Mental Health Association of Portland

By Amanda Waldroupe, published in Street Roots, July 13, 2011

The Oregon Legislature adjourned on June 30, and in its final week, passed two bills reforming the Psychiatric Security Review Board (PSRB) that aim to eventually reduce the number of people staying, and the length of stays in the Oregon State Hospital.

House Bill 3100 and Senate Bill 420 passed both the House and Senate with large margins and now await Gov. John Kitzhaber’s signature. He is expected to sign them into law.

Chris Bouneff, the executive director of Oregon’s chapter of the National Alliance for Mental Illness, said the bills will make the most substantive reforms to Oregon’s mental health system in years.

“We haven’t seen anything of this magnitude in a number of sessions,” he said. “They will help modernize our system.”

The new laws will now require that a state-certified psychologist or psychiatrist evaluate a person wanting to plea “guilty except for insanity.” That means that they committed a crime they would not have if they were not mentally ill at the time. The law now also requires that people who committed misdemeanor-level crimes and Class C felonies be evaluated to determine whether they can receive care at a community treatment program, rather than at the Oregon State Hospital.

Senate Bill 420 strips away some of the PSRB’s jurisdictional authority. Currently, it has jurisdiction over all patients at the Oregon State Hospital who have been found by a court to be guilty except for insanity.

With that authority comes the power to decide when patients are ready to be released from the hospital, and whether they are released to live independently or in a community treatment facility. Mental health advocates, legislators and other groups have strongly criticized the PSRB over the years for not releasing a higher number of patients, sooner.

Senate Bill 420 will give the Oregon Health Authority, which oversees the state hospital, jurisdiction over hospital patients who committed non-Measure 11 offenses (crimes that are not violent person-on-person crimes). The PSRB will continue to have jurisdiction over patients who committed Measure 11 crimes, as well as patients who have been released into community treatment settings.

“(Senate Bill 420) is long overdue,” said Sen. Jackie Winters (R-Salem), before the Senate approved the bill by a 20-9 margin.

The biggest hope is that long hospitalizations of patients who no longer need intensive care, treatment and 24-hour supervision at the State Hospital will end.

“In some instances, we’re doing a job of warehousing individuals,” Winters said. “Senate Bill 420 will help us … use our beds more wisely.”

“There are quite a few people who shouldn’t be there,” said Rep. Brian Clem, (D-Salem), the chief sponsor of House Bill 3100. “They are well now, and it’s time for them to go home.”

He pointed to the PSRB as the reason why some patients aren’t released in a timely fashion. The PSRB is blamed for those long hospitalizations because of its hesitancy to release people they think may commit another crime. Its recidivism rate — the number of people who commit a crime once released — is 2.3 percent, compared to the Department of Corrections rate, which is in the 30th percentile.

“They’re too afraid that somebody’s going to do something once they get out,” he said.

Hospital patients who lobbied for the bills, particularly Senate Bill 420, are jubilant.

“We’re proud of our legislators that worked to pass Senate Bill 420,” they wrote in a press statement released on June 28. “This bill is the beginning of a long overdue modernization of the PSRB and Oregon’s mental health system. This bill will improve our treatment, fight stigma, and help us to live full lives.”

Originally, the bill would have given jurisdiction of all patients to the health authority. But a compromise was struck in closed door negotiations to gain the support of the Oregon District Attorneys Association and the law enforcement community, who argued that dangerous people would be released from the hospital and public safety would be threatened.

The compromise creates “Tier I” and “Tier II” populations. “Tier I” refers to patients who committed Measure 11 offenses (violent person-on-person crimes such as murder, rape, etc.). Tier II refers to non-Measure 11 offenses. It is estimated that the Tier I population, which the PSRB will continue having jurisdiction over, is approximately 60 percent of the hospital’s patients.

Advocates such as Bouneff strongly lobbied for the bill’s passage, arguing that doctors and clinicians interacting daily with patients are the most qualified to determine when someone is ready for release.

“The hospital (would have) some control over who comes in and leaves,” Bouneff said. “Right now, they have no control.”

The next step before Senate Bill 420 is implemented is administrative rule-making, which will determine what the Health Authority’s jurisdictional responsibilities are, as well as how it will conduct hearings to determine whether patients are ready for release.

It’s going to be very important for the (PSRB) and the Health Authority to work well together so that we can have an opportunity to have some people transition more effectively,” said Bob Joondeph, the executive director of Disability Rights Oregon. “I’m hoping the rules really emphasize that as much as possible.”

Joondeph says that the changes currently being made to the PSRB represent the beginnings of re-thinking the state hospital’s purpose and function. “The idea is to treat the state hospital like a hospital,” he says. “We don’t want to have it primarily be a prison.”

He expects the changes made this year to be the foundation of future changes to Oregon’s mental health system, and expects the discussion to shift toward considering increasing the budget for community treatment programs, preventive services, and other cost-effective, community-based methods of treating mental illness.

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From the Eugene Register Guard, June 25, 2011

A $5 million allocation from the Legislature is a fraction of the projected cost, but sources say the proposal is just delayed

Legislators are close to unveiling a proposal that would allocate $5 million for infrastructure costs over the next two years for the state psych­iatric hospital proposed for Junction City.

That’s down from the $83 million Gov. John Kitzhaber recommended for the project in his February budget — which would have funded full construction of the hospital — and down also from a later proposal of $33 million in the coming biennium for partial construction.

But the small allocation doesn’t necessarily mean the project is dead.

Multiple sources close to the situation say that the current intention is to carry on with the project, albeit in an altered form, and that the Legislature could come back with more construction funds as soon as the 2012 legislative session, which begins in February.

The $5 million allocation — which will primarily go to infrastructure and planning, not actual buildings — allows the Legislature to keep the project moving in a difficult budgetary time, proponents argue.

It also allows the state to defer the completion of a hospital that won’t be needed until early 2015, when two of Oregon’s smaller psychiatric hospitals, OSH Portland and Blue Mountain in Pendleton, are scheduled to close.

“We’re moving forward in a prudent way,” said Dr. Bruce Goldberg, the director of the Oregon Department of Human Services and who has been involved in the negotiations. “Why pay interest on construction bonds when we won’t need those hospital beds immediately?”

Now, legislative leaders envisage a facility in Junction City that would start out as a secure psychiatric hospital but would transition over time, as the need for secure hospital beds decreases, into a Department of Corrections facility, specializing in handling prisoners with mental health and addiction issues.

For Lane County’s economy, any new state facility at the Junction City site would be a boon, bringing hundreds of well-paying jobs. Local lawmakers are pushing for the project, but have met plenty of resistance, both on financial and mental health treatment grounds.

Hospital-based vs. community-based care

Part of the debate about the Junction City psychiatric facility has long centered on the question of the actual need in Oregon for hospital-setting secure psychiatric beds.

Those beds involve around-the-clock treatment and supervision, and they cost the state more than $200,000 a year per patient. By the end of 2011, the state’s largest psychiatric hospital, the new OSH Salem, is expected to have 620 operational beds, and the proposed Junction City facility is scheduled for 174 beds when completed.

Although the most recent forecast by the Department of Human Services concluded there was still a need for both facilities, mental health advocates argue that many individuals with mental illness would be better served and have a better quality of life in less restrictive community settings.

“That (DHS) forecast is based on our current patterns of locking down mentally ill people,” said Chris Bouneff, executive director of the National Alliance on Mental Illness (NAMI) Oregon.

“There is this supposition that there is a large group of people that can’t ever be let out, under any circumstances, and that’s not accurate. We need to develop a clear picture of who’s in (OSH Salem) and whether they could be better treated elsewhere.”

The move away from “big-box” psychiatric facilities to community-based mental health care is also one that the federal government is pushing for, particularly during the Obama administration.

The U.S. Department of Justice is investigating how Oregon treats individuals with mental illness. Records provided to The Register-Guard’s public records requests show that federal justice officials in April requested extensive state data relating to that type of treatment.

Federal Justice representatives met with Kitzhaber earlier this month, Christine Miles, a spokeswoman for the governor, confirmed Friday. The content of those discussions is a “private matter,” she said.

The federal Department of Justice does not comment on ongoing investigations.

The Legislature’s response

Two bills moving forward in the Legislature would attempt to tackle the problem of how to better utilize the beds in secure psychiatric facilities and potentially pave the way forward to smaller community-based facilities.

Both bills make changes to the authority of the Psychiatric Security Review Board, which has jurisdiction over individuals who plead “guilty except for insanity” to crimes and enter mental health treatment facilities.

House Bill 3100 would require a state-certified psychologist or psychiatrist to evaluate individuals before they can enter a guilty plea except for insanity.

Senate Bill 420 would place individuals in secure psychiatric hospitals under the jurisdiction of the Oregon Health Authority, which actually runs the state hospital.

Mental health advocates argue that that arrangement makes more sense and will allow people who have committed nonviolent crimes and who don’t need hospital-level care to move to community-based care more quickly. Critics worry that it could pose a public safety risk by letting unstable individuals back out into society.

Rep. Tina Kotek, a Portland Democrat who has worked on both bills, said she believes the proposals will allow psychiatric hospitals to be used more efficiently.

“It’s all about managing hospital populations better, and putting the right people in the right settings,” she said.

Though both bills — particularly SB 420 — are expected to be hotly debated once they hit the House and Senate floors, they passed out of the Legislature’s chief budget-crafting committee Friday, usually a sign that legislative leaders are supportive.

What effect the two bills could have on the need for the hospital beds at a possible Junction City facility remains to be seen.

While NAMI’s Bouneff and other advocacy groups say the bills could lead to a mental illness treatment system in Oregon that relies on only one secure hospital in OSH Salem, legislators are more cautious.

Rep. Val Hoyle, a Eugene Democrat, said that the state will still need a secure psychiatric facility in Junction City over the next few years as it starts to focus on expanding community-based care.

“If we do approve the two PSRB-related bills, it won’t be a case of us snapping our fingers and instantly changing the population with mental illness,” she said. “It will take time.”

Others agree.

“The effects (of the possible PSRB changes) are not going to be dramatic, but they will lower our bed need a bit,” Oregon DHS director Goldberg said. “It will take us a decade to significantly reduce our population to a point where we wouldn’t need a second hospital in Junction City.”

Lawmakers also will need to find money to build more community-based facilities, Goldberg said, as well find suitable sites for such facilities, often a challenge due to stigmas surrounding mental illness.

Both of those will take time, Goldberg said.

However, unlike earlier this session, proponents of the hospital now do see a point where a Junction City psychiatric hospital might not be needed in the long run.

When that occurs, legislators could transform the facility into a specialized prison that would handle criminals with mental illnesses but who haven’t pled guilty except for insanity, a growing population in the state’s prisons, experts say.

“It would be a correctional institution that could provide a higher level of care for individuals who don’t fit in with the general population,” Hoyle said.

“I think the (Junction City facility) will get built,” said Sen. Alan Bates, a Medford Democrat. “What it looks like in the future, however, is still up in the air.”

Bates said lawmakers don’t yet know if their plan for a slower transition to community-based mental health care, which involves moving forward with a Junction City facility, will be acceptable to federal Justice officials and prompt the federal government to end its investigation.

“It’s really a hard question to get at,” he said. “We don’t know. It’s all happening behind closed doors, and we’ve had no indication one way or another. We just know they want more community-based mental health care facilities.”

From OPB.org, May 27th 2011

LISTEN – The Doors of the Oregon State Hospital

The patients in the state’s mental hospital have landed there for a variety of reasons. A little more than half are there because they were found guilty of a crime “except for insanity.” That puts them under the jurisdiction of the Psychiatric Security Review Board, or PSRB.

Three bills in the Oregon State Legislature — HB 3100, HB 2701 and SB 420 — would change who goes into the Oregon State Hospital and the process by which those who do get in could ultimately get out. Bob Joondeph with Disability Rights Oregon says looking at the “front and back doors” of the hospital is long overdue. The primary tension is between public safety — which the PSRB is primarily changed with — and the needs of the patients themselves.

Two months ago, we had an hour-long conversation with the new Superintendent at the State Hospital, Greg Roberts, about the institution’s past and the broad internal changes he’s overseeing. This conversation will focus on the specific bills the legislature is considering and their implications.

Have you had experience dealing with the Psychiatric Security Review Board? Have you worked with patients who were placed at the Oregon State Hospital because they pleaded guilty except for insanity? How should the state strike the balance between treatment and public safety?

GUESTS:

Matthew Kirby: Patient at the Oregon State Hospital, under the jurisdiction of the PSRB
Bob Joondeph: Executive director of Disability Rights Oregon
Carole: Mom of a son who has been in and out of the Oregon State Hospital
Joseph Bloom: Former head of Psychiatry at OHSU, expert on the insanity defense and the PSRB

From The Oregonian, May 2, 2011

Lawmakers must carefully balance patient care, taxpayer cost and public safety

It’s clear that some patients spend too long in the Oregon State Hospital, where a year of care and confinement costs $200,000. It is less clear why that’s so, and what the Legislature should do about it.

There’s a rush on in Salem to lay blame for the lengthy hospital stays and extraordinary costs onto the Psychiatric Security Review Board, which decides when a forensics patient — someone who has pleaded guilty except for insanity to a crime — is ready for release from the hospital to less-restrictive community facilities.

It’s true that the PSRB has a long history of erring on the side of confinement. That’s what Oregonians apparently wanted when they established the pioneering PSRB in 1978, and wrote into law that the board’s primary responsibility was to protect public safety. It’s done that. Over the past three decades fewer than 2 percent of conditionally released patients committed new crimes. That’s a remarkable figure, but it’s come at a high cost to patients and taxpayers.

It’s also contributed to a damaging kink in Oregon’s mental health system, with patients stacking up at the overcrowded and expensive hospital, while little or no care is available to many other persons with mental illness. The crowded conditions and lengthy stays are part of an ongoing federal civil rights investigation of the hospital.

Given all this, it’s appropriate that lawmakers are debating legislation that would reduce the number of patients sent to the hospital, and, in theory at least, shorten the length of stay for some of those who are hospitalized.

We’re strongly in favor of Senate Bill 3100, which would reduce the number of patients coming in the hospital’s front door. It would require an evaluation by a state-certified psychologist or psychiatrist before a person could successfully plead guilty except for insanity. It would also exclude from the hospital persons who plead guilty except for insanity to misdemeanor crimes.

Senate Bill 420 is a more complex, difficult question. That bill proposes to take the responsibility for deciding when a hospital patient is ready for release away from the PSRB and give it to the Oregon Health Authority. Supporters, including patients and advocates for those with mental illness, strongly support the bill, arguing that decisions about the fitness of patients for release belong with physicians and the health authority.

That makes sense. But SB420 may have less impact than many people expect. In recent years, as scrutiny on the state hospital has grown, the PSRB has been more accommodating about moving people out of the hospital. In fact, it’s hard to find many recent cases in which state hospital physicians have recommended a patient’s release, and a community facility were ready and willing to accept that patient, and yet the PSRB denied the release.

Shifting responsibility for release decisions from the PSRB to the health authority will not magically open up more community beds for patients prepared for release from the hospital. We’re not opposed to the shift, but if the Legislature makes this change, it should be done with clear eyes. In the end, the only way to move people more quickly from the state hospital is to ensure that they have a place to go, one that provides an appropriate level of care and protects the public safety.

From the Salem Statesman Journal, April 24, 2011

Discharges of patients could be swifter if determined by hospital instead of board

A bill that could speed up sluggish release practices at the Oregon State Hospital is moving forward in the Legislature, boosting the hopes of patients at the Salem psychiatric facility.

Senate Bill 420 proposes to give the hospital rather than the state Psychiatric Security Review Board authority to say when a patient is ready for release from the hospital’s forensic program.

READ – Oregon Senate Bill 420, Calculates maximum period of jurisdiction of Psychiatric Security Review Board over person found guilty except for insanity of offense based on sentence person would have received had person been convicted of crime.

Patients and mental-health advocates say the legislation is needed because the PSRB takes a strict approach to releasing patients, resulting in excessively long and costly stints of hospital care.

Faced with an ongoing federal investigation of the state hospital and a $3.5 billion budget shortfall in 2011-13, Oregon can’t afford to continue warehousing patients, mental-health advocates say.

“In this fiscal environment, we can’t continue to shovel money into things that really don’t make sense,” said Robert Joondeph, executive director of Disability Rights Oregon.

The forensic program houses more than 400 patients, and it costs taxpayers about $200,000 a year for each. Community-based housing and mental health supports are much less expensive.

All too often, though, patients are kept inside the hospital after therapists have deemed them ready to leave, according to patient activists and mental health advocates.

The PSRB has become a frequent target of criticism and complaints.

“There are a lot of people locked up in the hospital that do not need to be here, and the reason they are here is due to the board and its stringent and overly cautious and conservative practices,” patient Matthew Kirby said last week. “Right now, the hospital feels like a prison. It feels like we are being warehoused.”

Kirby, who testified in favor of SB 420 at a legislative hearing on Monday, described the legislation as a much-needed reform.

“420 addresses the hospital’s back-door issues, so that people do not languish in an institution far longer than they need to,” he told the Statesman Journal. “In short, it places the determination of treatment needs in the hands of the doctors that work with us on a daily basis, as opposed to some alien body that listens to us for 20 minutes and doesn’t have to take our treatment needs into consideration.”

Senate Bill 420 was negotiated by a team that included the Chief Justice of the Oregon Supreme Court, representatives of the district attorneys association, the governor’s office and legislators.

The bill now awaits action by the Legislature’s budget-writing committee after clearing the Senate Judiciary Committee last week.

“What this bill is supposed to do is give us more efficiency in our mental health facilities,” said Sen. Floyd Prozanski, D-Eugene, chairman of the Senate Judiciary Committee. “This is also ensuring that the limited bed space we have is being used most appropriately for those in need of those services.”

Currently, the state hospital houses more than 400 forensic patients who were committed to OSH because they were judged guilty of crimes but insane at the time. Instead of doing time in state prisons or county jails, they were sent to the hospital for mental health treatment.

Under the current system, the PSRB controls patients’ discharge dates. The governor-appointed panel also monitors more than 300 former patients living in Oregon communities after being conditionally released from the state hospital.

Senate Bill 420 proposes to give the hospital the final say on when a patient is fit for release. The PSRB would continue to monitor the person after release.

The board also would retain its authority to order a person back to the state hospital for violations of release conditions, such as failing to take medication, drinking or drug use and skipping mental-health appointments. A person also can be returned to the hospital for stabilizing treatment if his or her mental-health condition deteriorates.

Since the PSRB was created in 1978 to provide added safeguards to the release process, fewer than two percent of conditionally released patients have committed new crimes.

Defenders of the board say that it has performed its primary mission, as set forth by state law, which is to protect public safety.

But mental health advocacy groups have persistently criticized the board’s strict stance on releasing patients.

“The feeling is that the PSRB has been very, very tight in terms of those decisions,” Joondeph said. “More to the point, the PSRB has not had any incentive to get people out of the hospital that don’t need to be there. It’s not their job to do that, so we spend a lot of money to keep certain people in there, even though the doctors, nurses and psychologists who evaluate them have decided they don’t need to be at that level of service. We essentially ask the state hospital to be a jail or a warehouse or a holding place for certain people, and we’re paying top dollar to keep them there.”

Shifting release authority to the hospital makes sense for economic, therapeutic and management reasons, Joondeph said.

“It’s one of a number of ideas kicked around about how to give the hospital more control over its beds,” he said. “We have been supportive of the idea as a way to do that, in order to make sure the right people are in the right place at the right time.”

The proposed legislation comes as federal investigators are scrutinizing length of patient stays as part of an ongoing civil rights investigation of the psychiatric facility.

The U.S. Department of Justice Civil Rights Division began investigating patient care and hospital conditions in June 2006. The investigation later expanded to include length of patient stays and community-based services and supports for people coming out of the hospital, as well as those at risk of being institutionalized.

Federal lawyers recently spent three days in Salem, April 6-8, conducting a series of interviews with state mental health administrators.

The federal Justice Department has not made any public statement about when the investigation might end or whether a lawsuit will be filed against the state for alleged violations of patients rights.