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Into the Institution

Hospitalization, communities and mental health
Illustration by Lily Padula
Illustration by Lily Padula

Last week I walked through the hallways of the Oregon State Hospital in Junction City. It felt like being locked into a Holiday Inn Suites … with psychiatric workers keeping an eye on you. Earlier in the week, strolling the halls of PeaceHealth Sacred Heart Medical Center University District felt like being in an office building — a little generic with some pleasant extras like art, comfy pillows and tinkling music. 

Oregon’s new mental hospital is a far cry from the notorious scenes of One Flew Over the Cuckoo’s Nest, but it’s nonetheless an institution behind locked doors, as is part of the facility replacing PeaceHealth’s circa 1969 Johnson Unit. And the question of institutionalization when it comes to the mentally ill is not an issue that has gone away, though it is trying to become kinder, gentler and more effective.

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The pendulum has swung from mass institutionalization to care in the community, and with the completion of new local hospital units, it continues to swing. “A neighborhood of care,” “a community of care,” the phrases arise again and again in the halls of the hospital as well as at PeaceHealth. 

Treating people in the community and bringing them home to the community is a focus across the mental health system. But once mental illness has opened the portals to institutionalization, from a short-term hospital stay to a long-term criminal sentence, what happens next? We can put them away if they are a danger to themselves or others, but people have the right to be mentally ill.

One-in-four people have a mental health crisis, I’m told again and again. It affects someone you know, maybe someone you love — a quarter of our community. There are not enough hospital beds for all those people, Junction City’s Interim Deputy Superintendent Kerry Kelly tells me, nor should there be. 

But for now, we have hospitals.

 

The Rise of the Asylum

Housing the mentally ill in hospitals began as early as the 1400s in Europe. By the 17th century, the word bedlam, meaning chaos or wild uproar, stemmed from the Bethlem Royal Hospital in London, infamous for its cruel and inhumane treatment of patients.

In the U.S. in the 1840s, Dorothea Dix “criticized cruel and neglectful practices toward the mentally ill, such as caging, incarceration without clothing and painful physical restraint,” according to the National Institutes of Health. NIH adds that Dix may have suffered from mental instability, which could have driven her push for reforms. 

Drugs and other treatment didn’t necessarily improve things for mental patients in the early 1900s. Electro-shock therapy — also seen in Cuckoo’s Nest — entered the picture. Ken Kesey’s novel takes place in the Oregon State Hospital in Salem, and gained even more fame for the issue of mental institutions as a movie starring Jack Nicholson. 

Finally, in the 1960s, a movement to deinstitutionalize mental patients took hold and the rise of anti-psychotic drugs helped, stabilizing some patients. In 1963, the Mental Retardation Facilities and Community Mental Health Centers Construction Act was passed, which was supposed to provide community-based health care and federal funding for such facilities.

According to Mental Health in America, by 1980 the number of hospitalized mental patients “drops from a peak of 560,000 to just over 130,000.” But, over time, the funding was not enough, and “many people became homeless because of inadequate follow-up care and housing.”

Rather than deinstitutionalized, many became “transinstitutionalized” — moving back and forth between hospitals and the prison system. That situation lingers today, and it shadows the 174-bed, $84 million state mental hospital in Lane County.

According to statistics kept by the National Institute of Mental Health (NIMH) in 2013, 18.5 percent of all U.S. adults had mental illness — that one in four number. NIMH cites a Department of Justice study that showed nearly two-thirds of jail inmates satisfied the criteria for a mental-health problem currently, or in the previous year. Yet the survey of local, state and federal jails and prisons showed fewer than half of inmates ever received treatment for their problem.

 

Against the Institution?

The National Alliance on Mental Illness, NAMI, was founded in 1979 to provide support, education and advocacy for mentally ill people and their families. Here in Lane County, local NAMI Executive Director Jose Soto-Gates says NAMI Lane County’s offices in the county Behavioral Health building house a library/resource center, seasonal affective disorder lights, a meeting space for support groups and much more. 

The group, a form of community care, provides outreach across the county, with volunteers giving presentations on dealing with mental illness and putting a face on the issue. “Look in the mirror,” Soto-Gates says, citing the one-in-four statistic. “That’s the face of mental health.” 

NAMI Lane County takes no funding from pharmaceutical companies, he says, in its work to reduce the stigma of mental illness. “People come to NAMI in a vulnerable place,” Soto-Gates says, not just those who are ill but family members who want information on how to support a loved one, and want more information on the illness itself. 

Soto-Gates and NAMI’s many volunteers “try to help people achieve what they want to achieve.” It’s not black or white, Soto-Gates says. “Recovery looks different for everyone.” 

On a state level, NAMI Oregon came out against building the hospital in Junction City. “Large environments are not conducive to good mental health care,” NAMI Oregon executive director Chris Bouneff tells me. “In an ideal world, centered on recovery and good health care, we would have smaller facilities closer to the people being served.”

NAMI Oregon took issue with the fact that closing the mental hospitals in Eastern Oregon and Portland meant long drives for families, putting patients far from their communities, and with spending large amounts of money on a large institution. “We can’t build our way out of this problem by building more and more state institutions,” Bouneff says.

“Junction City was a very tense and emotional battle for a lot of us,” Bouneff says. “From our perspective we lost that battle, but even those folks who we opposed on that, they know the wisdom of making local investment and how important that’s going to be.”

But there is a time and place for institutionalization, mental health workers and some patients tell me. NAMI Lane County outreach and enrollment coordinator Mechelle Hoselton says she was diagnosed bipolar in 2005, and she has been hospitalized “12 times, on and off,” including time at PeaceHealth hospital’s old psych facility, the Johnson Unit. 

“Each time I get ill, I don’t know I’m ill,” Hoselton says. She says sometimes “I know the right things to say to get out” and not get the help she needs. At one point, she says, she traveled to Utah and “really lost my mind” and is “so thankful they kept me long enough to get me stabilized.” A stay of a longer duration, she says, is more helpful because it gives time to adjust. 

One thing that came out of the statewide NAMI’s concerns over the Junction City hospital is that the group will be opening a resource center there. “We said to [State Rep.] Val Hoyle, ‘If this is built, we should be a part of it,’” Soto-Gates says. 

NAMI has also teamed up with the new $13 million PeaceHealth facility. NAMI has a clothing closet for patients and will have volunteers not only in an office in the Behavioral Health unit, but also in the emergency room to talk to family members who are waiting in limbo, often for hours, wondering what is happening with their loved one.

 

A Mental Health Unit by Any Other Name …

Sitting at a conference table at PeaceHealth in the University District, Dale Smith, director of Behavioral Health Services at PeaceHealth, stresses the idea that it is a neighborhood of care — there are many doors, she says. 

We are upstairs, touring the remodeled building where the outpatient therapy takes place and intensive outpatient and partial hospitalization programs have facilities. 

Intensive outpatient and partial hospitalization is for those who need a higher level of care than an outpatient, Smith explains. PeaceHealth offers group therapy, individual counseling, art and movement therapy and chronic pain management as part of its programs.

Smith and Janet Perez, manager for transition and sub-acute care, walk through the carpeted halls, showing rooms with tables, whiteboards for classes, fat pillows for relaxing on. There is coffee available, quiet music, workout machines in front of large windows and artwork on the walls. The facility is trying to take the edge off the institutional feel. There is a classroom for art therapy and a sensory room with lights and sound.  

Downstairs is the in-patient unit where acute patients are taken and stay for a short time, usually a week. This is what has replaced the Johnson Unit, the place whose name has been synonymous in Lane County with the idea of involuntary commitment. Patients come there either through the emergency room, or through a psychiatric referral. 

Where the Johnson Unit had eight beds, the new remodel has 35 private rooms, 20 of them secure. The goal, Smith says, is for patients to participate in their own care, with the patient and the family helping to make decisions about treatment.

Among the programs Smith is particularly excited about are the Early Assessment and Support Alliance (EASA) and Young Adult Hubs. Rather than wait until someone has had psychotic breaks to the point they are committed or wind up in jail, EASA seeks to identify and treat young people as early as possible. The goal of the intensive two-year transitional program is to stabilize symptoms, develop skills and help transition young people and their families in such a way they can access ongoing support in the community and “achieve their goals in life,” Smith tells me. Not spend years in and out of institutions and episodes. 

Young Adult Hub focuses on those who might be reluctant to access the traditional mental health system, with specific outreach to homeless and LGBT youth and those “aging out” of care facilities. 

I ask Smith the same question I later ask Kerry Kelly at the Junction City Hospital: Does a patient have a right to be mentally ill? 

I don’t doubt the one-in-four statistic for mental illness — I have friends who have struggled with it themselves, and have watched others painfully deal with family members having psychotic breaks. And when my friends relapse, I have watched people I care about lose touch with reality and been unable to help them, taking one to the emergency room, only for her to be released — she was not a danger to herself or others, despite the voices she was hearing in her head. 

To a certain extent the mentally ill do have the right to be mentally ill, if they are not a danger. Unless someone has been civilly committed or found guilt except for insanity, the mentally ill cannot be locked up against their will or medicated against their will. 

 

The New Institution

When the concrete walls of the new state hospital began to rise on the outskirts of Junction City, in the district of State Rep. Val Hoyle who advocated heavily for it, you could not help but notice how very prison-like they were. And the state hospital does indeed house “forensic patients” — those who have entered the hospital through the criminal justice system.

Patients come to the state hospital through two routes, Kelly tells me. They are civilly committed, meaning they have been found to be a danger to themselves or others, and they need the longer time the state hospital can provide to stabilize. Or they have committed a crime and pled guilty except for insanity (GEI) and “come to the hospital for treatment instead of a jail sentence.”

Kelly says the move is now away from custodial care, where patients are simply housed, to helping “people reach a point in recovery to safely return to the community.” That might take two weeks, she says, or years. 

“In an ideal world,” Kelly says, “we would be out of a job. People would be supported in the community.”

The hospital, on the edges of the communities of Eugene and Junction City, looks from the outside like a concrete monstrosity. Kelly says that with limited funds, the decision was made to put resources into the inside of the hospital — natural light, art, color. Rather than spend more than $1 million to paint the exterior, they saved the money and just sealed the concrete. Pointing to apple trees planted by FOOD for Lane County, Kelly laughs and says she hopes the façade will soften over time.

Kelly guides me through the halls — and layers of security — showing me treatment malls with classrooms for writing, meetings and yoga, sensory rooms, workout rooms and almost college-like dormitories in the lower level Mountain unit. The upper, higher-security Forest unit, for more acutely ill patients, has beds that can’t be moved, and shelves and faucets that can’t be broken. 

The hospital softens the institutional walls with light orange and blue hues, rays of sun streaming in through the windows and art work, positioned anywhere a patient’s gaze might fall, from the sculptures hanging from the ceiling to quilts on the walls. 

Outside in courtyards and fields there are basketball courts, gardens, a sweat lodge, all surrounded by a tall, tall fence.

Kelly says a patient is involved in his or her own plan of care, vocational and real-world skills are built working and shopping in the facility’s coffee shop, store and greenhouse, prepping them for jobs when released. “Our dream is to make the connection before our client leaves the hospital,” she says.

But once someone is stabilized, once he or she can make decisions, what happens if they decide to go off meds? Leave treatment? To be “insane”? 

If a patient is GEI, then for the length of the sentence — 20 years, a lifetime — if the Psychiatric Security Review Board allows them to leave the hospital and re-enter the community, a condition of release can be to stay medicated. 

A civilly committed patient can stop taking medication at the end of the commitment period. For both GEI and civilly committed patients, they do not need to spend their entire commitment or sentence in the hospital, Kelly says. 

The hospital provides education about the illness that hopefully helps patients make good decisions about treatment, and patients can create an advance directive, and give it to the right people who can help, to ensure that if they have an episode it is clear what treatment they want.

But once people are done with their time and treatment, and if they don’t have a directive saying they want meds or other treatment, “we all have rights,” Kelly says. “People can decline to take the psychiatric medications, the same as someone could refuse blood pressure medication.”

 

The Community 

The Oregon State Hospital in Junction City, with 75 beds open and about 100 more, as well as treatment cottages, ready to open, is here to stay. Rep. Val Hoyle, whose brother has suffered from mental illness, says such a hospital is needed to provide acute mental health care. But the hospital, she says, “was built to get patients out of the hospital” and back into the community.

But does that mean the pendulum swings again? People get out, but communities lack resources.

The hospital was supposed to be bigger, Hoyle says, 360 beds, but it was decided to put money into community health instead.

And Bouneff of NAMI says there have been encouraging signs in that direction in recent years. The 2015 Oregon Legislature put funds into mental health housing — $20 million for new housing dedicated to individuals living with mental illness or addictions given to Housing and Community Services (HCS), the state’s affordable housing agency.

 “In the end,” Bouneff tells me, “we all have to work together to continue to move forward to make investments in what we know has to happen in our state.”

 

Please read the other half of this feature, "Out of the Darkness," by Rick Levin.

This story has been updated.