By Robert Landauer – editorial columnist for The Oregonian, September 8, 1996. Not available elsewhere online.

Review these recent Portland scenes:

1. During Rose Festival, a woman was disrupting traffic, holding a baby doll, sucking her thumb and beating her head against trees, injuring herself.

2. He really thought he was Superman and would not stop lifting way too much weight for his safety at the Nautilus fitness club.

3. The turbaned woman, blessing everyone, released pigeons during mass at the Downtown Chapel. She was about to be evicted from her apartment, because she believed God called her to invite all of Portland’s homeless to live with her.

4. A man, filthy and shoeless, was found sleeping on a Parks Block bench. His toenails, 1 1/2 inches long and overlapped, had fused. He didn’t speak, only grunted. Eventually he hit someone and was jailed.

The episodes feed the perception that downsizing or closing state hospitals has few if any positive trade-offs and is causing the quality of life in our communities to drop.

Many want these unsavory people locked up in mental hospitals, out of sight.

Well, not so fast.

Another way to look at this is this: Could you solve these problems simply by reopening mothballed state hospitals or building new ones? No indeed.

If Oregon operated as it did 30 years ago, with the same ratio of people in mental hospitals as then, the state budget for the mentally ill would be close to $1 billion per biennium for 10,000 beds rather than $100 million for 760 beds statewide, says Barry Kast, administrator of Oregon’s Mental Health and Developmental Disability Services Division.

The patients then and now are the people with schizophrenia, major depression and bipolor disorder (formerly called manic depression), dementias and alcohol- and drug-induced psychoses.

The policy puzzle is easier to understand at Fairview Training Center in Salem. It has about 350 residents. That is 3 percent of Oregon’s 10,000 developmentally disabled. Yet Fairview gobbles dollars like an insatiable Pacman, consuming 37 percent of the budget for the entire developmentally disabled population as opposed to the mentally ill.

It doesn’t take long to calculate that the more people you serve in this institutionalized way, the fewer you serve in all.

Consider another piece of the mental-health puzzle. If you have a limited budget and treat people only in an acute phase, you will see fewer people who are more seriously ill, and they will be much more expensive to treat. So if you want to be both cost-effective and humane in preventing personal crises, you have to divert much of your attention and funds to intervening early.

The issue, then, is not just the number of state mental hospitals, but whether Oregon’s 50,000-60,000 mentally ill people are treated adequately in the communities.

A big difficulty is that the public sees treatment as incompatible with living on the street, says Kast, but budgets and how the mentally ill behave make street-level treatment inescapable.

The transition is happening, slowly. In Portland, for example, Project Respond operated like 9-1-1 and answered this column’s four mental -health emergencies right at the street level of crisis.

These mobile professionals, operating out of a van, work for the private, nonprofit Mental Health Services West. They give their own DNA — dogged nonjudgmental attention — to the mentally ill. This builds trust in people who hear the walls breathe and buttons talk. It helped the pigeon-releasing madonna of the Downtown Chapel to agree to move to the Bridgeview Community, a Mental Health Services West facility that offers services and safety to the chronically mentally ill.

The Parks Block derelict responded over months to Project Respond’s assertive outreach. Caseworkers say you can chat with him at the Broadway Deli “where he sits looking clean and dapper drinking tea with his pinkies up and his toenails clipped and inside a new pair of shoes.” He will eventually be able to maintain an apartment on his own.

Life is better than it was for the Superman weightlifter with manic bipolar disorder and for the woman who was so distraught during Rose Festival. The outreach workers carried them through their crises and out of emergency services’ revolving door by reconnecting them to treatment, housing, transportation, food and other social services.

Project Respond, helping to keep the clients stable, can assist a person to live in the community for $4,000. Institutionalized, the same person typically costs the public $75,000 to $100,000 a year.

Oregon tries to treat the mentally ill in the least restrictive setting possible. That is legally required, ethically proper and financially necessary. It is also far from perfect.

It is getting better, though, as acclaimed efforts like Project Respond help the chronically mentally ill to stay stable — and free.

By Robert Landauer – editorial columnist for The Oregonian, September 6, 1996. Not available elsewhere online.

A thirtyish woman stops paying her bills, appears dirty and disheveled, no longer talks to neighbors, sends family away when they come to the door and is described as delusional by her apartment manager.

She definitely needs help, says Barry S. Kast, administrator of Oregon’s Mental Health and Developmental Disabilities Services Division. But she rejects it.

It can’t be proved that she is gravely unable to care for herself. “But as night follows day,” says Kast, invoking Shakespeare, “we know that she will become gravely unable.”

Yet that forecast, validated by earlier episodes, is insufficient to commit her for treatment.

This woman later was taken to a Portland hospital in an acute stage of mental illness. Doctors felt she urgently needed longer hospitalization, but a judge refused to commit her because the treatment had eased the acute symptoms. The court released her — in hospital gown and slippers.

Kast describes another incident. A young man is pounding on a Portland department store’s windows and talking to the mannequins with rage. The public sees him as crazy, frightening. The county staff members see him as someone who doesn’t meet commitment criteria for dangerousness to self or others.

Then there is the Portland suburbanite, a paranoid schizophrenic, who had gone off his medications and started displaying bizarre behavior. He was arrested for an act of public disorder.

His family wanted him to commit himself for treatment. He saw no need for help. The well-to-do family had three doctors examine him. All testified that he should be hospitalized.

The judge released him. Even though the man’s public behavior was disorderly and even repugnant, there was no convincing evidence that he was dangerous or couldn’t minimally care for himself.

From the families’ point of view, each decision by the judges was an outrage: Their sons and daughters are mentally ill. As they lose touch with reality, becoming terrified, angry and isolated, they do not see themselves as ill, so they spurn medications, become suspicious of doctors and caseworkers and reject treatments. These are not knowing decisions, aware of consequences.

These cases are typical. That exposes the chasm that has opened between public perception and what the law allows.

Like a long-running road show, the same issues replay all across the country. Legal, ethical and financial pressures push states to treat the mentally disordered in settings that least restrict their liberties. But releasing them from institutions may lead to no treatment at all.

Indeed, doctors, caseworkers and police routinely encounter two problems with the mentally ill. The first is that there often is not a single empty mental -health bed in which to place a person suffering an acute attack. So on any given night, about 7 percent of those in Oregon jails are mentally ill.

The second difficulty is that it can be almost impossible to commit and treat a person who obviously needs help. Americans hate the idea of railroading anyone into involuntary detention. So, with U.S. Supreme Court blessing, the state must prove that the mentally ill persons — defended by state-paid lawyers and psychiatrists — are dangerous or so unable to care for themselves that life itself might be threatened.

Either one can be tough to prove. In fact, mental -health workers often remark that the patient died with his rights on.

When we go to court, we assume there are opposing interests. This is a distortion, even a delusion, in mental -health hearings. Everyone there wants the best for the afflicted person. That can be devilishly difficult to figure out — especially when the only real-life alternatives might be lockup treatment or unstructured exile to a psychiatric ghetto under a bridge.

This is a pathetic way to deal with sad issues. Even laymen devoutly concerned with rights should understand that families and doctors do not widely conspire to railroad the mentally ill into medical dungeons for years.

Oregon must find ways to help its 50,000-60,000 mentally ill before and during crises. Now, we get so entangled in law designed to protect the vulnerable ill that we deny them the freedom that can come with treatment.