Oregon’s new mental health chief Steve Allen is used to harsh winters as a long-time resident of Wisconsin and Minnesota, but has yet to experience Oregon’s damp and dangerous cold.
At the start of winter, the mild-mannered Midwesterner said that he had already the heard the joke that newcomers show up in the Pacific Northwest with shovels only to get laughed at by locals who never bother with one, knowing the snow will be gone by the next day.
But then there are times like January 2017 when snow blanketed the streets of Portland for weeks. That winter, four people died outside of hypothermia, nearly all of whom were in the midst of a mental health crisis.
Allen is tasked with digging Oregon out of a mental health system that has come under fire for allowing those deaths to happen. Oregon Health Authority Director Pat Allen, no relation to Steve Allen, hired the longtime mental health executive and consultant as a reformer with broad authority and a strong mandate to fix one of Oregon’s most daunting problems.
For the past several years, Oregon has had the highest rate of people with mental illness in the country – one in four. It is also one of the worst at providing access to treatment and keeping people in care. The system has been so troubled that the U.S. Department of Justice has been demanding reform for more than a decade. The Oregon Health Authority’s director has been open about some of the mental health system’s persistent failures.
Local officials and advocates have been left to figure out how to save some of the state’s most vulnerable people and complain that there isn’t the cash, capacity or cooperation to make sure winter isn’t deadly for mentally ill or addicted people.
Allen acknowledges the stats and can list the symptoms: Oregon has the highest rate of substance abuse in the country, more people die of overdoses than car crashes, suicide is the second leading cause of death for young people.
And the state’s acute housing crisis exacerbates the problems.
Six months into the job, though, Allen has not laid out a grand plan that to remake Oregon’s broken mental health system from the ground up. He instead suggests that the most revolutionary route would be to work within the existing bureaucracy to make it better.
“We don’t have, in my view, the luxury of rebuilding a better system,” Allen said. “The change in Oregon is all about making the systems we have better.”
NEW ACCOUNTABILITY FOR REFORMER
Allen has done it all. Well, nearly. He’s been a psychotherapist for sex offenders, overseen the mental health system in Minnesota’s prisons and advised multiple states, including Oregon, on ways to keep people with mental illness out of the criminal justice system.
He worked with the Council for State Governments, a nonprofit headquartered in Kentucky that works with various levels of government to help formulate policy. Allen first visited Oregon through that consulting work.
Oregon was the 10th state he helped figure out how to keep people who were repeatedly in jail and prisons because of mental health issues from continuing to cycle through. Watchdogs in the state would argue that still happens.
Through that work, Allen helped get a bill passed into law that created a $10 million fund that the state will dole out to counties and tribes that propose their own local projects to keep people with mental illness out of jails.
While the work was serious, he enjoyed the vibe of the Northwest and the stark beauty of the mountains, forests and high desert.
The last of his children had just moved out of the house when he heard Pat Allen, the health agency director, say he was looking for someone to run the state’s behavioral health system.
Steve Allen tucked the idea away, until it came up a second time.
“There was all this energy around doing something different and I essentially fell in love with the state,” Allen said.
He applied and was hired. Now, for the first time, he will be on the line for the success or continued failure of a system he manages on a permanent basis.
Nearly a million people receive mental health services through the state’s Medicaid system on a $50 million budget. Officials, advocates and people who need services have waited for years for someone to make significant changes for the better.
Allen said he recognizes that he is under pressure to perform.
“The opportunity is right here, right now,” Allen said in an interview in the Oregon Health Authority’s Salem offices the week before Thanksgiving. “And we cannot fail. There’s too many people depending on us.”
‘START OUT LISTENING’
Recently, Allen spent few hours in Riverfront Park in Salem as part of his quest to acquaint himself with Oregon.
He wasn’t taking in the scenery, though, but surveying the landscape of his new job. There, he met with 15 people who receive mental health services or are advocates for people who do.
Allen has visited the Pendleton area, where specialists told him that they had ideas that work
, but state regulations prevented them from implementing them on a broader scale.
And he sat down in November with Portland Mayor Ted Wheeler from whom he heard about how the housing crisis is overlain on an inability to meet the needs of people facing mental health challenges.
“Just start out listening,” Allen said. “People respond if you’re not just coming in with your own ideas.”
The listening sessions have already started to spark ideas. Allen wants to start reevaluating policies created by the Oregon Health Authority and make recommendations to the Oregon Legislature about how to enable people on the ground in places like Pendleton or the coast to bring their ideas to scale if they work.
These conversations are also an education for Allen.
The wrinkle posed by housing prices – which have steadily forced more people with severe, persistent mental health issues like schizophrenia to the street, especially if they are unable to work – is new to Allen.
While there are homeless people throughout the country, he has never had to contend with the magnitude of a 4,000-person homeless population before.
In the last year, more Portland residents and policy makers have started to realize that the homelessness crisis is directly connected to shortages of mental health service and growth in the population of people suffering major episodes of mental illness.
Wheeler is an example of a person who has gained new insight. As Multnomah County chair in 2007, he worked to preserve a crashed mental health system when the county’s main service provider went bankrupt. At the time, nonprofit Cascadia Behavioral Services was the sole organization tasked with serving people with little or no insurance. When it hit financial straits, the service stopped abruptly and Wheeler and state officials had to figure out how to keep enough workers on the ground to help the thousands of people with mental illness served through the county.
But once the system stabilized and out of the chair’s seat, he treated it as a fait accompli and rarely mentioned it after that, even when he became mayor and became partially responsible for trying to tackle a growing homeless population. Then, at a meeting this November he declared it was his top priority for the rest of his tenure in office.
The unusual aspect of that announcement is that Wheeler has no role in creating, providing or delivering mental health services as mayor of Portland. That role belongs to Multnomah County, which is delegated by the state to do so.
“I’m trying to be a helpful but pushy partner — a helpful but highly motivated partner — to help those in a position of those in authority, particular those who can fund the services in the state to come to the table to treat this as a true emergency,” Wheeler said in an interview about his meeting with Allen.
He felt Allen listened intently and understood Wheeler’s frustration with how psychiatric and medical hospitals deal only with crises, then dump people back to the street because of a lack of transitional or affordable housing. Those people then end up back in the hospital with a more severe issue or end up dead or inflicting violence because of the underlying mental health issue, he said.
“It just makes it harder for us to get people off the streets,” Wheeler said. “While housing is certainly central to the housing crisis, it’s not the totality of the housing crisis.”
Allen sees housing as his concern, too. He visited Portland’s premier mental health crisis treatment clinic, Unity Center, last month and heard about the dilemma of a patient who faced several obstacles to housing – she had severe mental illness and is transgender and low-income, all of which make obtaining a safe place to sleep difficult.
So Allen called together mid-level managers from the state hospital, Unity, counties and other parts of the system to start an ongoing conversation about how to make sure people like this woman do not end up back on the street, suffering, after receiving mental health care intended to heal them.
“We’re going to figure out how to get to a placement some way, somehow,” Allen said.
Unfortunately, he runs into the same problem that Unity staff said they did – even with the best minds in the room, there is just not enough housing and treatment capacity for everyone who needs it.
And homelessness is not the only challenge the Portland
– area faces in making its mental health system function for all who need it.
Multnomah County Commissioner Sharon Meieran, a former ER doctor, has taken on the task of trying to sort out the county’s byzantine mental health system to make it more efficient, smoother and better able to serve the people she used to see traumatized in her emergency department.
She has sat on or watched task forces, committees and councils suggest changes for decades.
“But nothing has changed despite all that,” Meieran said.
She wants Allen to make big decisions: She has proposed cutting about 20 beds at the Oregon State Hospital to save the state about $11 million dollars to direct instead to community care. She wants to reinvest a portion of that money in caring for sick people locally, in environments that don’t resemble institutions.
While counties desperately need more money to help more people, Meieran said, the Oregon State Hospital must continue to operate because some very sick people will continue to need that intense a level of care.
At the same time, she has so far been unable to even get a basic information from her health department or state health leaders: Where does all the funding for Multnomah County’s system come from?
“We should not have a system that is so opaque that no one understands it or can describe it,” Meieran said.
The quandary is now Allen’s problem.
Advocates, officials and lawmakers are looking to him to propose broad reforms, tune up service delivery and kickstart new funding to make a system that slows the state’s suicide rate, delivers on the promise to invest in best practices and helps low-income people with mental health conditions stay in housing.
But first he must be able to answer simple questions about just how the system fits together on a federal, state and local level.
“We don’t even know where we would call at the Oregon Health Authority if we do have questions,” Meieran said. “And if we do call, we don’t get a response.”
BIG CHALLENGES TO TACKLE
Allen has so far named one concrete priority: staffing.
The state’s system relies on a vast army of on-the-ground workers who are most often underpaid and overworked. Most of the direct care for people with mental illness isn’t delivered by M.D.s, psychologists or psychiatrists but by social workers, mental health counselors and other lower-status workers. Turnover is high, resulting in confusion and breaks in care for patients.
Multnomah County quantified its turnover rate at 60% a year in a 2018 analysis.
Allen charged the newly formed Senate Committee on Mental Health with tackling this issue as one of its first orders of business.
The Oregon House also has a new committee dedicated to the issue, which joins a governor’s advisory council and several other groups that have formed around the idea that Oregon needs to change its approach.
Allen is optimistic about this moment of enthusiasm, but he is also wary of letting a committee report or a listening session become all that is produced in the next five years.
“I recognize this position has a lot of potential impact,” Allen said. “I don’t take that lightly. I claim that accountability.”
He insists that taking it slow is the right approach, so that he can work within the existing framework to make tweaks. He sees that it has had success in the past.
Sue Abderholden, executive director of Minnesota’s National Alliance on Mental Illness, said she met with Allen every month over the years that both served on a state advisory committee when he worked in Minnesota’s Department of Corrections. Throughout, she said, she got the impression that he took pains to understand how things worked at the local level.
“He would reach out and talk to people and would try to figure out a solution that wasn’t just from him but also reflected the community,” Abderholden said.
But those tweaks could be hard-won. First, there’s the budget he’s got to work with. Lawmakers control that, not him. He plans to urge the legislature to allot more money, which could be vital for other work he wants to accomplish. But he’ll face competition from other competing interests with a better track record of protecting or expanding their slice of the state budget pie.
The Oregon Health Authority has recently gotten in trouble with mental health advocates and families and guardians of people with severe mental illness after the agency hired a contractor and explicitly asked it to cut how long people stay in residential facilities. Some people ended up getting seriously hurt because they moved out before they were ready to do so.
The agency did that because it made an agreement with the U.S. Department of Justice to reduce how long people stay at the Oregon State Hospital and in locked residential facilities. But the state has said it won’t renew the company’s contract.
That tension extends to other core problems, such as that there’s not enough space in specialized facilities for people with mental illness and that the community services people get aren’t always appropriate for the level of help they need.
There are myriad programs intended to help people with mental illness, many of which the U.S. Department of Justice has been monitoring from afar. Oregon has shown improvement in some areas since the Oregon Performance Plan began in mid-2016, according to the latest report, but has shown little improvement in others.
At the same time, the state did make progress on other measures. It has far exceeded, for example, its goal for helping people via its mobile crisis units. The agency aimed to reach 3,700 people that way by June but in fact treated nearly 8,600 people by March.
Yet people haven’t been getting out of the state hospital as fast as the state and feds had hoped. About 46% of patients were discharged within 20 days of being deemed ready to be discharged, according to the latest numbers. The goal is 90%.
The Oregon Legislature acted on reporting by The Oregonian/OregonLive that showed hundreds of people charged with low-level crimes were being held for long periods in the state hospital because they couldn’t assist in their trial. The stays often exceeded the maximum time they would have spent in jail or prison, if convicted.
A bill to reduce those incidences, however, has unintentionally caused a backup of patients in ERs and other ill-fitting places.
The stakes are high, but so far, officials and advocates see reason to give Allen time to show he can make change.
“It’s way too early in his tenure to answer the question, ‘Can one person in one position make a huge difference?’” said Chris Bouneff, director of the Oregon chapter of the National Alliance on Mental Illness and Oregon’s leading mental health advocate.
ADVOCATES WANT CONTINUITY
Those intertwined crises of how and where people are treated are just the easy things, said long-time mental health services consumer and advocate Kevin Fitts.
He sits next to Allen in meetings of the governor’s advisory council and has been cheered so far with what he’s seen.
“I admire his CV and I appreciate his kindness and his reaching out and encouragement,” Fitts said. “His reputation is good.”
But Fitts, who has lived with schizophrenia for more than 30 years, using the state’s Medicaid mental health services for most of it, said that he remains cautious in his optimism.
Once the fires are put out, Fitts still sees a system with few options for people who need care. Expanding those options to fit more cases might be the true marker of success, he said.
At the very least, Fitts is ready for someone who will stay. Allen’s predecessor, Royce Bowlin, lasted just a few years before leaving in 2018, followed by an interim director who retired within a year – a pattern that has left the political environment around behavioral health unstable.
“I really want him to succeed because I want people who are getting services to succeed,” Fitts said.
— Molly Harbarger
firstname.lastname@example.org | 503-294-5923 | @MollyHarbarger
Subscribe to Oregonian/OregonLive newsletters and podcasts for the latest news and top stories.
— Fedor Zarkhin