A short history of the public mental health system in Oregon
By Bob Nikkel, MSW, Deputy Assistant Administrator, Office of Mental
Health Services, MHDDSD
February 2000
[The material for
this short history is based primarily on an article by O. Larsell, which
appeared in the December, 1945 issue of Oregon Historical Quarterly; and a
paper by Jim Carlson entitled, "Emergent Issues in the Public Mental Health
System", published by the Mental Health and
Developmental Disability Services Division in 1995.]
The first references to white
men with mental illnesses in the Oregon Territory were focused on Astoria, the
oldest of permanent white settlements in the Northwest. Only a few years after Lewis and Clark's rainy winter encampment near Astoria, a massacre of
an American Fur Company trading post near Three Forks of the Missouri by a
group of Native Americans left a lone survivor who became mentally ill or
"demented." The survivor
wandered around for weeks until he was captured and cared for by Native
Americans in the Snake River country.
Larsell attributes his survival to the "superstitious attitude of
the savages."
Whatever the cause of this
first psychiatric stabilization, John Jacob Astor's overland party in 1811 came
across the Native American group which had been caring for the white man, whose
name was Archibald Pelton. He had
recovered enough to be turned over to the trading party and he reached Astoria
with this group in January 1812. Mental
illness as manifested by Pelton may have been unusual for the Native Americans
he encountered in the Northwest because Pelton's name became a part of Chinook
jargon as designating a "mental affliction."
One of the Astor expedition
members also became "demented" during the overland journey. His name
is very familiar to Oregonians--John
Day. Mr. Day arrived in Astoria about
a month after Mr. Pelton, where he too recovered enough that he was able to
begin his journey back to the eastern part of the United States in the
spring. Here then are the first two
white men with mental illnesses in some degree of recovery, a concept which we
sometimes mistakenly believe we invented in the recent decades.
John Day, however, became ill
again on the trip east, and lost his life, apparently as a result of his
becoming violent. In spite of this,
there are two rivers named for John Day in Oregon, one town in Central Oregon,
a dam on the Columbia River, and several other geographical features. I believe it to be a source of pride that we
work in a state that has so honored one of the first persons identified with
mental illness to live here.
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The
next recorded mention of mental illness in Oregon comes with the establishment
of the Oregon Territorial
government in 1843. The provisional government formed at Champoeg
adopted laws to outline arrangements for the care of the mentally ill. Probate
courts were to direct the county
sheriff to summon "a jury of twelve intelligent and impartial men" to
investigate whether a person was "insane." If this jury so determined,
the mentally ill person would be appointed a trio of guardians to sell his or
her property and dispose of the
proceeds to pay for the person's care.
If there was no property, the
guardians were to ensure that the person received care at their own charge and
were to ensure that the "unfortunate" receive "relief as paupers
and be maintained under the care of the overseers of the poor." The guardians also had responsibility for
safekeeping and maintenance of the mentally ill person and his or her
family. Finally, If there were not
sufficient resources, the county was required to pay for these supports out of
the county treasury. Thus, the
beginning of tensions and conflicts between state and counties in Oregon over
the care of the mentally ill.
Further modifications came
quickly. The next year, another law was
passed which specified that a mentally ill person should be "let out
publicly...to the lowest bidder, to be boarded and clothed for one year...". By
1850, there were 5 such persons identified
out of a total population of 13,294.
Counties soon appealed for state funds, which were granted in 1855 and
then taken away the next year when another law passed which repealed the first. The
A tug
of war continues to this day regarding the responsibility
and capacity of counties to provide local care for persons with mental illness.
By 1861, Dr. J. C. Hawthorne
had opened a private institution in Portland to care for persons with mental
illness. His first temporary quarters
were established in Portland between 1st and 2nd Streets and Taylor. In the fall of 1862, Dr. Hawthorne was the
only respondent when the governor was required to contact suitable persons to
care for persons with mental illness and to provide them with medical treatment. This surely must have been one of the
shorter procurement processes in state history, since only two days elapsed
between the legislature's passage of the necessary legislation which authorized
the governor to seek a provider and the signing of a contract with Dr.
Hawthorne.
By the time of the actual
opening of this new service, he had moved the facility about a mile away to
what is now 12th and Hawthorne. This
site was on the edge of the settled area, adjacent to woods and on a sloping
hillside which provided a relaxed and healthy environment. The state contracted with Dr. Hawthorne to
care for, at first, 12 patients in the fall of 1862. When spring came in 1863, the population of the institution had
already increased to 28 patients. As
the population of Oregon increased over the next 15 years, so too did the size
and census of Dr. Hawthorne's "Oregon Insane Hospital." In 1866 there were 77 patients; in 1870
there were 111; in 1874 there were 194.
In 1877, the costs of caring for these patients took up 52% of the total
state budget!
Dr. Hawthorne, by almost all
accounts, operated a very safe, sanitary, and efficient asylum, in the best
sense of this sometimes misunderstood term.
Inevitably, there were critics almost from the beginning, who accused
Dr. Hawthorne of charging too much, of keeping patients who were too well--because
they represented no challenges. Several
investigations into these charges resulted in a complete affirmation of the
work to which Dr. Hawthorne had devoted his life. It was not uncommon for Dr. Hawthorne, for example, to pay for
the transportation of persons sufficiently recovered so that they could return
to their home communities. These inquiries, however, may represent our earliest
efforts at oversight and utilization review.
Dr. Hawthorne's thinking
about early intervention and the likelihood of recovery bear quotation even
today. In his report to the governor in
1878, he stated:
"The percentage of the recoveries for the past two
years shows an increase
over that exhibited in my last report. This result is attributable
to the condition of the patients when admitted, the form of
insanity being acute in a greater number of cases. It is a fact which
the experience of all engaged in the treatment of this class of patients
shows, that judicious treatment in the early stages of the disease
is, in a majority of cases, attended with success, while but a small
proportion are restored to reason where a considerable period of time
has elapsed before the patient has been put under systematic hospital
treatment."
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All this nearly a hundred
years before our sophisticated antipsychotic medication and antidepressant
medications. Dr. Hawthorne died within
two years of the opening of what later became Oregon State Hospital. The
population of persons in need continued to grow steadily until the legislature
decided to open its own state-operated facility in 1883, at which time
370 persons with mental illness were transferred from the Portland facility to
Salem.
Oregon State Insane Asylum
grew by leaps and bounds. Just over 25
years after it opened, there were over 1,500 patients. By 1901, the county courts were committing
so many patients that even the families were objecting that they could and
would care for their mentally ill relatives through private resources. In 1913, 325 patients were transferred east
to Pendleton where the state had built and opened a second state hospital. Families were assisted to care for their
relatives during periods of stability by the passage in 1917 of legislation
that allowed for persons to be released temporarily under "parole."
Nevertheless, treatment
concepts were gaining in acceptability so that in 1907 Oregon State Insane
Asylum's name was changed to Oregon State Hospital.
Greater differentiation
between types of mental disorders led to the recognition that a separate
facility was needed for persons who were mentally retarded or developmentally
disabled. For this purpose, Fairview Home
was established in 1908.
The perpetual struggle for
sufficient capacity and resources is illustrated by the continued inability of
funded bed space to keep up with demand.
Between 1920 and 1940, the Legislature approved funding for an average
annual increase of 28 patients. The actual
increase was an annual average of 50 patients.
By 1942, the state hospital census had reached 2,622. In about 1958, state hospital
census peaked
at over 5,000. Our current state
hospital census is just under 700.
The Board of Control, which
traditionally oversaw the state institutions, reports for this period indicate
that many patients were beginning to show improvement as a result of the new
psychotropic drugs, like Thorazine, coming along at that time. This trend paralleled the national pattern
though possibly a little later in Oregon than the national average. The rate of decrease in state hospital
populations nationally for a 40 year period was 83%; for Oregon it was 81%. At the same time, the number of new
admissions was also increasing, a trend which continues to this day with
Oregon's community-based acute psychiatric hospital system.
Jim Carlson's 1995 paper,
"Emergent Issues in the Public Mental Health System," points out that
if the trend in hospital census had continued at the 1958 level, by 1994,
Oregon would have needed nearly 9,000 state hospital beds (we now have about
725) and the cost even five years ago would have reached $767 million per year--just
for state hospitals.
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In the late 1950s, then
Governor Mark Hatfield recognized the need for greater attention to the needs
of persons in Oregon communities for mental health programming. Until that time,
nearly all of the focus of
mental health care took place in the state institutions. The Mental Health Division
was established in 1961 to work in collaboration with county governments to promote
the
development of a system of community mental health programs. These and other
efforts eventually led to the establishment of community mental health services
in all of Oregon's 36
counties. These programs have
increasingly offered a variety of mental health services from aftercare to day
treatment to children's outpatient services.
At the time of the formation
of the Mental Health Division, the public mental health system in Oregon
consisted of three state hospitals, two training centers, 11 child guidance
clinics, and one alcohol outpatient clinic.
The Division, as directed by ORS 430, set about building a network of
locally directed community mental health services and to upgrade institutional
care and treatment. While federal
legislation in the 1960s
provided funds for establishing Community Mental Health Centers (CMHPs), Oregon
took relatively little advantage of this opportunity--only a few
such projects were developed. The areas
in which such CMHPs were established included Eastern Oregon, Lane County,
Clackamas County, and several in Multnomah County by the 1970s. Most community mental health programs were
developed without federal funds using the State's 50-50 matching formula
of state and local funds. By the early
1970s, there were a total of 27 CMHPs and 17 contract programs serving all 36
Oregon counties.
Further system and financing
refinements took place in 1973 with Oregon's Community Mental Health Programs
Act, which set up three regions for tying together state hospitals and
community programs. It also established
the structure which we currently still have with three program categories--Alcohol
and Drug (A&D), Mental and Emotional Disturbances (MED), and Mental
Retardation and Developmental Disabilities
(MR/DD). This act further divided
funding into two major categories--a continuation of the 50-50
mix for outpatient services, aftercare, training, consultation and education,
and prevention services. And 100% state
funding for "alternatives to state hospitalization" which included
24-hour emergency care, day and night treatment services, local housing resources,
and
inpatient care in community hospitals.
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However, in spite of the incentives
established in 1973, and in recognition of the difficulties in adequately
serving persons with severe mental illnesses, Oregon was one of the earliest
states to pilot a Community Support Project in the late 1970s. This project highlighted the need for case
management and outreach services for serving persons with the most severe
disorders. By 1980, Oregon continued
its attempt to focus on the most impaired individuals, both children and
adults, by establishing in statute the now familiar Priority system for
funneling funds to those most in need first.
Off and on, Oregon has
demonstrated the effectiveness of focusing on those most in need. When state hospital census pressures have
been great, crisis efforts have been increased to develop creative and cost-effective
programs as alternatives. In addition,
Medicaid Fee-for-Services funding gradually increased from the
early 1980s until the mid-1990s, when it had become the primary funding
mechanism for a range of services for adults.
Services to children were dramatically increased through the early 1990s
as a result of a lawsuit over access to Early and Periodic Screening, Diagnosis
and Treatment (EPSDT).
Two key initiatives have
driven the Oregon public mental health system over the past 10 years. One of
these was the implementation of the 1988 Governor's Task Force on Inpatient Psychiatric
Services Report--unfortunately
in the context of budget constraints induced by the unanticipated Ballot
Measure 5--and the integration of mental health services under the
Oregon Health Plan. Both initiatives have relied
heavily on federal financing. The
development of a larger but decentralized extended care treatment system for
adults (conversely stated as the closure of Dammasch State Hospital) was the
most dramatic example of Oregon's attempt to deal with the values embodied in
ORS 430 and the financial realities of fewer state General Funds for the
support of state hospitals.
The Oregon Health Plan has
been implemented using a capitated, managed care financing model for a portion
of Medicaid services to an expanded pool of Oregonians. For persons eligible for Medicaid, the old
Priority system no longer applies so that persons with treatable mental
disorders are now assured of preventive care and earlier intervention. In this sense, the Oregon public mental
health system has moved much farther toward "parity" in the treatment
of psychiatric disorders compared to other physical health care problems. While this system of financing continues to
hold much promise, there are many implementation issues remaining to be
resolved in both rural and urban areas, of which more will be heard later.
From these historical
developments, at least three areas of concern might be noted here in
conclusion. These include:
- the continued
evolution of state and county relationships in the delivery of mental
health services,
- the future role
of the state hospital and alternatives to extended care such as the
Childrens Intensive Services (residential and psychiatric day treatment services)
and
the PASSAGES-type projects which have been notably successful in reducing
reliance on state hospital services for adults; and
- the development
of adequate financing and management mechanisms so that Oregonians
with mental health needs are assured of a high quality, stable, and integrated
system of
health care delivery.
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