The Oregonian October, 28 1987

Kenneth R. Case, a convicted killer found criminally insane, faced the unhappy prospect at the age of 21 of spending the rest of his life in Oregon State Hospital, until he discovered a simple way out.

Murder.

Case, now 23, earned what amounted to a transfer out of the hospital’s unit for the criminally insane into prison after pleading guilty to murder for strangling his 45-year-old hospital roommate, Peter Isaac Richardson in March 1985. It was a killing planned, he said, to escape hospital conditions and patients he found abhorrent.

In the view of Dr. Peter J. Batten, a former hospital psychiatrist who is Marion County’s medical examiner, Richardson was a “harmless alcoholic” who had no business being in what is in fact the most dangerous ward in the forensic unit, much less in the same room with Case, who had just been convicted of the brutal slaying of a 72-year-old Junction City man.

The bizarre tale of Richardson’s death offers but one example of the danger and absurdity that prevails in the state hospital’s forensic program unit for the criminally insane.

It is a place where two hospital patients say they have tried to kill people in the last three years in hope of getting out and being sent to prison. Case succeeded.

In a hospital troubled by patient-caused violence, the forensic program stands out as one of the most dangerous parts.

It is without doubt the deadliest. In addition to injuring others, inmates also do violence to themselves.

Batten, who worked at the hospital from 1972-86, says an “astounding” number of suicides have occurred on the 330-patient forensic unit — 12 since 1978.

By contrast, only four suicides have been reported in the rest of the hospital, which houses about 380 other patients.

And over the same period, there have been only eight suicides among the combined 2,700-inmate population of the Oregon State Penitentiary and Oregon State Correctional Institution. Batten says the suicide rate in the forensic unit is 13 times the combined rate for the state’s two largest prisons.

Batten said the suicides raised questions about the staffing for the unit and its anti-suicide procedures.

Details of the suicides themselves depict a place where just about anything can happen, and sometimes does.

In at least one case, circumstances surrounding one of the suicides were so suspicious that the Marion County district attorney’s office called for an inquest, an unusual hearing held to determine whether a death is a homicide.

David Leaf, 45, died of asphyxiation while strapped down on a bed in an isolation room in October 1981. A pathologist found a 12-inch by 7-inch piece of brown terrycloth stuck in the airway in Leaf’s throat. The inquest jury concluded that Leaf purposely tried to swallow a piece of his terrycloth shirt, which lodged in his throat, all while his wrists and ankles were loosely strapped to a cot in a seclusion room.

In another case, Miguel Hernandez hung himself after receiving what a roommate called “help.” In a signed statement to Oregon State Police, the roommate said he helped put a makeshift noose around Hernandez’s neck and then pulled a table out from under him, allowing him to commit suicide. No criminal charges were brought.

Interviews with present and former state hospital employees, patients and families of patients portray the forensic unit as a place where the criminally insane face long terms in conditions so crowded that their safety cannot be guaranteed.

“The living conditions are terrible,” acknowledges Roger Smith, who served as director of the state’s forensic psychiatric program for two years until resigning in August to take a federal government job.

Employees say they are too few to see, much less prevent, violence or even to defend themselves.

“It seems like getting hurt is part of the job,” said Steve Krank, security aide supervisor who has been bitten, punched in the face and gotten three cracked ribs in the last five years.

Some of the most acute problems occur on Ward 48C. Of two maximum-security wards, 48C holds the most dangerous clients. Both security wards also serve as the two “admissions” wards for the program.

That designation means that the most violent and dangerous patients in the forensic program — including men who have committed heinous murders — share space with patients convicted of such lesser crimes as trespassing, or who are convicted of nothing. Many of them are accused of crimes but have been found mentally unfit to be tried.

The maximum security wards and a ward for sex offenders are located in an older three-story wing of the hospital, known as the “48 Building.” The other four wards, which are medium security, are housed in a six-story building a short distance away.

Richardson died on 48C, and four of the nine suicides since 1982 have been here.

Richardson’s murder came on March 19, 1985, only 11 days after he was admitted for the 20th time to Oregon State Hospital. Batten called him an alcoholic in a weakened condition and unable to defend himself. Records released by the hospital said Richardson was put on the maximum-security ward because of “physical aggressiveness” and “inappropriate familiarity with female patients and staff.”

“He was considered a harmless alcoholic,” Batten , the medical examiner, said of Richardson. “He had no reason to be over in the forensic unit. Of course, if he hadn’t been there, he would not have been killed. Peter was in the wrong place at the wrong time.”

Smith said the population of the forensic program wards were often a bad mix of two distinct, and often incompatible groups: those who typically are quite docile when under medication, and those long-term dangerous, criminal offenders, whose mental ailments often cannot be controlled by medication.

“We just don’t have the facilities to segregate the two,” Smith says.

The program’s population is booming.

Persons who are found guilty except for insanity of crimes in Oregon are sentenced to terms under the supervision of the Psychiatric Security Review Board.

Created 10 years ago in a move to toughen sentences for mentally ill criminals, the board has been a great success in the view of most corrections and mental health experts in Oregon.

Typically, the criminally insane are housed at the Oregon State Hospital. The board may discharge patients early only on conditional release when they are deemed mentally fit and no longer dangerous.

Under the board, the average criminally insane defendant spends 2.4 years in the state hospital — nearly double the 1.3 years that the average state prison inmate stays behind bars.

But in holding the insane longer and protecting the public, the board is creating a logjam at the state hospital.

“It’s such a good thing that it’s become a monster,” says Dr. Prasanna K. Pati, who served as the forensic unit’s director until 1985 and who retired from the state hospital last year.

Over the last decade, the forensic program’s population has more than doubled. The state has added three new wards in the unit since 1985 and plans to add another soon. A recent state study concludes that a new ward will be required every 18 months.

The board’s tougher sentences may be pushing some mentally ill criminals into prisons and jails.

Jim Henning, executive director of the Metropolitan Public Defender’s office in Portland, said indigent clients represented by his office began opting against using the insanity defense soon after the security review board was created and began began stiffening terms.

“Insanity defenses were never frequent,” he said. “Now, they are even less frequent.” He said some clients believed they would get more lenient terms from the State Board of Parole, and opted against pleading insanity.

Crowding in the forensic unit — which now holds about 20 more patients than its budget allows — has been compounded by a dearth of community programs to house conditionally released patients.

The board monitors 118 criminally insane patients in such programs. The state plans to add 50 conditional releases to help relieve the state hospital glut.

Mary Dolan, who has just been hired to find beds for the conditional releases, says private contractors are worried about potential liability for misdeeds.

Such concerns were heightened by the case of William K. Maude, 31, who was on conditional release under the security board when he killed his mother in Portland in August 1984.

The family sued the Salem group home where he had been living, the state and Marion County for damages. No negligence was found, but the case sent a chill through the mental health system.

In the hospital, the criminally insane residents of “48C” routinely complain about the strictness of the board’s sentences. Some like Roger Martin, 38, who is serving time for burglary, say they don’t belong there.

“I faked my way in here, and now I can’t get out,” said Martin, who arrived in 1985. “There are dangerous psychotic people here. They strike out for no reason here, for nothing.”

Martin has filed suit against the Security Review Board seeking to be released on grounds that he is not mentally ill.

A hospital psychiatrist says that Martin suffers from an “antisocial personality.”

Others talk of violent deeds or escapes that they hope will free them, or perhaps result in a transfer to prison, although only two actually have carried out such plans.

Over the last two years, the hospital’s forensics staff has repeatedly warned managers at Oregon State Hospital that crowding endangers the lives of patients and employees.

“The Forensic Psychiatric Program is so overcrowded, most wards have reached a position of being dangerous and unmanageable. There are incidents taking place throughout the program,” one hospital memorandum warned last January.

Inmates also complain about the lack of activities and programs. On 48C, for example, it is common to find inmates who spend long hours lounging in the rooms and walking a long corridor. Jerry McGee, the former Fairview Training Center superintendent who was named the forensic program’s director in August, said, “Our greatest concern with safety In fact, there were indications that a murder like the one committed by Case would actually take place, long before it occurred.

Case and Thomas F. Grenfell, another patient who admitted conspiring with Case to kill Isaacson, were well known to the state as dangerous killers.

On July 6, 1984, Grenfell, who was serving time for killing a prison guard, stabbed a hospital barber in the arm with a pair of scissors.

According to a hospital report written in November 1984, Grenfell told a staff employee just after the assault that he believed he would be transferred to prison and released earlier if he “killed someone here.”

Eight months before the murder of Richardson, on July 18, 1984, Case was released from the forensic program at Oregon State Hospital. He was transferred to the unit in the first place from Dammasch State Hospital in Wilsonville after allegedly assaulting a woman custodian.

Two days after getting out of Oregon State Hospital, he beat to death George Irvin, 72, outside a Junction City bar. After being found guilty except for insanity of Irvin’s murder, Case was returned to the hospital in October 1984. He strangled Richardson about six months later.

Both Case and Grenfell confessed to planning the Richardson killing.

Grenfell initially said he alone killed Richardson because the dead man owed him five cigarettes.

But Case told a different story four days later. He said that he alone killed Richardson because he was a bothersome roommate who cried, talked to himself and failed to clean up urine that he spilled. Grenfell then recanted his confession.

Grenfell acknowledged that he taught Case how to use a “Japanese sleeper hold” on the day before the murder and agreed to help kill Isaacson. But Grenfell denied any part in the actual killing, in which Case said he strangled Richardson with the hold then jumped off his bed onto Richardson’s chest three times.

Case pleaded guilty to murder, and was sentenced to life in prison for Richardson’s killing. After he finishes his life prison term, however, he’ll be back under the Psychiatric Security Review Board’s jurisdiction for the remainder of his life plus 20-year sentence in the Junction City killing.

Mind Games: Oregon’s Mental Health System

Fourth of a five part series on the Oregon State Hospital

From The Oregonian, October 26, 1987 – not available online elsewhere

When Lois Gleason closed the door for the last time on her West Hills apartment this month, she headed downstairs to another crisis in her 11-year history of mental illness.

“My friends all tell me I finally made it,” Gleason said, smiling weakly. “I finally made it to the street.”

Months earlier, Gleason spoke glowingly of a new beginning in her West Hills studio apartment, after years of being cooped up in unattractive apartments and overly strict group homes. But a tiff with her latest landlord had turned yet another new start into just one more dead end — her third move in a year.

A slender 27-year-old, with a taste for bright, sporty clothing, Gleason once aspired to be a model and still has the rail-thin physique of the runner she once was at Jefferson High School.

While in the West Hills, she hoped to enroll in an aerobics class, to get back her old job as a nursing assistant and to be middle class.

Now her world, the confused and confusing universe of paranoid schizophrenia , was falling apart. She told friends she might be going off the deep end. She was going out into “the street.”

The state Mental Health Division estimates 34,400 chronically and severely mentally ill people live in Oregon. About 55 percent of them receive treatment in state-financed mental institutions or community programs.

The rest, some 15,000 Oregonians, occupy an uncharted territory outside Oregon’s public mental health system. Many literally wander the streets.

A 1986 League of Women Voters report chronicled gaping holes in Oregon’s mental health care system — once reputed to be among the best in the nation.

“Many populations of mentally ill are unserved or underserved,” it concluded. “Community programs currently are serving twice as many persons as funded for, and yet they serve less than 60 percent of the chronically (or severely) mentally ill.”

These “outsiders” contribute to a glut in the state’s jail and prison system. Newspaper headlines proclaim their occasional acts of self-destruction and homicide. Last May 19, for example, two FBI agents fatally shot Stanley William Peregoy, a Tillamook man with what his family described as a history of mental illness, after he stormed into the agency’s Portland office and took five other agents hostage at gunpoint. The county medical examiner found Peregoy was intent on self-destruction and deemed his death a suicide.

Others are homeless. A Multnomah County survey of about 320 homeless people in 1984 and 1985 found that about a fifth of the men and nearly half of the women had been in psychiatric hospitals.

Social service providers such as Jean DeMaster, executive director of Burnside Projects Inc., estimate that as many as 40 percent to 60 percent of the state’s estimated 6,000 homeless suffer from mental illness.

Thousands of other outsiders, such as Lois Gleason, may be found in hotels, apartments and boarding houses across Oregon.

Bill Kruger, a social worker who runs the highly regarded 65-bed psychiatric day treatment program at the Providence Medical Center in Portland, calls them “the new lepers.”

“As lepers were in biblical times, they are shunned, scorned and misunderstood,” Kruger said. “Nobody is counting them. No one cares. They are a group our society would just as soon not exist.”

Medical researchers say mental illness may be hereditary. But unlike other genetic diseases, schizophrenia appears long after birth. It strikes when people are young, typically in their teens and early 20s.

While Lois Gleason was a student at Wilson and Jefferson high schools in the mid-1970s, she dabbled in hard drugs like LSD and methedrine and wondered whether she would survive to be 30.

Only much later would she recognize these years as precursors of madness.

Mental illness also afflicts her twin sister, Leah, now a patient at Dammasch State Hospital. It would devastate their lives, and their family.

Family relations would deteriorate. Lois would lose a baby to a medically recommended abortion. A roller-coaster lifestyle would take her in and out of hospitals for most of a decade.

Asked to describe the onset of his daughters’ illnesses, Bill Gleason, 61, a retired Portland schoolteacher who is now an elected Tualatin City Council member, paused, trying to recall a precise event or some telltale quirk.

Delinquent behavior and truancy first prompted Gleason and his wife, Doris, 55, to seek help. School officials called it a family problem, as did the police, even after Lois began running away from home.

The Gleasons tried to discipline her, without success. Private medical diagnoses concluded she suffered from early signs of mental illness.

When she was 13, the Gleasons reluctantly made Lois a ward of the court. A succession of foster homes would follow. “It was the only way we could afford care for her,” Gleason recalled.

By high school, Lois had gravitated to the “hoods” — a loose subculture of drug users and occasional criminals. Bill Gleason, a mild man who now serves as the chapel sexton at the Oregon Episcopal School, once brandished a baseball bat to scare off one of the “hoods,” a suspected drug dealer.

As the illness deepened, the Gleasons found themselves increasingly isolated.

“One of the big feelings I have is of being alone, of people wanting to stay away from that part of your life, as though it was contagious,” Doris Gleason, 55, recalled. “There was no help. There’s still a stigma. It was very painful.”

At 16, Lois smashed a foster home window with her left hand and was committed for the first time to Dammasch State Hospital. She had begun hearing imaginary voices — they said she was evil and urged evil acts. Lois was receding into what she called her “cartoon world.”

Her 10-month stay at Dammasch would be the “first relief” in years for Bill and Doris Gleason. For Lois, it would be the first of nine visits over the next eight years.

Options limited

Tom Jacobsen, a private psychologist at the Goose Hollow Mental Health Clinic, counsels about 100 “chronics,” most of whom reside in West Portland apartments and hotels.

One is Lois Gleason.

A former Southern Baptist minister, Jacobsen, 42, considers himself a kind of last resort for patients who have nowhere else to turn. His flat rate for counseling is $65 an hour, but Jacobsen offers his low-income clients a discount, which he declines to specify.

He says most of his clients do not qualify for traditional community care programs because of a history of “obnoxious or bizarre behavior.”

Some are combative and assaultive. They threaten suicide. They badger, sometimes blaming Jacobsen for their troubles. But most of the time, their illness is hidden from public view.

Jacobsen takes it all in stride. He sees his clients once or twice a month, and sometimes counsels them by telephone, for free.

Not all therapists are as patient, or charitable.

“A lot of us don’t really want to deal with crazy people,” confided Dr. Ed Colbach, a Portland psychiatrist who admits he avoids deranged patients.

“They create havoc in our lives. And you get sued if you screw up,” he said. “I get stuck sometimes with a person who’s in my office, who’s threatening. I don’t want to be a part of that anymore. I’m too old.”

Other professionals privately agree with him. They say they will not work in public institutions or programs because the wages are too low, and caseloads too heavy.

“The most talented people,” said Colbach, “shy away from the sickest population.”

That kind of concern heightened after two psychiatrists were killed two years ago. Dr. Brian J. Buss, 37, was bludgeoned to death by a deranged patient at Salem Hospital in February 1985, and four months later a shotgun blast allegedly fired by a client killed Dr. Michael J. McCulloch in his downtown Portland office. (Buss’ assailant was found guilty except for insanity, while McCulloch’s client has been deemed unable to assist in his own defense and is at Oregon State Hospital until he is capable of being tried.)

Even if they could find willing private therapists, outsiders often can not afford them.

Public assistance provides barely enough to subsist on. Many, like Lois, receive about $340 per month in Social Security income. Others get only $230 a month in welfare from the state Adult and Family Services Division. The checks must cover rent, food and any private therapy. A welfare medical card issued to each mentally ill person covers only the cost of medications.

Some shun care, even if they can afford it.

Unlike their predecessors, the younger generations of mentally ill often eschew traditional structured forms of treatment as unwanted interference, and may reject medication.

Some make it alone. Others end up on Skid Road, a last refuge for clouded minds. Mental illness for the most seriously ill makes even such elementary tasks as managing money, keeping track of possessions and remembering appointments difficult.

Social service groups on Skid Road form the last line of defense for Oregon’s outsiders. Counselors of the mentally ill, who try to help them survive here, say many are victimized. They may be robbed, injured, even killed.

Not all the stories end so dramatically.

In early October, after being displaced from her $285-a-month Southwest Portland apartment, Lois returned to Oregon City, where she said she had spent some of the best and worst years in her life. It would be the first stop on what she called her journey into “the street.” She stayed with a friend there for a week, then moved in with a friend in downtown Portland.

“I know I’m getting worse. I’m going to end up in Burnside Projects,” she said of the Skid Road social service agency.

In 1984, after her last release from Dammasch, Lois had lived in Oregon City and had met a young man who was also mentally ill. She got pregnant, just as the relationship was disintegrating.

Her mental health counselors in Clackamas County advised an abortion, warning of potential birth defects caused by one of her medications, lithium, an anti-depressant. Lois said one counselor escorted her to the clinic for the operation on Sept. 9, 1985.

When she moved to Portland a year ago, Lois hoped to sever her ties with Oregon City and to make a new start. She moved in and out of a series of apartments and residential care programs. Some she found unacceptable and abandoned. At others, operators objected when they found out she is chronically mentally ill.

Her past record of drug and alcohol abuse, and a history of occasional run-ins and arguments with caseworkers, neighbors and therapists had made her unwanted in some established treatment programs. Mental Health Service West Inc., a non-profit group that is the main contract provider of care to the chronically mentally ill in Southwest Portland, had no room for her on its crowded caseload.

Finally, last year, she turned to Jacobsen, whose clinic agreed to supervise medications necessary to stabilize her erratic behavior.

Shots of Haldol, a powerful anti-psychotic, every three weeks controlled her auditory hallucinations, the voices in her head. Other pills controlled the drug’s side effects — wavering hands and a slackened jaw. Liquid doses of orange-flavored Antabuse deterred her liquor abuse.

But when her moods darkened, Lois sometimes fell back on illicit drugs and alcohol. Her spirits plummeted last summer, when she visited her twin sister, Leah, at Dammasch.

In July, Leah approached a Portland policeman in Hillsdale. “She asked (the officer) to contact Ronald Reagan. She said he would get her a place to stay,” recalled Doris Gleason, the women’s mother. Leah Gleason was found to be delusional and committed to Dammasch.

In the days leading up to her move out of the West Hills, Lois worried that she, too, might have to be hospitalized. She made and then canceled an appointment to be evaluated at the psychiatric crisis unit at Oregon Health Sciences University.

On the night she moved out of the West Hills, Gleason called Jacobsen to say she had reached her limit of coping.

Several days later, her outlook had brightened.

“I’m going to be all right,” she said. “I’m OK.”

From The Oregonian, October 27, 1987 – not available elsewhere online

A man who was shot and killed by a Portland policeman last week during an altercation in a Southwest Portland apartment was a manic-depressive who became aggressive and assaultive when he wasn’t taking his medication, his mother said Monday.

Daniel Ynosente Reyes, 26, who listed several Portland addresses, died of a single gunshot wound to the chest shortly before 10 p.m. Thursday. Reyes was shot inside his mother’s apartment.

His mother, Annette Caisse, of 6213 S.W. Beaverton-Hillsdale Highway, Apt. 201, said Monday that her son wasn’t a “bad person.”

“He just had these terrible mood swings,” she said. “He was big — about 6 feet 1 and 215 pounds — and he would be fine one moment and then really aggressive the next. He was supposed to be taking lithium (carbonate) to control it.”

Caisse said that in recent weeks her son had thrown rocks through windows at a Portland school and had gotten into a fistfight with a skateboard rider in downtown Portland.

The night of the shooting, two policemen were sent to the apartment to investigate a complaint from a woman who said she had been assaulted by Reyes and wanted him arrested. The arrest was mandatory under Oregon’s domestic violence law.

While Reyes was being handcuffed, he grabbed a baton from one of the policemen and began hitting Officer Michael H. McDonald, 39, a 17-year veteran and Officer Michael H. Peterson, 38, who has been with the bureau for three years, said Henry Groepper, bureau public information officer.

Groepper said McDonald suffered a blow below one eye during the struggle. He said Reyes was struck several times with a baton, but it had no effect on him and he continued to fight.

Groepper said Reyes eventually let go of the baton, grabbed Peterson’s gun and attempted to remove it from the holster. McDonald then pulled his own gun and fired once when Reyes lunged at him, Groepper said. Reyes died at the scene.

About five hours before the shooting , Reyes had been cited without incident by another police officer in downtown Portland for felony driving with a suspended license. McDonald had assisted in the stop.

“I was trying to get him some help,” Caisse said of her son’s behavior. “I didn’t want him coming into my apartment, and I told the assistant manager that when I went to work. But someone didn’t get the message and they let him in here.”

Caisse, who was not at home at the time of the shooting , said her son and a friend of his were visiting in the apartment when they had a disagreement. Caisse said the woman told her Reyes pushed her but didn’t hit her.

“She ran screaming out of the apartment and ran to the manager’s unit,” Caisse said. “I guess that’s who called the police .”

The results of an investigation into the shooting will be turned over to the Multnomah County district attorney’s office.

Mind Games: Oregon’s Mental Health System

First of a five part series on the Oregon State Hospital

From The Oregonian – October 25, 1987. Not available elsewhere online.

Asylum: A place where one is safe and secure.” — Webster’s New World Dictionary.

When George Lewis Archer, 60, collapsed dead in a pool of blood by a nursing station in Oregon State Hospital’s general psychiatric ward last Nov. 6, staff employees took it in stride.

According to hospital records, no one at the time pressed to determine the cause of Archer’s bleeding or even suspected foul play. Two doctors at the hospital called it a natural death, from esophageal bleeding.

The Oregon State Police, which routinely looks into institutional deaths, asked for an autopsy. Four days later a pathologist discovered the true cause of Archer’s demise — he had been stabbed in the face with a butter knife.

A state police investigation would find that Archer had been stabbed by another patient in the ward’s visiting room while five staff members were on duty — none of whom noticed what happened.

Good gumshoe work solved one of the hospital’s secrets. Not all the secrets of Oregon’s mental institutions reveal themselves so completely.

The stabbing death is just one extreme example of what can happen in Oregon’s mental institutions. According to hospital records, Archer’s homicide was the second on hospital grounds in 16 years. One patient was killed in the hospital’s forensic unit for the criminally insane in 1985, and at least one other murder attempt has taken place there.

At least one other patient’s death, listed as from natural causes, should have been classified as homicide, according to Dr. Peter J. Batten, the Marion County medical examiner. Batten, who formerly served as a psychiatrist at the Oregon State Hospital, said a 68-year-old patient’s death of a heart attack in 1983 was sparked by another patient’s assault.

In contrast, the Oregon State Penitentiary, the state’s maximum-security prison, has had but one homicide in the last 15 years, although it houses nearly three times as many inmates as the hospital has residents.

Patient advocates and current and former staff members at the Oregon and Dammasch state hospitals for the mentally ill say patients are threatened by inadequate supervision. Similar problems also plagued the Fairview Training Center for the mentally handicapped until the state began a massive, $25 million plan of correction last spring — prompted by a federal lawsuit and termination of federal Medicaid and Medicare funding.

Injuries, rapes and, on occasion, even deaths continue to occur in the state’s mental institutions when patients hurt themselves or prey upon others, both patients and staff members. Sometimes the cause is determined, sometimes not — no one sees them, or no one will or can tell what he saw.

Consider the following:

• In addition to Archer’s homicide at Oregon State Hospital, bizarre accidental and unexplained deaths have occurred. Two middle-age women patients at Dammasch have died of heat exposure after wandering onto the grounds in the last four years. Two older women died — one from complications arising from a broken hip — after one fell from a bed and the other from a chair at Oregon State Hospital last winter.A 24-year-old woman wandered off Fairview’s grounds in March and was found dead three days later, drowned in a creek nearby.
• So ineffective is normal supervision that stopgap solutions must be devised. For example, Dammasch officials, frustrated by their inability to protect a middle-age woman from rapes, have put her in a thick plastic coverall secured by locks — a 1980s version of the medieval chastity belt. The ratio of staff members to patients is far below what the state says are federal standards.
• Injuries to staff members, often caused by combative patients, have been so common in the state’s three largest mental institutions that they cause staff shortages and millions of dollars in workers’ compensation claims.
• Federal certification has been yanked for almost all of the state’s institutions, at least temporarily, costing the state millions in lost federal aid.

Proud record tarnished

Oregon’s mental institutions once ranked among the best and most progressive in America. The state burnished its reputation for progressive thinking in matters of the mind 12 years ago when it permitted the filming in Oregon State Hospital of the movie “One Flew Over the Cuckoo’s Nest,” an indictment of inhumanity in mental hospitals; state officials believed that Oregon had nothing to hide.

But as the 1990s approach, the state has not fulfilled the promise of its progressivism, and the reputation of its institutions is tottering.

Oregon’s two main state hospitals for the mentally ill operate on the very edge of respectability. Fairview Training Center, the state’s largest institution for the mentally handicapped, also has had a history of safety problems.

Since the spring of 1986, Dammasch, Oregon State Hospital and Fairview Training Center all have been at least temporarily denied federal Medicaid and Medicare payments for substandard conditions.

The state last week announced new superintendents for all three of the state’s large mental institutions. Linda K. Gustafson, director of a mental health hospital in Lincoln, Ill., will become Fairview’s new superintendent Dec. 1. Stanley F. Mazur-Hart, the acting superintendent of Oregon State Hospital, will replace Dr. Victor M. Holm as superintendent of Dammasch on Nov. 23. Holm announced his retirement last week. George Bachik, director of the Idaho State Hospital South, will take over as superintendent of the Oregon State Hospital on Dec. 7, it was announced Friday.

Dammasch continues to operate without federal funding certification. Oregon State Hospital has regained partial funding but has chosen to forgo certification review for three of its five main sections, knowing that conditions in them do not meet federal standards for either adequate treatment or staffing.

In April, federal health-care inspectors concluded that too many Fairview patients were being injured, and they cut off funding. They charged that inadequate staff and poor procedures posed a immediate threat to residents’ health and safety.

The state regained federal funding for Fairview after a 14-week hiatus — and a $7 million loss — by agreeing to spend $25 million over two years to hire 500 new employees and move 300 of Fairview’s more than 1,000 residents into community care.

Health Care Financing Administration officials say that Fairview now meets standards for safety but barely complies with those for treatment. In a pending lawsuit separate from the financing administration’s review, the U.S. Department of Justice alleges that care at Fairview violates patients’ constitutional rights to safety, training, medical treatment and education.

Two smaller state institutions, Eastern Oregon Psychiatric Center and Eastern Oregon Training Center, both in Pendleton, continue to have federal funding certification. The state Department of Human Resources director, Kevin Concannon, said he thought both were doing well and, with a combined population about 150, were examples of his belief that “small is better.”

Violations of federal treatment standards, designed to prevent warehousing of patients, account for the continuing lack of certification of Dammasch and parts of Oregon State Hospital.

According to state officials, one of the key federal benchmarks not met by Oregon’s state hospitals is the ratio of staff members to patients. While the federal officials deny that they use a specific standard, top state administrators say they believe the unwritten expectation for state hospitals is about 1.2 direct-care staff members per patient. The state hospitals have only about 0.6 direct-care staff members per patient — half of what the federal government says is adequate. Only the children’s and geriatric programs at Oregon State Hospital approximate the federal staffing standard and are certified.

The federal expectation for training centers for the mentally handicapped is about 1.5 direct-care staff members per patient, state officials say. At Fairview the ratio is about 0.9.

Concannon, who took office Oct. 12 as director of the state Department of Human Resources after a brief term as mental health chief, said the state planned improvements at both state mental hospitals but not on the same scale as at Fairview, and not enough to regain federal funding soon.

The Legislative Emergency Board earlier this month appropriated $900,000 to relieve staff workload by shifting 50 long-term Dammasch patients into community care. It rejected a request to pay for more Oregon State Hospital employees, saying such a decision should wait for the 1989 Legislature.

The state hopes that a new law, designed to increase civil commitments by providing for closer monitoring of those with two or more commitments in the last three years, won’t increase the pressure on state hospitals. It has set aside $7 million to keep track of such chronic patients more closely and provide community programs for them, and it has made no plans for enlarging the hospitals.

Fewer patients

The overall number of people in institutions has dropped sharply for the last 30 years under the state’s policy of diverting patients into the community, called deinstitutionalization.

Despite that drop, the state’s institutions suffer from insufficient staff, inadequate programs and conditions that critics call not only unhealthy but also dangerous to inmates and staff members alike.

State officials attribute the problems of the three larger state institutions to their size, outdated buildings and a lack of staff.

“Standards have moved a considerable distance in 20 years,” Gov. Neil Goldschmidt said last year. “And our programs didn’t move enough in 20 years to keep up. . . . It’s going to take a little catch-up time.”

The amount of money needed to catch up may be great.

For example, Holm, Dammasch ‘s superintendent, said the hospital “ideally” needed a 50 percent staff increase. “It’s like an airplane: You can guarantee it’s safe, but it’ll never fly,” he said.

In addition, the state says it has had problems recruiting and keeping doctors, nurses and other professionals. Dr. Philip Shapiro, clinical director of Oregon State Hospital, said he had had one to four vacancies for physicians for three years and had a standing help-wanted ad in five psychiatric journals.

One reason given for the shortage, especially for doctors, is the relatively low pay, compared to private practice. The starting state maximum is $63,000 a year, and Shapiro said earnings can be far higher in private practice.

Concannon said he could not predict when or whether Dammasch and the decertified 70-patient general psychiatric section of Oregon State Hospital could regain federal funding. The state has no plans to comply with federal treatment standards for the forensics and correctional treatment programs. Those three decertified programs house 70 percent of Oregon State Hospital’s patients.

Assaults occur daily

Violent assaults by patients are a daily occurrence in the state’s three largest mental institutions.

The most violent and threatening patients in the state end up in the security ward at Dammasch and the forensic unit for the criminally insane at Oregon State Hospital.

But violence inside state institutions is not confined to these units.

For example, according to figures compiled by the state for The Oregonian, 4,469 assaults by patients on other patients and on staff members were recorded during the 20-month period from January 1986 through August 1987 at Oregon State Hospital — an average of more than seven per day.

By far the greatest number occurred in the five wards of the hospital’s 160-patient geriatric program, for mentally ill patients who are 65 and older. The program averages about five patient assaults on other patients or staff members a day.

Indeed, hospital employees say some of the most dangerous conditions exist on the 12 general psychiatric wards for both large state hospitals. None of the wards meets federal treatment and staffing standards.

Oregon State Hospital continues to accept patients who voluntarily check into its 70-bed general psychiatric program, but Dammasch has reserved nearly all its 345 beds for patients who have been committed by the courts.

Diane Neubert, the Dammasch nursing chief, said the hospital’s patients over the last five years had become much more difficult to handle, particularly since voluntary patients were shut out.

“We’ve condensed down. We have a totally different population. . . . People are sicker. Patients get injured more,” she said.

“We have a very poorly staffed facility. It needs more staff to be truly safe,” she said.

During the state employees’ strike in September, hospital workers complained loudly about patient-caused injuries to them and wore buttons portraying black-eyed employees.

About 340 injury claims were filed by employees of Dammasch and Oregon state hospitals last year — nearly one a day. At Fairview, 920 similar workers’ compensation claims were filed in 1986.

The cost to the state in workers’ compensation: nearly $6 million last year.

Jan Curry, Fairview’s former acting superintendent, said the addition of 500 employees in recent months had helped reduce the severity of injuries caused by accidents or patients, but not their number.

Curry and a spokeswoman for the Fairview workers’ union said they believed the new workers had improved the overall safety at the institution.

Even so, “We have enough to watch (patients), but not enough to provide active treatment,” said Colleen Moen, of the American Federation of State, County and Municipal Employees.

Archer’s stabbing death on one of the program’s two wards was just an example of conditions inside it, said Chuck Forward, a psychiatric aide who is president of the hospital’s Oregon Public Employees Union unit.

“It’s not a safe place,” Forward said of the general psychiatric program where he works. “When you got four (psychiatric) aides, it’s hard to cover 30 to 40 patients on all parts of the ward.”

The aides and two nurses typically cover each ward, a long corridor of single and double rooms that stretches roughly two-thirds the length of a football field and includes a large day room, porch, two bathrooms and a shower.

State police concluded that Archer was fatally stabbed while in the visiting room.

Batten, the Marion County medical examiner, said that the assailant, Daniel Edison Miller, 30, had time to stab Archer with a butter knife, hide the weapon and wash the blood from his hands, all without the staff’s knowledge. Miller later confessed and was found guilty except for insanity.

The inability of staff members to prevent such assaults also was demonstrated by the 1983 death of George Nosen, 68, who in 1947 mistook cockroach poison for powdered milk while helping prepare a dish of scrambled eggs and accidentally killed 47 fellow Oregon State Hospital patients.

Nosen died of an apparent heart attack that occurred after he had been in a scuffle with another patient in the hospital’s geriatric ward. The fight occurred while about seven ward employees were in a 7 a.m. staff meeting.

At the time, Batten said, he listed Nosen’s cause of death as natural — arteriosclerotic heart disease. He listed a “non-fatal assault” by another inmate as a possible contributing cause. Batten said he had since changed his mind, and that the death was actually an “inadvertent” homicide — a heart attack caused by an assault by another patient.

In addition to the three homicides at Oregon State Hospital, four accidental deaths have occurred there in the last two years, two in falls and two from choking on food.

One person, Wanda Jackson, 50, died of “complications” two days after surgery for repair of a hip that was broken in a fall from her bed in a general psychiatric ward at Oregon State Hospital in January. Batten said the hospital initially wanted to have an autopsy done but the woman’s family refused to give permission. He said the hospital then concluded it was “probably a routine death that should be handled in a routine manner” and did not advise his office of it until after the woman was buried.

Delores Perez, 77, died of serious head injuries after she fell off a chair onto the floor of the geriatric unit on Dec. 25.

Two other patients died after choking on food. Byron Jacobs, another geriatric patient, who had a history of swallowing non-edible objects, choked to death after gorging himself on a magazine page and breakfast on Dec. 9. 1986.

LeRoy Lancaster, 60, died after choking on food in the hospital’s forensic unit on April 12. 1987.

In the last 10 years, there have been at least two other bizarre deaths at the hospital. Joshua Goodman, 21, choked to death on a rope in July 1981 while climbing on a painter’s rigging. Hospital officials and state police concluded he had been practicing rappelling for a planned rock-climbing expedition.

In the other case, Mark Radke, 25, died in June 1979 of “undetermined natural causes” eight days after being arrested for failing to pay for a meal in a Marion County restaurant. Batten said Radke possibly died from a drug overdose, but that an autopsy could not confirm that or any other specific cause.

Assaults by patients and unusual deaths offer two examples of what employees of both state hospitals say are products of inadequate staffing. Patient advocates say staffing not only creates safety problems but also results in inadequate treatment for patients.

“State institutions are abominations,” said Steven H. Gorham, a Salem attorney, who represents mentally ill and handicapped clients. “The object now is to get patients out as fast as you can. What they are concerned about is doing it the cheapest way possible.”

From the Oregonian – October 24, 1987. Not available elsewhere online.

Completing a round of assignments to provide leadership at the state’s three largest mental health institutions, the Human Resources Department announced Friday that George W. Bachik would become the superintendent of the Oregon State Hospital in Salem.

Bachik, 45, holds a similar job at Idaho State Hospital South, a 232-bed facility in Blackfoot, Idaho. He has worked there since 1979. Previously, he worked 15 years at a state hospital in Colorado.

“He comes to us with glowing references both in terms of personal energy level and professional skills and leadership,” said Kevin Concannon, director of the Human Resources Department.

Oregon State Hospital, with 710 patients, operates on a $6.7 million yearly budget, according to the Mental Health Division, and specializes in geriatrics, child and adolescent treatment, forensics and general psychiatrics.

In Colorado and in Idaho, Bachik worked to move patients into semi-independent group homes rather than keeping them inside the hospital. These experiences might be useful in cutting the number of patients at OSH, Concannon said Friday.

Bachik, who has a master’s degree in social work from the University of Denver and has completed postgraduate work in public administration, was selected from about 30 applicants in a nationwide search. He was interviewed by a screening panel and by Concannon.

Bachik will begin his new position Dec. 7. His salary will be $52,848.

He will replace Robert Benning, who resigned in May. Stanley F. Mazur-Hart, the acting superintendent of OSH, will take over supervision of Dammasch State Hospital in Wilsonville, Concannon said Thursday.

The third major appointment to the state mental institutions announced this week was Wednesday’s selection of Linda K. Gustafson, director of an Illinois hospital, to take over the Fairview Training Center.

From The Oregonian – October 23, 1987. Not available elsewhere online.

Stanley F. Mazur-Hart was named Thursday to be the new superintendent of the Dammasch State Hospital.

Mazur-Hart, 41, has been acting superintendent of the Oregon State Hospital since May. He will take his new position Nov. 23, replacing Dr. Victor M. Holm, 58, who announced Monday he would retire.

The new superintendent holds a doctorate from the University of Nebraska and is a licensed psychologist. He is a member and past chairman of the Oregon State Board of Psychologist Examiners.

In a prepared statement, Kevin Concannon, director of the Human Resources Department, said Mazur-Hart was an “outstanding professional” who would make a “fresh and welcome contribution.”

Dammasch State Hospital, a psychiatric hospital in Wilsonville, serves more than 2,000 patients a year and has an operating budget of $29.4 million for the 1987-89 biennium.

Mazur-Hart met Thursday afternoon with about 60 staff members at Dammasch , and their questions indicated their frustrations and concerns. Issues of patient safety, overcrowding, understaffing and lack of vacations cropped up during the half-hour session.

On Thursday, there were 371 patients at the hospital, which was 41 more patients than the budget provides for and too many for the staff to handle, Mazur-Hart said. He said he wasn’t sure the hospital could provide a doctor for each ward at all times.

The staff-to-patient ratio is about 3-to-4, Mazur-Hart said. To comply with federal guidelines, he said the hospital would need six staff members for every five patients.

Mazur-Hart had applied to be superintendent of the Oregon State Hospital, a position to be announced Friday. Instead, he was selected for the Dammasch job.

In his new position, he will earn $52,848.

From the Oregonian – October 20, 1987. Not available elsewhere online.

Dr. Victor M. Holm, the superintendent of Dammasch State Hospital in Wilsonville for the past seven years, announced his retirement Monday, citing what he called a “mutual” decision he had reached with Kevin Concannon, the new state Human Resources chief.

Concannon announced his decision to accept Holm’s retirement Monday in a letter released by the state Mental Health Division. Concannon could not be reached for comment Monday. Holm said he would remain on the job through Dec. 12 to help run the hospital and to help his successor.

Holm said that he had been considering retirement since last summer and that he had submitted a letter to Concannon last week expressing his intention to retire at the end of the year.

“I wanted to retire,” Holm said. “He (Concannon) wanted to make changes in the administration of all hospitals and the state Mental Health Division.”

The new Dammasch State Hospital is shown in this 1960 aerial view.

Holm’s retirement will complete a clean sweep of the superintendents of Oregon’s three largest mental health institutions this year and comes as part of a major reorganization of the state Mental Health Division under Gov. Neil Goldschmidt.

The state announced the reassignment of Jerry McGee, the longtime superintendent of Fairview Training Center for the mentally retarded, in early May, just after the state received results of a federal inspection critical of the institution. The inspection resulted in a 14-week cutoff of federal Medicaid and Medicare funding for inadequate staffing and poor care.

The state also has yet to replace Robert J. Benning, the former superintendent of Oregon State Hospital, who resigned his job effective May 22, to take a job with a private hospital in Tennessee.

On the same day that Benning officially resigned, Joseph E. Murray, the administrator of the state Mental Health Division, announced his resignation.

Murray was replaced initially by Concannon, a former state mental health and corrections chief in Maine.

Concannon was elevated by Goldschmidt to director of the state Department of Human Resources earlier this month.

Holm said his stay at Dammasch had been “deeply rewarding” but that it had also been “frustrating some of the time” because he believed he had been given limited resources to care for patients.

In his letter, Concannon praised Holm for leading Dammasch through “difficult years” during which he had “lean” resources. He said that Holm had had to work with fewer staff members “than what your professional judgment dictated.”

On Oct. 9, the Legislative Emergency Board approved a $900,000 plan to put 50 of Dammasch ‘s 380 mentally ill residents into community programs. The move was designed to bring Dammasch ‘s population down to 330, a number that had been specified in its 1987-89 budget as an upper limit, but which has been exceeded for much of this year.

Holm said that the new population cut would help but that he believed the hospital still had “not enough resources” to properly care for 330 patients.

The federal Health Care Financing Adminstration last year revoked the hospital’s certification to receive federal Medicare and Medicaid funding. The federal agency cited the hospital’s failure to meet federal treatment standards.

Holm said the loss of certification and the inability of the state to pay for improvements needed to regain it had been a “big disappointment.”

“It ultimately played a role in the decision” to retire, he said.

Holm had served as a clinical director at both Dammasch and Oregon State hospitals for about two years before being appointed superintendent.

He previously had served for 21 years as a captain and a psychiatrist in the Navy. He was for a time the chief of psychiatry at the National Naval Medical Center in Bethesda, Md.

From The Oregonian, October 1, 1987 – by columnist Phil Stanford

Phil Stanford, Oregonian Columnist

At the Old Town Market, on the corner of Northwest Third and Couch, the word is definitely Thunderbird. A pint (or more precisely, 375 milliliters) costs $1. That’s not much for wine, but it’s a lot for kerosene.

The wholesale price for the same bottle is 66 cents, which gives you some idea of what Ernest and Julio Gallo think of this particular product of their vintner’s art.

Another thing it tells you is that the markup on this particular item is more than 50 percent — which begins to explain why, at least for some, the bedraggled drunks who congregate in the Old Town area are more than just a social dilemma.

They are also a dependable source of profits.

All day, from 6 a.m. to 11 p.m., they come and go at the Old Town Market. They put their money down and leave with bottles of T-Bird inside brown paper bags.

Outside, they deposit themselves on the sidewalk and start drinking again.

And after a while, they pass out and have to be picked up by the detox van from the Hooper Memorial Detoxification Center.

The detox center, it should be noted, is operated by a social services agency called Central City Concern.

According to Richard Harris, the director of the detox center, last year the detox van made 18,000 pickups. Nearly all were in the Old Town area.

In other words, there’s not much to distinguish the Old Town Market from any other small grocery store that specializes in selling cheap wine to winos.

In fact, the only difference worth noting is that the Old Town Market operates in space leased from Central City Concern — which, as has already been noted, operates the Hooper detox center.

It’s really quite simple.

In September 1986, with money from the city of Portland and private foundations, Central City Concern purchased the Estate Hotel to use as housing for the poor.

Along with the Beaver Hotel, which was bought about the same time, the Estate Hotel is usually considered to be the centerpiece in Mayor Bud Clark‘s 12-point plan for the indigent.

On the fourth floor of the Estate Hotel is a treatment center for recovering alcoholics who have gone through the detoxification program.

And then on the first floor, there’s Old Town Market, which sells them the wine in the first place.

If you didn’t know better, you might think of it as a full-service alcoholism treatment program.

Doesn’t this make the folks at Central City Concern feel just a little bit uncomfortable?

Not Richard Harris, the head of the detox program.

“As a treatment professional,” he said “it makes no difference to me whether they sell the wine there or four blocks away.”

Harris actually got testy when someone suggested that Central City Concern might be in a compromising position. When Central City Concern bought the hotel, he said, a 10-year lease on the store went along with the deal.

Then why did Central City Concern buy the hotel at all?

Michelle Williams, office manager at the Central City Concern, had a good answer for that one.

“We only did it because of the money,” she said. Before Central City Concern purchased the Estate Hotel, she explained, it was paying $3,000 a month for offices and other space. Now, as landlords, it makes $1,400 a month renting out the Old Town Market.

That’s a turnaround of $52,800 a year, which, as she hardly needed to point out, can pay for a lot of detoxification.

Williams, whose office is on the third floor of the Estate Hotel, said that before Central City Concern purchased the hotel, board members passed a resolution dealing with the situation.

Although profiting from wino grocery store might send “an inappropriate message to the community,” they said, it was OK to go ahead with the deal because as treatment professionals they understood that alcoholism is a “disease” that can be controlled only through “abstinence.”

As treatment professionals they could not condemn selling alcohol, because, as they put it, “The consumption and sale of alcoholic beverages does not cause alcoholism.”

Down on the street, the white detox van had stopped to pick up another satisfied customer. He was sleeping with his head in the crook his arm. Drool was running down his cheeks.

When he came to, he would no doubt be happy to hear how they had worked it out.