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This story first ran in the Oct. 20, 1981, issue of Willamette Week under the headline “The Empty Asylum.”
Sometimes they’re hard to miss. Like the young man with stringy black hair and long, yellowing toenails pacing barefoot up and down Northwest 23rd Avenue proclaiming he’s the 1,029-year-old son of Jesus Christ.
Sometimes you have to search them out. Like the 38-year-old woman who recently gave birth in the bathtub to her fourth son, and then immediately threw the baby on the couch and disappeared for 24 hours. During her recent involuntary commitment hearing, she burst into a tirade against the psychiatrist questioning her, calling him a “nut, a fraudulator, and the biggest liar I’ve ever seen in the state of Seattle.”
But mostly you never notice them at all. Bill Murphy watches TV most of the day in the lobby of the Hamilton Hotel. Recently he almost set fire to his room. Martha Dickinson usually keeps to herself in a boarding house in Southeast Portland. Her manager keeps all but $25 of her monthly welfare check and, in return, furnishes a 10-by-10 basement apartment and three meals a day that seldom include meat, and almost always feature white bread or potatoes.
These are only a few of the estimated 6,000 chronically mentally ill who live in Multnomah County. (Most of the names in this story have been changed at their holders’ request.) More than three-quarters of them suffer from two frequently misunderstood illnesses: schizophrenia and manic-depressive disorders. Almost all the 6,000 are single, under 35 and unemployed; very few will ever be “cured” of their ailment. Most have spent a substantial part of their adult lives in a state or private mental hospital.
The horrors of the nation’s mental hospitals have been exposed and popularized in such books as Ken Kesey’s One Flew Over the Cuckoo’s Nest: sadistic guards, the warehousing of patients, the punitive use of powerful drugs, electric-shock treatments and the all-too-frequent lobotomy. In the last quarter-century, the nation’s mental hospitals have become far more difficult to get into than to leave. Since 1955, the population of state and county hospitals has plummeted from 505,000 to less than 150.000. Most of this reduction resulted from the advent of neuroleptic drugs such as Thorazine, which have revolutionized psychiatry as much as, if not more than, Sigmund Freud’s “discovery” of the subconscious. State and local officials, eager to hold down expenses in an era of dwindling government resources, have pushed open the asylum gates even wider.
Such deinstitutionalization has been embraced by psychiatrists and politicians as an opportunity to treat the mentally ill more compassionately in their own communities. “Reliance on the cold mercy of custodial isolation will he supplanted by the open warmth of community concern and capability,” John F. Kennedy told the U.S. Congress when he introduced the Community Mental Health Centers Act of 1963.
That was the promise. But in practice, deinstitutionalization has often brought the patient to the community but left the mental health resources behind. Returning to the community has meant little more than a succession of single room occupancy hotels and dreary boarding and flop houses, punctuated by periodic returns to the hospital. In some respects, today’s is a crueler fate: Hospitals at least provide heat, meals, and the company of others rather than the prospect of starving or freezing to death in one of the nation’s burgeoning “mental health ghettoes.”
“We’ve gotten rid of the big snake pits in the hospitals and replaced them with a lot of little snake pits in the community,” says Dr. David Kinzie, professor of psychiatry and director of Psychiatric and Clinical Services at the University of Oregon Health Sciences Center. Dr. Ed Colbach, clinical director of the recently opened Northeast Mental Health Center—Portland’s only reward from the now defunct 1963 Act—says simply, “Deinstitutionalization has become a national scandal.”
And a local one, as well.
Downtown Portland’s Burnside neighborhood, long the haven of transients, alcoholics, and impoverished pensioners, now houses the largest concentration of chronically mentally ill citizens in the state. “I’ve seen a lot more in the last two years. At least a couple dozen sleep on the floor at the drop-in center every night because they don’t have anywhere else to go,” says Bob Skall, crisis coordinator for Burnside Projects Inc.
Dr. Doug Johnson estimates that, of the 250 inmates at Rocky Butte Jail, 10% have spent time in a mental hospital, Colbach observes. “In the late 19th century, Dorothea Dix led a movement to clear out the prisons and put the menially ill in hospitals. We’re doing a full circle.”
Throughout the city, an increasing number of chronically mentally ill are finding shelter in deteriorating hotels or boarding houses, many of which violate numerous fire and safety standards. Yet enforcement of those standards is sporadic and ineffectual. “Many times I think, ‘My God, we’re sending people out who are not that well to begin with to these filthy places,’” says a Dammasch social worker, who tries to find housing for discharged patients.
Multnomah County has only one group home for the chronically ill, with a capacity of 15—men only. It has no other halfway houses or apartments.
Nor does the county have a 24-hour crisis service to assist mentally ill clients in need of emergency shelter, food, or medical care. “Mental health is a 9-to-5 job here,” Colbach says grimly. The waiting list is several months long for those who want job training.
Case workers are so swamped with work they virtually never leave their offices during working hours; clients who skip their appointments can’t be followed. And most significantly, the county’s three outpatient clinics serve only the chronically menially ill, and only a third of those.
“To say the system has cracks in it presupposes we cover most things,” says Tom Higgins, the county’s Human Services director. “We don’t. We actually have huge gaping holes.” He adds, “Multnomah County may be progressive in other things, but when it comes to mental health, it’s reminiscent of the era when we took people and locked them up in the attic.”
The immediate cause is not a lack of compassion but of money. The result is inevitable: The state treats someone intensively at Dammasch for several weeks, then returns him or her to the community, where only a few receive any treatment at all. When a psychotic crisis recurs, the county will most likely be bypassed again and the person will return straight to Dammasch.
It’s a system commonly likened to a revolving door. Of the 1,600 people admitted to Dammasch from Multnomah County last year, 65% had previously been at the hospital, some of them more than a dozen times.
The stark reality of the county’s system is this: Of those county residents returning from Dammasch, two-thirds will never receive any county assistance between their release and their next hospitalization. And of those just entering Dammasch from Multnomah County, 85% are not using county services and therefore are not likely to ask the county to intervene between themselves and the state hospital.
The few chronically mentally ill the county serves with its $3.5 million yearly budget are probably those who least need the help. Social workers have 50 to 60 clients apiece at any given time, making it virtually impossible to go into the community to inspect living conditions, reschedule missed appointments, and ensure that medication is being taken. The county sees only those chronically menially ill sufficiently motivated to seek it—the same people who, studies show, are least likely to return to Dammasch anyway. “We’re not connecting with the most disturbed patients,” observes Monty Cobb, program development specialist for the county’s Mental Health Division. “In a way it’s completely backwards, but, given the resources, that’s the way the system works.”
Those missed connections can prove costly. Keeping a patient at Dammasch costs the state approximately $3,000 a month. Timely intervention by the county before a patient experiences an acute psychotic episode could save substantial hospitalization costs. “It’s simply absurd,” observes Jack Rowsky, for five years a psychiatric aide at Dammasch. “You discharge a person to the county, which is so overloaded, and time and time again people are so fragile they never make it to their appointments. And if you let a chronic fall apart simply because you don’t have anyone to see him, and if that person ends up spending another six months at Dammasch, it costs the state $18,000.” That’s enough for one full-time case worker.
In certain key respects, the system works against itself. Linda Kaesar, associate professor of nursing at the University of Oregon Health Sciences Center, says, “We have a structure where the state is responsible for acute care at the hospital, and the county is responsible for non-acute care in the community. When times get tough, like now, it becomes inevitable that people pass the buck back and forth.” It may save the state money to prevent hospitalization in Dammasch, but it may cost the county a substantial amount, and vice versa. A Dammasch social worker recalls a patient who’d been released after two years because Dammasch simply wanted to be rid of him. “I talked to him that day and asked if he was having hallucinations. He says he was seeing rats the size of people eating babies. Just sick! But they let him out. I called the county clinic to warn them and apologized. I called back a while later and heard he’d beaten up his brother and ended up in jail.”
The costs of inadequate service involve far more than money. Of those who return time and again to dingy hotel rooms or boarding houses, some will inevitably give up. Last spring, Gary Stoddard, due to be discharged from Dammasch, took a bus to Portland and later that morning leapt to his death from the Vista Bridge. The county’s downtown clinic sees 400 clients at any given time—or about one-fifteenth of the rural county population. But six have committed suicide in the last 18 months—three of them since June. No one keeps statistics on such fatalities in Multnomah County, but Dr. James Shore, of the University of Oregon Health Sciences Center, estimates that the suicide rate of the chronically mentally ill is 25 times that of the general population.
The prognosis for those who don’t take such drastic action isn’t much better. Dr. Jules Atlas, one of two half-time psychiatrists at the West Side Clinic, remarks, “From a strictly human point of view, there are some salvageable human beings out there. Some aren’t, I hate to admit. But we can’t even deal with the ones who are salvageable—and it scares the hell out of me.”
Keeping a client on medication is the single most important device for avoiding a return to Dammasch. “Of those who have a schizophrenic break, and who stop taking their medication, 80% will have another one within two years,” observes Kinzie. “Of those continuing their medication, only 20% will have one.”
But the drugs that once promised so much also have their perils. Neuroleptics cause debilitating side effects, including constipation, muscle tremors, “dry mouth,” and drowsiness. The most serious of them is a disease known as “tardive dyskinesia,” which causes muscle stiffness and involuntary contortions of the face and tongue. Not only is the syndrome painful, but it provokes unpleasant reactions in other people.
The unpleasant side effects lead many to stop the medication; others do so as a matter of principle. They do not like being coerced to take drugs. Since the drugs stay in the blood for up to six months, discontinuing them may have the immediate effect of making the person feel better because the side effects subside. But the relief is often illusory. Charles IreIan says his son, a chronic schizophrenic who has been to Dammasch a dozen times, has repeatedly been through the cycle. “After a couple of months out of Dammasch, he usually stops taking his medication, and within 6 to 8 months he’s usually back.” Irelan says of his son.
The drugs don’t “cure” the disease. “They may stop you from yelling and screaming on the street corner, or hallucinating,” observes Beth Taylor, director of the county’s West Side Clinic. “But they don’t mean you can interact normally with people. They don’t give you average sleeping patterns. They don’t give you a work ethic or a healthy living environment.”
Since the county can’t force clients to take medicine, it tries to encourage an atmosphere in which they decide they need to take it. But it’s here that the county’s mental health system has its worst failure.
Consider what the county isn’t doing for Bruce Kent.
Kent lives in the Biltmore Motel on Northwest 6th Avenue. For $27.50 a week—$120 a month—payable in advance, he rents a 12-by-15-foot third-floor cubicle that contains a sagging bed, two small dressers, and a water-stained corner sink. The lock on his door doesn’t work, nor does his cold water. Before he moved in, the room had not been cleaned; the carpet is peppered with cigarette ashes, and the previous tenant has left behind a half-dozen bottles, most of them filled with cigarette butts. Protruding from one wall are about a dozen rusty nails; a bedspread is draped over the window. The bedspread came with the room; a blanket didn’t. The bathroom lies down the hall, the shower is encrusted with rust.
“I walked in here last night for the first time and laid down on my bed. I didn’t even see the room. I saw the bugs, in my head. But I was happy. I had $5 in my pocket. I have peace and quiet when I have money. When I ‘m broke, that’s when I hear the voices.” He talks clearly, carefully.
Kent is 27; he began going to Dammasch when he was 19 and has been back about half a dozen times. Doctors tell him he is a paranoid schizophrenic. In nine years of on-again-off-again hospitalization, he says he has tried 13 types of medication. Exacerbating his illness has been his past use of marijuana and speed.
He receives about $266 a month in Social Security disability. His problem is not so much affordable housing as a place where he can exorcise the voices, which his recent stay at Dammasch didn’t stop. “I was kicked out of the Rich Hotel. I was threatening people who weren’t there, seeing them in my mind and getting angry that they weren’t there. I was at the Campbell Hotel for a while, until the visions got out of hand. I was at the Athens for a week, but I was seeing police in the hotel. People were spying on me.”
Some of the voices scare him. “Someone hit me two weeks ago. Something shot right up to my brain. I heard this voice say, ‘Kill!’ I froze. I didn’t move for two minutes. I’m a peaceable man.”
The Biltmore has no cooking facilities. Kent eats at one of the missions or, if he feels extravagant, will buy a burger, fries and shake at the nearby Burger King. He says he’s taking his medication and that the voices still remain.
About once a week, he sees someone briefly at the county, though he’s not exactly sure why he keeps going back. No one from the county has ever visited him where he lives. He’d like to work, preferably at a job hauling freight, where he could ride in the passenger seat and help empty a truck. He doesn’t know how he’d get such a job.
He’s not sure how long he’ll stay at the Biltmore. “I’m thinking about leaving. I don’t know anyone really well now; I’m starting to feel the effects of losing friends.” He may even return to Dammasch. “I’m partial to Dammasch. Part of my life is in there and it draws me back sometimes.”
Thirty years ago, Kent and others like him probably would have stayed at the state’s mental hospital; four out of five patients admitted then never left. But today, neuroleptic drugs make it possible to release half of Dammasch’s patients within two weeks of admission. For better or worse, Kent will spend most of his time in the Burnside community. Chances are slim he’ll find a job. If he stops going to the clinic, no one will track him down. He probably could stop taking his drugs without anyone’s noticing.
If the manager of the Biltmore throws him out for arguing with his voices, chances are he’ll find another hotel, or maybe sleep at the Everett Drop-In Center. And more likely than not, he’ll soon return to Dammasch, where they’ll give him more drugs and send him back to Burnside, where the cycle will begin again as his illness continues to worsen.
For the county resident leaving Dammasch, few things are as important as finding an affordable place to live. Yet even Betty Brunette, the county’s mental health administrator, observes that the housing possibilities for mentally ill residents are “grossly inadequate.” John Parker, director of the Phoenix Center in Southeast Portland, goes further. “The level of housing available for the mentally ill in this community is appalling,” he says. “One of the principal reasons for rehospitalization is bad housing; even if you provide other services, where you live often precipitates crises.”
Kinzie agrees. “When you’re isolated around a lot of unsympathetic people, your paranoia—or just plain fear—is reinforced,” he says. “The system really needs something halfway between the hospitals and the flophouses.”
But it doesn’t have it. Multnomah County has about half the state’s chronically mentally ill, yet only one supervised group home: the Rita Owens home in Northwest Portland. Only males aged 25 to 44 are eligible. The county operates no halfway houses, or short-term crisis beds. Nor does it have formal arrangements with apartment landlords to accept referrals, though Phoenix Center recently got a $66,000 grant from the city to develop about two dozen units in a Southeast Portland Housing and Urban Development Project.
In stark comparison, Clackamas County has 41 group home slots for both men and women, and contracts with about 20 landlords. A nonprofit group known as Homestreet is establishing several group homes in Washington County.
One reason Portland lacks such housing is the stiff requirements the city imposes for residential care facilities. Ann Campbell, of the Task Force for the Mentally and Emotionally Disabled, a parents’ advocacy group for the mentally ill, says she has worked extensively, though in vain, to start another home. “The most suitable places already are taken.” she says. “Then you have to do a lot of remodeling, and get permission of all the neighbors within 150 feet.” The city also requires trained, supervisory personnel be on duty 24 hours a day, seven days a week.
The lack of group homes forces the mentally ill to rely on the private marketplace, where the adage of getting what you pay for operates. The county estimates that 40% of its chronically mentally ill outpatients receive either $188 a month welfare or about $250 in supplemental Social Security. About 15% report no income at all. Such resources strictly limit housing options, not to mention eating. David Bledsoe, a lawyer in the public defender’s office who has represented many mentally ill citizens at involuntary commitment proceedings, remarks, “It’s really depressing trying to help someone put together a viable life plan on $188 a month.”
For many people, the only option is a boarding house. Many operators will dole out a small amount of spending money after renters sign over their welfare or Social Security checks. If the boarder returns to Dammasch, or is kicked out of the house soon after the check is cashed, chances are no refund will be forthcoming.
Conditions in these boarding homes generally run from tolerable to terrible. Martha Wilkins lived in a Southeast Portland home run by a woman who drank so much she’d often pass out. At the time, Williams was trying to overcome a drinking problem, as well as her mental illness. “Another place, I got crabs the first day I got there. And I got lice all over my hair,” she recalls.
Tom Johnson lived in another Southeast Portland home, which he calls a “breeding ground for insanity.” He says the back porch was filled with rancid food, and rather than eat there, he stole from stores. “I think the whole experience led me to the hospital,” he says, adding that at one point he almost tried to kill his landlady’s husband. “I was hallucinating vigorously and I saw his face turn pale white. I thought he was white evil. So I took a fishing knife and tied it to the end of a baseball bat. But I went upstairs to think it over and fell asleep.”
No one in the city knows how many boarding homes operate or how many comply with city regulations, especially those prohibiting more than five people in each house or bedrooms in the basement or on the third floor.
“Violations of the code are pretty frequent,” says Chief Fire Inspector Capt. Lynn Davis. But sanctions are almost nonexistent. “The first time is considered ignorance,” Davis explains. " If the violation recurs, we could fine them $50.” But inspections are seldom made, and for every illegal tenant, an operator can reap about $200 a month—a hefty incentive to continue breaking the law until the inspector returns.
A small step up in price range are the single room occupancy hotels scattered through downtown and Northwest Portland. Robert Lowry pays $154 for a 15-by-15-foot room with a private bath at the Campbell Motel on Northwest 23rd Avenue. Within a four-block area around the Campbell are several other residences, including the 40-room Westport Villa, which caters to released mental patients. “I call this the Northwest mental hospital, and the Winchell’s across the street is our canteen,” Lowry jokes. Since there’s no kitchen in the building, Lowry has the choice of paying $135 a month for food or eating out. But with his $188 welfare check, that leaves about $25 a month for cigarettes and $74 in food stamps. “I’ve got 10 jars of peanut butter and five loaves of bread,” he says, pointing to his closet.
Often as important to a person’s sense of well-being as a decent apartment is some type of employment. Only about 5% of the county’s chronically mentally ill hold full-time employment. The county has no job training program for its clients, though it can help place people through Goodwill Industries or in the stale’s Vocational Rehabilitation program, though the waiting list for the latter is several months long. Absent are options for sharing full-time jobs or the sheltered workshop projects such as Peter Freedman has with his Open Gate program in Washington County. “With medication, people can get out of the hospitals,” Freedman says. “But if they get into room and boards, they get lonely, and they often stop taking their medication—so they’re right back in the hospital. Our idea is that each person should lead as normal a life as possible, and that means working.” Freedman has raised some private foundation money to establish a workshop, and he hopes to subcontract with some local businesses, such as Tektronix. People will be able to work part-time, since many people can’t deal with a full-time job immediately. “At some point in a person’s illness, I think maybe 90% could benefit from this program,” he says.
Chronically mentally ill people also have a great deal of time on their hands—time often used to reinforce feelings of loneliness and isolation. Yet only a few programs are available in Multnomah County for such people to socialize and learn basic living skills. The Phoenix program in Southeast Portland is one such, as is Club 53 in Northwest Portland. Phoenix’s contract calls for serving 45 people, though director Parker estimates that nearly 800 of the 1,500 chronically mentally ill in Southeast Portland could benefit from it. “We’re serving about one-twentieth of the need,” he says.
The biggest obstacle to improving the county’s mental health system is money. Next month, the Legislature’s Emergency Board will consider a proposal by Multnomah County to appropriate $900,000 in return for a pledge that the money will be spent to reduce the need for Dammasch beds by 92—or roughly 40%t of the county’s total. It is an ambitious program, and given the county’s record, it has made many people understandably nervous.
Campbell advocates establishing programs before attempting to close wards. “The biggest need is housing; it will probably take a year to start one group home,” she says. “We have so little in place in the county this is just frightening. Because once you close those wards, they’re gone for good.” She is also afraid that the clients who are left at Dammasch are the ones most difficult to treat.
Colbach agrees: “We’ve been deinstitutionalizing in Oregon for the last 15 years. My assumption is we’re down to such hardcore cases it may end up costing us even more dollars to keep them in the community.”
The county says its research shows that a substantial number of days at Dammasch could be saved if more extensive community services were available in Multnomah County. And mental health director Brunette points out that since Dammasch is running substantially under capacity now, the county has flexibility in exactly how and when it meets the 92-bed target. With impending federal cutbacks in mental health, this might be the county’s best opportunity to secure additional resources.
Whatever the outcome of the debate, it’s clear that continuation of current service levels will not alter Multnomah County’s relatively bleak performance. Noting that Washington and Clackamas counties offer far more extensive services to their chronic mentally ill population, Kaesar, who is a member of a recent Governor’s Task Force on Mental Health, notes, “Multnomah County is one of the worst places in Oregon to be mentally ill.” She adds, “The mentally ill here are the most neglected group of our disadvantaged [citizens]—second-class citizens among second-class citizens.”
After working as an investigative reporter at WW, Phil Keisling went on to serve two terms as Oregon secretary of state. He is now the chair of the National Vote at Home Institute.