"IN TERMS OF INSTITUTIONS that the state runs, there are more people with major mental illness in prison and jail in Oregon than there are in mental hospitals," says Bob Joondeph, executive director of Disability Rights Oregon, an advocacy group that works to protect the rights and safety of Oregonians with disabilities.
Here in Portland, many inmates spend time at the Multnomah County Detention Center (MCDC) on SW 3rd. The facility handles 40,000 inmates a year; 20 percent or 8,000 inmates have what's known as an "Axis I" mental health diagnosis like schizophrenia, major depression, or serious bipolar disorder, estimates Gayle Burrow, the county's corrections health director.
The jail spends half of its annual $600,000 drug budget on psychiatric medications for those inmates who will consent to taking them. For those who refuse, unlike a "real" psychiatric institution, jails can't force inmates to take their meds. Far from solving our state's mental health problems, almost everyone acknowledges that the current situation is probably making them worse.
"Jail is not a therapeutic environment," says Joel Greenberg, a lawyer who works with Disability Rights Oregon. "It's a scary place to be if you're in good mental shape, let alone if you're not."
I went on a tour of the MCDC and talked to mental health advocates to find out more.
"ASSAULTIVE, WALK ALONE."
"December 23, 1985, I got my first jail concussion right in that cell," says Captain Ron Bishop, the Multnomah County sheriff in charge of operations at MCDC, giving me a tour in December. "An inmate jumped me from the side and punched me in the head."
Hardly bitter, Bishop seems almost nostalgic describing the incident. We're in unit 4B on the fourth floor at the jail. It's where the 10 most psychologically unstable inmates are kept. Even though they're all locked in their cells, there's a crackle of menace in the air. One inmate is shirtless, looking out his cell window at us, shouting repeatedly, "What's he writing?" as I take notes. Another kneels in his cell with his arms outstretched like he's being crucified, talking to himself.
Each inmate has a notice on his cell, labeled with their names in black marker and in almost all cases the words, "Assaultive, two deputies, walk alone." It means that when the inmates are let out of their cells they must have two deputies with them at all times, and they are not to associate with other inmates because they are likely to assault them. As one of the two deputies on duty, Kevin Fuller, puts it, "This is a very stressful place to work." Bishop himself worked here for four months, five days a week. "And I finally said, 'I have to be moved,'" he says.
As we leave, the shouting inmate seems to have figured out that I'm a reporter. He yells, "Extra! Extra! Read all about it!"
Downstairs in the booking area, Sergeant Jesse Luna has been trying to communicate with a mentally ill inmate who was booked half an hour ago for allegedly stealing a car. A big man in the mold of Bishop and Fuller (I wonder if there's something about the job that makes them all so hulking), he also has an air of intelligence, compassion, and patience at odds with his size. Luna approaches an isolation cell and attempts to engage the inmate in conversation to stop him from further kicking and hitting the cell door.
"What's your name?" asks the inmate.
"I'm Sergeant Luna," he says.
"As in lunar eclipse?" asks the inmate.
"I'll be right back," Luna says.
"Fuck me, nigger!" shouts the inmate, hitting the door again.
Luna turns to me. "We like to get them through the process," he says, calmly. "If it takes me an hour, I've got an hour. We check the cells every 15 minutes, and I do have medical and psychiatric staff. The problem we have is no history on this guy. Is there contact information for a family member, maybe?"
Luna explains that though the inmate is hitting the cell door repeatedly, he can "work with" that level of self-harm. His medical staff has checked the inmate, he says, and he sees no blood. But if the inmate starts to hit his head against the wall then Luna may have to restrain him further.
Most mentally ill inmates end up at the detention center because they have acted out in a way that could be construed as criminal. A common charge, for example, is "interfering with public transportation," when someone causes concern on TriMet buses or the MAX. Once they've been booked into the system, all inmates at MCDC go through ongoing evaluation by nurses and mental health counselors, and treatment plans are discussed at twice-weekly meetings.
Sometimes, treatment plans can be pretty creative, says Maureen Raczko, a corrections counselor. "You find out what is important to the person," she says. "It might mean giving them a piece of paper and a crayon or books or just giving them two glasses of Kool-Aid instead of one. In one case, a deputy was helping an extremely schizophrenic person, who thought all the jail towels and uniforms were poisoned and soaked in gasoline. So the deputy just refolded all the towels and uniforms, and the inmate was eventually convinced it was linen from somewhere else. They finally got him to take a shower."
Another inmate was "really obsessed with getting an ID," says Steve Sutton, Raczko's manager. "So we provided him a generic copy of his own mug shot."
One of the biggest frustrations faced by the jail staff is that it's almost impossible to get an inmate admitted to the psychiatric wards at local hospitals.
"We're providing the best service that we can to a population that truly does not belong here in the jail," says Captain Linda Yankee, who shares responsibility for running the jail with Captain Bishop. "The response that we get from local hospitals is that 'there's nothing we can do that you can't do,' and that's simply an inaccuracy. They need medication, but we can't force medication here."
A BROKEN SYSTEM?
It's very difficult for psychiatric hospitals to deal with mentally ill inmates, says Robin Henderson, chair of the Oregon Psychiatric Inpatient Committee, which represents hospitals around the state.
"Some hospitals have what are called custody agreements, but most require a sheriff's deputy to stay with the inmate, and that causes significant staffing problems at the jail," she says.
As such, inmates often stay in jail when it doesn't seem safe for them to be there. Disability Rights Oregon filed a lawsuit against the jail along with the Oregon Law Center in November 2008 on behalf of Ken Yeo, a mentally ill inmate who was Tasered twice and cut in the head at MCDC after he lost touch with reality, also technically known as decompensating.
Yeo was originally booked in Washington County on May 27 of Memorial Day Weekend in 2007. He told jail staff that without medication he would go psychotic, and his family contacted sheriffs there to tell them about his needs. Nevertheless, Yeo wasn't evaluated or given medication, and was transported to MCDC on an outstanding warrant in a spit sock and restraint chair.
Yeo wasn't evaluated at MCDC, either, because of the holiday, and three days later staff found him covered with excrement, raving, and completely unresponsive to simple commands or questions. He was eventually Tasered in his cell after refusing to be handcuffed while it was cleaned, according to the suit.
This is the first lawsuit that lawyer Greenberg has filed in five years at Disability Rights Oregon. Normally he works cooperatively with jail staff to try to get better treatment for mentally ill inmates.
"But I think this particular case just encompassed so many things that we've been dealing with over and over, it just seemed like the only way to get them to focus on this stuff," he says.
Greenberg says he can't speak in depth about the lawsuit, but is happy to talk about the general problems his organization has encountered with jails that have led up to the filing of the suit.
"People with mental illness are frequently picked up for low-level crimes. Frequently, these folks are off their meds, and they're obnoxious and difficult to deal with. When they get to the jail, they undergo a cursory evaluation of their mental and medical health, but it's based on looking at the guy and asking some questions," Greenberg says.
"And the ones who are really out there, they tend not to evaluate them, if they're not cooperating or whatever," he continues. "And once the jail staff has decided they can't do this, the inmates don't tend to see a medical professional very quickly. And so these folks, if they've not fully decompensated when they arrive, they [do so] soon. Then they're Tasered and roughed up."
County staff can't discuss outstanding lawsuits, but almost everyone I spoke to for this story stressed that responsibility for the current problems does not necessarily lie with the jail.
"What we really need are for psychiatric services to be more available in the community, so we don't have what is essentially a criminalization of mental illness," says Sutton, MCDC mental health program manager.
As is the case for any agency providing care to seriously and persistently mentally ill people, Sutton says, "There are challenges to meeting their needs." Working within the "structure and limitations of a jail compounds those challenges," he adds, extending an invitation to anyone who is invested in the jail's patients' lives to pay him a visit.
"We have a transparent system," he says.
NO COMMUNITY CARE
The county spends $2.2 million each year on Project Respond, a 24/7, 35-person mobile outreach team that responds to calls about mental health crisis from the police and concerned community members. For example, a neighbor might call the police about a neighbor acting increasingly paranoid, and a team from Project Respond would be dispatched to look into it. The city also contributes $365,000 annually to Project Respond
Project Respond gets about 10,000 calls every year, but is frequently dispatched to see the same person "many, many times," says Greg Borders, clinical director of crisis services at Cascadia Behavioral Healthcare, which runs Project Respond.
The biggest problem, says Borders, is the lack of insurance coverage for the people he visits. That means he can't send them for counseling or treatment or even get drugs prescribed.
"That's our biggest frustration," he says. "Because we leave thinking, sure, we may have deescalated them for the moment, but what's going to happen next time there's a crisis? These people simply don't have access to ongoing mental health treatment.
Inevitably, many of the people Borders sees end up in jail when they could have gotten treatment earlier, if only they had health insurance.
THE BOTTOM LINE
Aside from the cruelty, the senseless business of waiting for mentally ill inmates to decompensate before we take responsibility for their mental health in Oregon's jail system is that it's cheaper to provide housing and treatment for them instead. But policy makers have tended to focus on funding the "Band-Aids" like Project Respond, rather than preventative care in the community that might alleviate pressure on jails, says Joondeph of Disability Rights Oregon.
Many have grown sick of a triage approach to this issue.
"It's basically flushing money down the toilet," says Jason Renaud, co-founder of the Mental Health Association of Portland, who is now running against City Commissioner Dan Saltzman for Portland City Council. "We could spend money far more effectively by providing community care and outpatient treatment earlier. What we want to do is be providing evidence-based, outcome-driven treatment, on demand. That means when there are 25 people in line at Hooper Detox wanting treatment, we give it to all of them, not just two or three. It means that someone doesn't have to commit a crime to get inpatient mental health treatment."
FIXING THE HOLE
The picture, though bleak, is not entirely hopeless. Following the settlement of its part in a lawsuit brought by the family of James Chasse, a man with schizophrenia who died in police custody in 2006, Multnomah County is moving forward with plans for a new Crisis Assessment and Treatment Center. It will be a 16-bed facility on East Burnside where the existing Hooper Detox Center is.
Chasse's death "focused the public's attention on the lives of people with mental illness who live here in the community, and who lack the services they need," says Multnomah County Chair Ted Wheeler.
The treatment center will cost $4 million to build—the Portland Development Commission has committed $2 million and $2 million is yet to be procured. Wheeler hopes the $3 million a year operating costs will be funded by equal contributions from the county, city, and state. Wheeler says he's "very encouraged" by conversations at the state level and with Mayor Sam Adams about funding the center when it opens in late 2011 or early 2012.
People in mental health crisis will stay on average four to 16 days at the center, says Dave Austin, with Multnomah County Department of Human Services.
"The idea is to let the person calm down to the point where the crisis is over, but you don't just want to kick the person out on the street," he says. "We want to make sure that they get access to services."
Meanwhile, Cascadia Behavioral Healthcare has just procured a $30,000 grant from the Bazelon Center for Mental Health Law in Washington, DC, to look into scenarios where mentally ill people come into contact with police.
"It's a three-year project doing root-cause analysis," says Ashleigh Flynn, communications director at Cascadia. "We'll take case scenarios of when our clients and those with mental illness end up being first contacted by police, and try to determine in those scenarios where the system went wrong and what could have been done to eliminate the police contact."
The program began in the fall, and has also secured some money from the Soros Foundation. Perhaps unsurprisingly, it's still looking for more local support.