, medical professionals could assess them and connect them with treatment or services.

But that effort failed after it was rejected by the board that distributed treatment funds under the drug decriminalization Measure 110. The county government is now looking for a sobering center, but has yet to find the funding. The county also provided $7 million for a special 20-bed stabilization center.

Waller said people with mental illness must be able to seek treatment regardless of whether they face criminal charges or the severity of their illness.

Those in the criminal justice system with behavioral health issues are sometimes literally left out in the cold when they are turned away by housing or programs, she said. The stigma of criminal charges on top of the stigma of mental illness really puts people in the criminal justice system at a huge disadvantage.

Lielah Leighton, a licensed clinical social worker and interim director of Portland Street Response, said there is a time and a place for restrictive interventions, such as placing someone in psychiatric care who cannot make their own decisions.

But, she said, many patients might be more inclined to seek treatment if their basic needs, such as shelter and physical safety, were addressed.

I think that voluntarily choosing to care starts you on the right path, Layton said. But what I’m more interested in is being realistic about what people were being asked to agree to. It may sound like a great idea to help them get to an ambulance, but what does that mean for their belongings, their safety? Will they have to return after dark? Get fired in two hours? Many of their complaints are driven by these unmet basic needs.

Jonathan Mroz, a communications specialist for Central City Concern, said the struggle to meet those basic needs is an obstacle in his recovery.

Several years ago, Mroz said, he started using drugs after traumatic events in his personal life. He ended up living on the streets of the Old Town in what he described as a constant state of hypervigilance.

Homelessness is deeply traumatic even without drugs, he said. An endless cycle appeared. Losing a backpack, a cell phone, getting back all the things that make us human, it takes a long time. And it puts the onus on the individual to be reasonable enough to get help.

He cited a severe shortage of psychiatric beds and the residential facilities patients need afterward, as well as the need for a place for patients to simply get off the streets while they stabilize.

We created an endless cycle of abandonment at that point, he said.

While the panelists considered immediate solutions, some emphasized the need for a long-term plan.

We don’t have a plan or a functioning system, said Multnomah County Commissioner Sharon Meyeran, who also works as an emergency room physician. Unless we have that, we’d just be throwing good money after bad.

Meiran suggested someone who could coordinate mental health efforts between the state and the county.

We don’t need more studies, meetings, working groups or committees, she said. We need someone to bring it together and connect the dots, leading us forward.

Jayati Ramakrishnan; jramakrishnan@oregonian.com