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High bar for hospitalizing mentally ill Portlanders without consent leaves those in great need on the street
Updated: Nov. 30, 2023, 2:03 p.m.|Published: Nov. 26, 2023, 6:00 a.m.

L.B., who is 60 and unhoused, is unlikely to make it through the winter.

She can often be found sleeping under a blanket in an Old Town doorway,
not understanding the very real threats of frostbite and hypothermia, even
as temperatures drop.

Diagnosed with schizophrenia, L.B. often experiences paranoia and
delusions that frighten her and make her aggressive toward the outside
world. She does not use drugs or alcohol. But she fixates on passers-by, particularly men who she warns are child molesters, abusers and
kidnappers.

Her physical deterioration most worries employees at Blanchet House, an
Old Town nonprofit that feeds and clothes unhoused people. Already frail,
L.B. has lost weight and doesn't always eat, even though Blanchet House
offers free meals. She is often soaked in her own urine and feces and has
been physically assaulted on multiple occasions.

Scott Kerman, Blanchet House's director, thought the saving grace for L.B. would be civil commitment, a legal step that forces a person in grave
danger to undergo mental health care. A person can be forced into care if
they pose harm to themselves or others or are unable to provide for basic personal needs. L.B. is a perfect example, Kerman and her other advocates
say.

But five times over the past year, Multnomah County's state-certified
civil commitment investigators, all with master's degrees in behavioral
health, said she did not meet the criteria.

Kerman was floored.

L.B.'s story highlights aspects of Oregon's mental health system that can endanger lives, particularly local officials' interpretations of the
state's civil commitment law.

Despite help from well-connected professionals, L.B. remains on a dire trajectory. Advocates and family members of people like her often walk a
legal tightrope: State law protects people's rights to make their own
health care decisions with very limited exceptions. As a result, workers
in law enforcement, health care, nonprofits and legal roles who want to
save people in heartbreaking situations often can't.

And, in a cruel turn, the steps that L.B.'s advocates have taken to help
her – getting her briefly hospitalized, coaxing her to eat, helping her
take a much-needed shower – have caused county workers to determine she
does not need mandated long-term mental health treatment.

If the county's investigators had ruled the other way, it would have
triggered the start of the civil commitment process. Behavioral health
workers would have taken L.B.'s case to the Multnomah County's District Attorney's Office. She likely would have stayed in the hospital until she
could stand in front of a judge, typically around 24 hours, according to
the county's process.

Previously, people could only be committed if they were at risk of harm
that could occur that day. In 2015, the statute was updated to expand the requirements, stating the risk could occur over the next few days.

However, Terry Schroeder, a civil commitment expert at the Oregon Health Authority, said many counties incorrectly make commitment decisions based
on the old law.

After learning about L.B.'s case from The Oregonian/OregonLive, Schroeder
said there appeared to be enough evidence to take her case to a judge.

"Being homeless in and of itself is not enough for civil commitment. But
if you have a mental health disorder that is causing you to be houseless
and causing you to harm yourself or harm others, then that could be
enough," he said. "In this case, it sounds like there is a good argument
that is true."

Channa Newell, a deputy Multnomah County district attorney who also
learned about L.B.'s case from The Oregonian/OregonLive, said with the
facts presented, L.B. is likely "really, really close to being civilly committable" but isn't there yet. Weight loss, for instance, must be
documented by objectively measured weights at a doctor's office on two different dates, not simply attested to by people who see her, she said.
And the fact L.B.'s advocates help her shower and access other services
lessens her need for other help in the court's eyes since someone is
providing her a morsel of care.

Many people who see someone in crisis on the streets cannot understand how
a system that allows them to remain deeply mentally ill could possibly be
right or humane.

But not everyone agrees that involuntary commitment is the answer. In
fact, they worry it could cause more harm than help.

Emily Cooper, legal director at Disability Rights Oregon, recoils at talk
of forced care and said civil commitment shouldn't be used as a blunt tool
to coerce difficult patients to cooperate. Rather, she said, it should be
used sparingly and thoughtfully to preserve people's right to consent.

Even if the county had honored the request to force L.B. into treatment,
there would likely not be enough long-term residential mental health beds
to ensure she and others in severe need could get care, experts say.
L.B.'S STORY

In L.B.'s most lucid state, she can describe what makes a great sandwich.
A sliced tomato. Avocado, but not that smashed up guacamole, just a few
nice slices. Onion. Cucumber. And a real good slice of cheese. They call
it a vegetarian sandwich, she tells her advocate, whom she calls "That
Lady."

As she talks, she munches on hot fries and a hamburger. She offers "That
Lady" some fries and says, "I haven't had them in so long … Thank you."

To her advocates, times like that provide proof there is still a joyous
life for L.B. to live if she gets treatment.

Records indicate she has flitted in and out of Portland area shelters and treatment centers over the past decade, with a handful of temporary
hospital holds. The Blanchet House team didn't start managing her mental
health case – something they don't typically do for the vulnerable people
they help feed, shelter and clothe – until about a year ago, when they
found her in dire need of help.

L.B.

As of late, L.B.'s advocates have struggled to treat a large wound on her
head stemming from a bad lice infection. Unsure of what is true and what
is not, L.B. is skeptical of treatment for it.Nicole Hayden, Oregonian/OregonLive

The first of many incidents involving L.B. that Blanchet House tracked
occurred in November 2022. Emergency services were called because "a woman
with blood in her hair asked for help," according to call logs the
nonprofit keeps.

Staffers soon learned her narrative primarily included her being sex
trafficked and her children being taken away from her. They believe she
has experienced severe trauma, sexual abuse and rape. Her advocates say
L.B. believes that many men walking by might kidnap her or the Blanchet
workers she cares about. She warned them to take photos of the men's cars
and be on guard.

Her advocates believe she has children, that her fears are rooted in past traumatic experiences and that she at one time lived in Walla Walla, Washington.

For the many people like L.B. living on the streets of Portland, severe
mental health symptoms, such as paranoia and violent outbursts, prevent
them from being a good fit at most area shelters or housing programs.
Without substantial mental health resources or capacity to meet such
people's needs, shelters boot them back to the streets.

Since Blanchet's first encounter with L.B., the team has called 911,
Portland Street Response and Project Respond dozens of times on her
behalf. They've accumulated even more emails tracking L.B.'s progress amid their attempts to find services for her. What she needs, they say, is
clear: a long-term residential mental health program followed by placement
in permanent supportive housing.

In February, Blanchet workers called Street Response because she was
freezing and wanted shelter. The street response team said they had no
cold weather supplies or shelter beds to offer, so she slept in a coat on
the ground, they said. A few days later, she stayed in a shelter for one
night. But she returned to sleeping outdoors near Blanchet House because
she preferred the food it serves, she told workers, not understanding her
risk of frostbite or hypothermia. She fears not having access to food,
said Jen Ransdell, Blanchet House program manager.

Schroeder, the Oregon Health Authority expert, said a civil commitment
could be justified if L.B. is losing weight because she can't access
services on her own, if she is suffering from a medical issue that hasn't
been treated and if she is disoriented enough that she can't take care of herself. Still, a physician would have to say those challenges are rooted
in her mental health diagnosis.

Newell, the deputy county D.A., said "a doctor would have to testify how
much she weighed months ago versus how much she weighed now and say they
think she is at risk of starvation … If she eats in the hospital, that
goes out the window."

By May, L.B.'s "cognitive ability was fading," according to Blanchet House logs, and she couldn't figure out how to leave the doorway where she
slept. She also wouldn't eat. Staff once again called Street Response but
were told there was nothing the responding EMT and social worker could do, given Oregon's laws on personal autonomy. In July, L.B. had a large gash
in her foot that Portland Fire cleaned and bandaged.

Rick Graves, Portland Street Response spokesperson, said while he can't
comment on L.B. specifically, her story is sadly common. But without appropriate services to connect such people, he said his agency can offer little meaningful help.

"Our crews have many of the same challenges that other health care,
behavioral health and social service providers face, which boil down to
scarce resources in the community at large," he said. "(Short term)
involuntary treatment can aid in the stabilization … (but) it only defers dealing with the fundamental issue: The people who are most in need of
service and support have nowhere to be and no place to go."

Later in the spring of 2023, L.B.'s clothes were too soiled to allow her
inside to eat next to other Blanchet House guests, the nonprofit's
officials said. Ransdell coaxed her out of her clothes while holding a
blanket up to shield her from passersby. L.B. cleaned herself with baby
wipes and asked for deodorant.

"She told me it wasn't her urine, but that it was from a donkey," Ransdell said. "But that moment of washing, that's how we established our trust."
And that's when Ransdell earned the name of "That Lady."

At the end of July, L.B. arrived at the nonprofit with a black eye and
acted unusually aggressive. Security cameras caught footage the night
before showing someone physically assaulting her. Jon Seibert, Blanchet
House program director, called Multnomah County Adult Protective Services Division, which in turn called Project Respond. It took several calls and
seven hours before Project Respond arrived, Seibert said, partly due to
the crisis workers waiting for a police escort due to L.B.'s history of aggression.

Later that night, a temporary court-ordered mental health hold was issued
after police escorted L.B. to Unity Center for Behavioral Health.

Living outside with mental illness

L.B. can often be found sitting in the doorway of Blanchet House where she feels most safe. She has access to food and coffee, if she wants it, but
not much else.Beth Nakamura

If people are an imminent danger to themselves or others, police or
Project Respond workers can request a 72-hour to seven-day hold. To extend
that into forced long-term treatment lasting weeks or months, which
Blanchet House keeps hoping for, a county civil commitment worker must
confirm she meets their requirements.

Newell, the deputy district attorney, said, "The civil commitment process
is about a particular moment in time … When I am in a hearing, I am
focused on making sure this person doesn't die today" without forced
mental health care.

When L.B. does want help, she willingly gets into an ambulance, Blanchet workers said. But she doesn't understand that, to get her health issues
fully addressed and her mental health stabilized, she must stay in the
hospital for a longer time.

While L.B. was hospitalized for seven days at Unity at the end of July,
county workers "determined through interviews … that (she) was able to
take care of herself," Seibert, the Blanchet House worker, said. "But then
she was dropped off from the hospital right at our door. One of our staff members found her behind a dumpster with her medication and discharge
papers."

Newell said patients on short-term mental health holds who respond quickly
to medication and become stabilized can be challenging to commit to longer treatment because "as soon as that immediacy is gone, I can't move
forward." Newell said L.B.'s advocates could attempt to show that every
time she has left a hospital, she quickly spiraled back into psychosis – something they have been working to track. That could help the case,
Newell said, but she'd still have to show the judge there was an immediate danger.

While at Unity, L.B. enjoyed the food, slept well in the comfortable bed
and took her medication, said Ransdell. She was calm and participated in counseling appointments.

"She made such a huge leap in just a matter of days," Ransdell said. "But instead of that being proof that if she had a longer hold, she would be
even more successful, they used that to say she was lucid enough to take
care of herself and make her own decisions."

A caseworker from Unity also recommended that L.B. not be allowed to leave after the short stay. But without a judge's order, the caseworker and
L.B.'s advocates had no power.

"After seven days, they asked her if she wanted to stay and she said she
wanted to go home," Ransdell said.

She failed to remember she didn't have a home.

When L.B. left, she was prescribed Haldol, a powerful antipsychotic that
helps lessen the symptoms of schizophrenia, and given a supply to take
with her. But she told Blanchet workers the name on her bottle of
medication was not hers but that of a woman who was stalking her. She
refused to continue taking the pills.

Melissa Eckstein, president of Unity, said the facility is designed to
offer acute inpatient treatment for up to 15 days but not long-term care –
a significant gap in Oregon's behavioral health system, she said.

With the Oregon State Hospital at full capacity treating people charged
with or convicted of crimes, there is virtually no access to long-term residential mental health treatment for law-abiding people like L.B.,
Eckstein said. Patients can be referred to secure residential treatment facilities or other residential programs throughout the state, said Ryan
Frank, a Unity spokesperson. But the number of beds available to people on
the Oregon Health Plan is very limited, L.B. hasn't received a referral to
one.

Within days, the medication L.B. received at Unity wore off and she
returned to living coated in urine and feces, barely eating, Blanchet
staff said. Ransdell called the county's new downtown Behavioral Health Resource Center and asked if she could bring L.B. there to take a shower. Workers, familiar with the frail older woman's situation, agreed to let
her cut to the front of the line. Knowing her moments of lucidity are far
and few between, they wanted to help her shower quickly. Ransdell and L.B.
set off to the center, both dragging roller bags of supplies behind them.

"She was pretty lucid during that walk," Ransdell said. "She said she'd
love a Coke. We walked where we could avoid people and she smoked a
cigarette. I said, 'Ok, just a couple more blocks,' and then they let us
in through a side door." She showered while Ransdell picked up her
discarded clothes, which were coated in feces.

Newell said if a person is constantly soiling their clothes, that could
prove they have lost the ability to take care of themselves, prompting a
civil commitment. But because someone helps L.B. shower and provides care
for her, it makes it harder to commit her, Newell said.

The downtown center had a bed available where L.B. could sleep peacefully
and receive some mental health care, Ransdell said. But to qualify for it,
she would have had to tell workers what her plan for improvement would be, something she wasn't able to coherently answer, Ransdell said. L.B. also
isn't allowed at the downtown center without a chaperone because she has
such high needs.

"I could tell, though, she didn't want to leave because it is such a nice, calming space," Ransdell said. On the way back, the two stopped to eat at
a food cart pod, where L.B. told Ransdell about her perfect sandwich.

In mid-October, emergency room staff issued a temporary hold for L.B.
because she had a suspected urinary tract infection. Newell said an UTI
could be enough to justify a civil commitment, but a physician would need
to testify that her kidneys would fail without the hold.

"UTIs can turn into much bigger problems," Newell said. "We need to be
able to say she is refusing treatment for this because of her
schizophrenia."

Suspicious of the request to provide a urine sample, however, L.B.
refused. Without a test to confirm an infection, hospital workers released
her once again.

"The next morning as I am calling the hospital social worker again to make
sure that (L.B.) is not going to be discharged, I look out the window and
see (L.B.) walking towards us with no shoes on," said Duke Reiss, a
Blanchet House peer support specialist.

Since then, because L.B. recently turned 60, Blanchet staffers were able
to get county workers to reopen an adult protective services case,
potentially meaning she will qualify for more physical health care, even
if she doesn't consent to it.

Newell said adult services are often a good option for people who
repeatedly fall through cracks in the civil commitment process. County
workers told Blanchet officials that if they were to characterize L.B.'s behavior as caused by dementia instead of schizophrenia, they might be
able to get her more help. However, county workers advised that adult
services won't begin investigating a mental health case for her until she
turns 65.

In the meantime, L.B. continues to spend many days and nights camped in
the doorway of Blanchet House, tearing filters off cigarettes before she
smokes them. Her body forcibly shivers from the cold as her eyes roam, on
guard to perceived threats. The nonprofit says it regularly feeds at least
five other Portland residents in its small Northwest Portland neighborhood
who need the same intensive support.

Even though their help with basic needs complicates the equation for civil commitment, they cannot look away.

"I am terrified, honestly," Reiss said. "I am hoping we can get her help
before the winter comes."

Oregon 'community navigator' program aims to ease transition out of
state psychiatric hospital
Multnomah County mental health leaders agree some patients need
involuntary treatment — but where?
Oregon mental health leader says state finally has money to boost
treatment beds; Staffing them is another matter
Letter from the Editor: We're focusing on mental health challenges in Oregon
Oregon's mental health workforce 'crisis' exacerbates challenges
finding care

Nicole Hayden reports on homelessness for The Oregonian/OregonLive. She
can be reached at nhayden@oregonian.com.






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