High bar for hospitalizing mentally ill Portlanders without consent leaves those in great need on the street

Editor’s note: The Oregonian/OregonLive is not naming L.B. to protect her medical privacy and because her illness currently renders her unable to meaningfully consent to have her story made public with her full name included. Neither her advocates nor The Oregonian/OregonLive could locate a relative who could speak on her behalf.

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.

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.

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.”

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