Nathan Anderson is looking back at me through the visitor’s window at the Lane County Jail. He’s wearing inmate scrubs and has old, shiny scars up his left forearm. He holds a note up to the glass.

“PTSD, depression, ADHD, obsessive compulsive disorder, bipolar disorder,” the note reads.

I hold up my response to the glass: “When you were on the streets of Eugene, what were your daily symptoms?”

He writes back: “Out on the street, depends on how people treats me. Mostly I feel depressed. Keeping my mind on how bad I want death. Sometimes I feel anxious when I had a good day. Sometimes I see bad things that give me sadness and/or PTSD attacks.”

Framed by the window, Anderson’s torso stands out starkly in the barren and somewhat haunting jail visiting room. All of Eugene’s madness comes charging through this building at weird hours; Anderson is sharing a facility with people facing charges of homicide, assault and rape.

With his cocktail of mental health issues, is this really the place for Anderson to heal?

Anderson, 34, has been deaf and mute his whole life. Currently he is being held at the Lane County Jail for a charge of possession of methamphetamine and first-degree arson. Police records state Anderson set fire to a cement wall of C & K Petroleum Equipment on West 2nd Avenue on July 15. The charge could carry a hefty prison sentence if he is convicted.

Anderson writes another note, saying he was admitted to the Sacred Heart University District “psych ward” [his words] for four days in January and then a second time for about a week in the spring.

“Felt rage and felt homicidal with suicidal,” his next note reads.

Anderson’s time in the ER on 13th Avenue, his rocky journey trying to keep a bed at the Eugene Mission, and St. Vincent de Paul’s Service Station and his subsequent arrest in July are a grim reminder of the broken circuit of services for homeless mentally ill people in Eugene and Springfield.

The Eugene-Springfield area is under an immense strain for available resources for members of the homeless community going through a psychotic break, partially because of the closure of the Royal Avenue Shelter in 2014, which had 19 beds for mental health crises. The only psychiatric beds available between the area’s two emergency rooms are routinely filling up due to staffing shortages for nurses. That leaves services like CAHOOTS (Crisis Assistance Helping Out on the Streets), city ambulances and the police with little wiggle room for incoming patients who are suicidal, or suicidal from meth-induced psychosis. The CAHOOTS staff of the White Bird Clinic tell EW that the area’s two emergency rooms with psychiatric beds are prematurely discharging mentally ill clients experiencing a psychotic break, often because those clients test positive for meth, though meth-induced psychosis is a diagnosis in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders.

However, a new state plan and a new mental health crisis office in town (Hourglass) may carry new leads for breaking Oregon’s cycle of overloaded emergency rooms.

At the state level, the government knows this is an Oregon-wide problem. In 2010, the federal government began investigating Oregon’s management of people with severe and persistent mental illness, after claims that the Oregon State Hospital was institutionalizing people for too long. That investigation resulted in the new Oregon Performance Plan, which rolls out over the next three years with the overall intent of patching up Oregon’s very overloaded emergency rooms and public mental health services. Ironically, it was a loss of state funding that caused ShelterCare to shut down the 19-bed Royal Avenue Shelter in 2014.

The Perspective of an ER Staffer

Consider the psychiatric bed options at the Sacred Heart Medical Center emergency rooms, both at the University District facility on 13th Avenue near the University of Oregon and the RiverBend facility in Springfield.

EW spoke with a staff member at the Sacred Heart Medical Center emergency room, who wished to remain anonymous for fear of repercussion from PeaceHealth.

“I know that frequently we are at capacity much of the time in terms of our psychiatric unit,” the staffer explains. “This is way out of proportion to other communities I’ve worked in. Part of it has to do with the sheer number of people in this community with psychiatric problems who are living on their own and who are not in in-patient settings.”

Methamphetamines often play a role in sending a mentally ill homeless person over the edge to psychosis.

“If they are agitated to the point where we can’t talk them down and get them calmed down, then we consider them a danger to others and us at that point. We decide if they need to be medicated,” the staffer adds.

A two-physician hold (different than a civil commitment hold, which is approved by a county official) would mean forcing that person to stay in a contained psychiatric room for a few nights, either in the University District’s psychiatric care rooms, or in the more long-term Behavioral Health Unit floor. But to qualify for a forced two-physician hold, a person has to be really out of control, including having a plausible way to actually kill themselves or others, such as a weapon or pills.

The issue of putting a civil commitment hold on clients who do make it up to the Behavioral Health Unit floor saw some press last year when the Oregon State Legislature passed House Bill 3347, which changed some of the wording around a civil commitment. The new bill was supposed to make it easier to have someone forcibly committed, but a Lane County mental health assessor told EW that the county won’t change how many people it commits to the BHU or the Oregon State Hospital because the bill “just changed the wording” of the law.

The gritty affair of “calming someone down” can involve sedation, which means staff pin down an out-of-control client to inject sedatives. Once the person is calmer, staff then can decide if they should spend the night in one of the available psychiatric beds.

The RiverBend and University District emergency rooms have two beds and nine beds, respectively, to hold a patient experiencing a mental health crisis, such as serious suicidal ideation. That count does not include the larger Behavioral Health Unit floor (formerly called the Johnson Unit) located at the University District building.

The staff member says the waiting rooms at both emergency rooms are often packed, with a long wait (for both medical and mental health crises), particularly RiverBend — largely because there is a chronic lack of nurses to do intake for incoming patients.

PeaceHealth has “a business model that is what they see as being optimal staffing. If their level of staffing was optimal, why is it that we are always short? It basically comes down to they don’t want to pay more people and they don’t want to pay benefits for more employees. They try to run the hospital according to business models of efficiency,” the staff member says.

The staffer says that sometimes, beds at the RiverBend emergency room will stay vacant while the emergency room fills up, also because there aren’t enough nurses to do intake for a rush of patients, adding that of the nine psychiatric beds available at the University District, four to six are full every night, and two to four of those clients are waiting for a bed to open in the Behavioral Health Unit floor.

According to the senior head of nursing at RiverBend, Leah Gehri, that emergency room has seen a bigger volume of incoming patients in the past year. Some new staffing measures were put in place April 13 — such as reducing door-to-doctor time as well as hiring some new positions, Gehri writes in an email to EW.

“Nurses must prioritize sickest patients first, which does sometimes create longer than optimal waits for some individuals whose presenting illness is less acute,” Gehri writes. “We do face the challenge of recruiting experienced Emergency Department nurses.”

Often, CAHOOTS or the Eugene Police Department will drop off at the ER homeless clients undergoing a psychotic break — signs of extreme agitation include repeated threats to kill themselves or others. Enough nurses must be on the clock to do the intake procedures for incoming clients.

“One of the problems that we have in this community is people who are repeats [to the ER]. They have chronic drug problems and alcohol problems as well as psychosis. It creates a dilemma that I don’t have a great answer for,” the staff member at the ER says, adding that when crisis services drop off a patient, they don’t see the results of a drug test or the results of treatment; they only see the initial intake process.

“What they see is people who are bouncing in over and over again, “the staff member says. “I’m sure it’s frustrating to them.”

While Anderson could hardly be called a repeat offender when it comes to using the emergency room (two visits to the psych ward in six months), it is clear that his quest earlier this year to find resources for himself, such as stable housing, did not stick.

A driving component of the Oregon Performance Plan is to stop the cycle of homeless people coming in to the emergency room on repeated visits; if enough follow-up care is offered after a stay in a psychiatric ward, the OPP reasons, that might be just enough to avoid another psychotic break.

Occupy Medical (OM) sends a volunteer with its homeless clients down to the University District emergency room, because the free medical organization has seen far too many homeless clients come back a few hours later, no services rendered, according to OM clinic manager, Sue Sierralupe. OM put that policy in place two years ago.

In one situation before OM started sending a volunteer with their patient to the ER, Sierrelupe says an unhoused person had gone to the ER four times to have a painful MRSA (methicillin-resistant Staphylococcus aureus) infection treated. He was turned away each time.

“The infection deepened along with the pain,” Sierralupe says. He went again to the ER with a community volunteer. The ER admitted him and ended up putting a catheter into his heart to save his life, she says.

“I would like to remind the public how contagious MRSA is. This is not a disease that should be left untreated,” Sierralupe tells EW.

“The reticent staff that works at the ER, whichever ER that might be, seems to have some biases about the population that we are bringing in. They may dismiss the condition as being well, it’s just because they are homeless,” Sierralupe says.

Ben Brubaker, volunteer coordinator with White Bird and the CAHOOTS mobile crisis service, is particularly critical of the ER system in Eugene because physicians and ER staff have the power to put a forced two-physician hold on a suicidal client, but are increasingly just discharging people just a few hours after admittance.

But to the contrary, there are some very stringent legal criteria for putting a two-physician hold on a client, says Janet Perez, manager of sub-acute/transition services for behavioral health at Sacred Heart.

“I certainly empathize with CAHOOTS,” Perez says. “We too see patients who come in drug affected. And we will care for them, treat them medically, psychiatrically, in the emergency room. And if they don’t meet that threshold [for a two-physician hold], then we are bound to let them go and offer resources and referral to other places. It is a person’s choice to use substances.”

Brubaker also says his CAHOOTS staff have become hesitant to bring a homeless person experiencing a psychotic break down to the ER, for fear the ER will reject them if they have methamphetamines in their system. The staff member who works for Peace Health Sacred Heart emergency rooms says that while the issue of methamphetamines in someone’s system can often hinder staff’s ability to determine if the person is having a severe mental health crisis or is just on drugs, ER staff still do admit homeless clients with meth in their system to the floor’s psychiatric care rooms. The staff member adds that intake staff have to be discerning if a homeless person actually intends to kill themselves or is simply trying to get a free bed for the night.

“A majority of people with psychiatric problems don’t meet the criteria for [in-patient] admission, and even those who do meet in-patient criteria, there’s a good percent of those patients who come in on a volunteer basis,” the staff member says. “You can imagine there are people who want to be admitted but don’t meet the criteria for a psychiatric condition.”

Either way, the loss two years ago of the Royal Avenue Shelter has left a gaping hole in help for low-income clients experiencing a mental health crisis. Brubaker says the loss of those 19 beds — along with the week of care offered to those using them — has left CAHOOTS, as well as the Eugene Police Department, with very few options for a longer term psychiatric stay in this community.

Riding with CAHOOTS: The Night Shift

It’s midnight on an August full moon in Eugene, and I’m in the backseat of a CAHOOTS crisis response van rumbling down an alley off W. 6th Avenue. All night, the two CAHOOTS crisis workers have been dropping people off to Hourglass (a short-term mental health crisis center), Buckley House (a walk-in detox center run by Willamette Family) and the Sacred Heart University District emergency room.

To my left is a shelf of plastic gloves and behind me is a 5-gallon bucket full of snacks, including several cans of tropical fruit. We are approached several times for needle exchanges, snacks and blankets. Crisis worker Matt Eads offers short, compact summaries of what he thinks of the ER and clients in a mental health crisis.

“Depends on how busy they are,” Eads says. “The hospital exhausts every resource possible and if they have no option for a safety plan, then some people get let out on the street without a safety plan or reference.”

Eads points out that some people are discharged from the ER with an appointment to see a counselor in place, but the psychological state of many homeless clients means they would never be able to remember or follow through on an appointment.

“It’s not the fault of anybody,” he says of the deluge of clients seeking mental health care. “The system is broken. There’s just way too many people for the resources available.”

At one point, the van drives out to a call for a person grieving the long-ago suicide of a partner. Eads and his crisis colleague chat with the individual for a few minutes, listening quietly as the person goes over each detail. Eads mentions, at the end of the conversation, that police dispatch said the person in question might be thinking of self-harm. The individual responds “no,” and seems calm. We get back in the van and drive off for another call.

“If a car with a bad batch of heroin comes into town, everyone gets hit by it,” Eads says of the calls he responds to. A bad batch of meth or heroin can mean a rise in overdoses over a short period of time. Calls can light up all through downtown as the same bad batch, like food poisoning at a single restaurant, is sold and resold to users throughout Eugene.

Occasionally, the psych beds in one of the city’s two emergency rooms fill up, and that office can send out a “diversion” message to all incoming crisis response vehicles, meaning that traffic should now go to the other emergency room. This happened twice in July, but not in June or August.

“It means we have to take people to RiverBend, which isn’t set up as firmly for mental health but then RiverBend was starting to call in and say they could no longer take mental health patients,” Brubaker says.  “What are we going to do if we really have somebody that needs to come in? We’re now circling the city looking for a bed to put people.”

Fixing the Problem?

The Oregon Performance Plan

Mike Morris, behavioral health administrator for the Oregon Health Authority (OHA), says the new state plan is particularly geared toward ending the cycle of “frequent flyers” to Oregon emergency rooms.

“If individuals have more than two re-admissions into the emergency department, we need to work to develop plans with those individuals to make sure they are getting services to prevent that revolving door with the emergency department,” Morris says.

The Oregon Performance Plan has already distributed new funding — to the tune of several million dollars — to Lane County facilities that currently serve people with severe mental illness. Laurel Hill Center in Eugene received $742,630 for 60 new slots to give people rental assistance, ShelterCare in Eugene received $1,032,515 for 75 new slots to give people rental assistance and Shangri La in Eugene received $524,742 for 30 new slots.

Tami Rust of OHA says the new housing slots come in the form of rental assistance dollars, which a client can use for any apartment in Eugene.

The new state plan, of which the Behavioral Health Unit staff at Sacred Health is aware, is using the mantra of  “assertive community treatment” as it goes forward. This means wrapping patients in a holistic regime of services, such as housing, peer support and regular visits with a therapist, to try to help stabilize people with severe mental illness so they don’t get to the point of needing the ER or being sent to jail.

Coping on the Streets

Nathan Anderson, who has not yet been arraigned for the July arson charge, had run the gauntlet for help with housing and his mental health issues before he was arrested. Anderson was kicked out of the Eugene Mission and the Service Station, and left a Conestoga Hut built by Community Supported Shelters because he was afraid he was being too loud (and he can’t discern if he actually is, because he is deaf).  He even traveled up to Washington state to look for help, but got frustrated and came back to Eugene in July.

A week later, he was arrested.

Part of the issue seems to be that Anderson’s own paranoia makes him distrustful of service providers. During the interview at the jail with Anderson, one of his notes read:

“I went to the crisis center at a hospital but I left due to they giving me bad meds that are killing me. Such as rash, itches, skyrocketing anxiety, restless and so on. Doctor listens to himself there.”

Not all homeless people with a mental illness get to the point of having a psychotic break; many people with depression, schizophrenia or PTSD on the street have many other options besides a visit to the ER for taking care of their mental health.

Twenty-nine year old Suzanne White lives on the streets of Eugene with her husband Erik. White says she likes to dress “gothic,” is from the South, and says she has combat PTSD from being molested.

Both of White’s newborn infants were taken from her by the state a day after they were born. To get her baby back, White says the Oregon State Court system requires her to find housing, find a job and go to therapy. Because she qualifies for the Oregon Health Plan, White can and does go to weekly meetings with a therapist at the Center for Family Development.

“She understands I’m applying for different jobs,” White says of her therapist. “I did have a different binder with different applications. She understands it’s hard to get the applications back when they have been stolen.”

White says she has never had a psychotic break. She feels her therapist really understands her pain of missing her two little girls, including the difficulty of working to find housing in Eugene. While her life on the streets is far from perfect, White is an example of one person whom the mental health system in Lane County is helping.

Some Brighter Figures for the Situation

of Mental Health Crisis in Lane County

A new Hourglass program, intended to offer a new county resource for mental health crises, saw 32 people transferred from the ER to their office in the month of July.

The Oregon Performance Plan has already distributed new funding — to the tune of several million dollars — to Lane County facilities that already help people with severe mental illness.  Laurel Hill Center in Eugene received $742,630 for 60 new slots to give people rental assistance, ShelterCare in Eugene received $1,032,515 for 75 new slots to give people rental assistance and Shangri La in Eugene received $524,742 for 30 new slots.

Thurston and Cabana apartments, run by Columbia Care, received funding for six new apartments, using $465,731 from the Oregon Performance Plan.