Illustration by Ilan Schraer

EYEBROWS WERE RAISED across political and social-services circles last week, when a City Club of Portland committee released the results of a year-long examination into how Multnomah County treats its mentally ill patients.

With a call to "blow up the system," the innocuously titled report, "Improving the Delivery of Mental Health Services in Multnomah County," issued a series of blistering accusations: muddy budgeting; opaque spending; slipshod communication between county agencies, and also with regional governments; and a failure to adequately assess whether Multnomah County's treatment programs actually, you know, work.

"Needy individuals fall through the cracks, sometimes receiving no care or care at inappropriate levels and locales," reads the report.

By stressing transparency and "measurables," the document—assembled after months of cooperation with County Chair Jeff Cogen's office—aims to impose clean, business-like standards on a mental health system (the largest in the state) that's anything but orderly. Budgets would clearly track which federal and state grants were funding which programs. And the county would consider giving up its fiefdom on mental health in favor of working more closely with other counties.

And, in a potential bright spot, the report also arrives at a time when more people might be paying attention: just before a storm of state and federal budget cuts, but right after a wave of high-profile police shootings.

That sounds promising. Until you ask advocates who have spent decades tackling the issue. Their take? "Blowing it up" isn't the answer.

"There's a problem with that," says Jason Renaud of the Mental Health Association of Portland. "Thousands and thousands of people rely on this system with their very lives. And these people don't react to change very well. They wind up in jail or in emergency rooms, and they cost even more."

For one, a businessperson's approach is usually a poor fit for something as subjective as mental illness. Do you measure money saved? Turnover in beds? Or a community's well being?

"Their jaws drop. They say, 'This is pure amateur witchcraft,'" says Renaud. "Because there really are substantive 'unmeasurables.' It's very difficult to know from an outside perspective whether something useful is being done or not."

Another question, if you buy into the City Club report's premise: Is there any political will to make it happen.

Note the swift and strong reaction from Cogen's office, coming off a bit defensive after all the time and energy its staffers invested in helping City Club produce the report.

David Austin, a Multnomah County spokesman, charitably called the thing an "attempt" to study the problem and said committee members drew mistaken conclusions. For one, he says, the county has already begun reaching out to the state and other regional governments. Officials also defended the county's budget process and how they measure patients' success.

"Maybe the committee didn't understand the information. Maybe it was a short timeframe," says Austin. "Like any public agency, we're always looking for things to improve. But certainly, we're just puzzled at their tone and some of their erroneous conclusions."

Not even Cogen's office would argue the system isn't troubled. Money for programs is hard to follow, most of it funneled to a small office in Salem from the federal government and then spread out to counties and nonprofit partners. And budget cuts on all levels of government have further shrunk a pool of cash that was never much to begin with.

Renaud reminds, with a measure of irony, that one of the City Club report's prime ideas—creating a regional system, in which data would be tracked and budgets would be clear—has already been attempted. It was called Cascadia Behavioral Healthcare, born last decade after years of study and thousands of dollars in consulting fees.

But county funding leaked away after only a few months. Cascadia eventually went broke, siphoning millions in loans from the county while it collapsed under the weight of poor accounting practices, and now it's just one of a handful of groups the county contracts with.

"You need a dictator, one person who's willing to be hated," but also take charge of the system, Renaud says. "The people who manage for the county are very good managers, but they don't have the political cover to be tyrants and they don't have the money to buy the services that people need."

And for all its bluster, advocates say, the City Club report had at least one surprisingly glaring blind spot: It doesn't address the Multnomah County jail, technically the county's largest provider of mental health services ["The Criminalization of Mental Illness," News, Jan 14, 2010]. Elizabeth Wakefield, a public defender who specializes in mental health cases, says the county has made strides when it comes to keeping the most impaired defendants from languishing in jail, removed from whatever care they'd been receiving, or, worse, being put back out on the streets.

"That system is slowly improving, and the lines of communication are working better," she says. "The treatment system knows what's going on and the legal system knows what's going on."

Wakefield says that while it's possible to "measure success" in mental health treatment, even when things are working, she says, "sometimes they do have police contacts or they pick up low-level charges."

"You can't measure success with this population the same way you measure success with other populations."