In the best of all worlds, the behavioral health programs in Oregon would all be interconnected, with well-worn pathways between them that lead patients through an expected system of recovery.

Meet Jack, a 50-year-old man in Klamath Falls who admits to his exasperated wife, Mary, that his heavy drinking has finally gotten the better of him and he wants and needs help.

The two of them call a crisis line, the crisis line tells them the closest rehab center, the rehab center takes him, and if he needs a higher level of care, they will transport him immediately to where help is waiting. Once stabilized, Jack would be referred to a group therapy program or an intensive outpatient experience or a partial hospitalization program and then, as he recovered, longer-term outpatient therapy - all these programs handing off to each other with warm hands and glad hearts. Throughout this recovery journey, Jack’s primary care physician would be kept in the loop and be following along passively until their care was needed.

In the worst of all worlds, there would be a crisis line, but it didn’t actually connect Jack to any program, and if it did properly connect him to the beginning of his needed help, that program would not have access. And if by chance it did have access, it was for a service that didn’t meet Jack’s needs of a 50-year-old man living in Klamath Falls with a drinking problem but perhaps a 20-year-old living in Portland with a methamphetamine addiction. In the worst of all worlds, these programs would not know about the existence of one another. In the worst of all worlds, Jack would be stabilized, then returned home without follow-up care because there wasn’t any. For Jack’s primary care physician trying to administer the best possible care in the worst of all worlds, they would not know where Jack was or what he was being prescribed or even what care he was receiving because programs were not connected electronically to medical records. Unfortunately, in 2023, Oregonians live in this exact world - the worst of all worlds.

I have been the administrative head of the Department of Psychiatry for over 15 years. This system wasn’t great when I arrived and has devolved into something far worse over time. Despite doing everything I can do to advocate for better care for patients in behavioral health crises, I am pretty disconsolate at the state of affairs. And before you judge me too harshly, please consider this - I’m not a policy maker, just a doer delivering the services with the limited funding allocated to me, and from my vantage point there were only limited options I could employ to be of any use:  

1.     Fix our hospital care

2.     Encourage and grow our outpatient services

3.     Employ best practices in treating the existing patients

4.     Keep our training programs open and full

Oregon Health and Science University, in collaboration with Legacy Health, Adventist Health, and Kaiser Permanente put together Unity Center for Behavioral Health and fixed our aging hospital issue by creating that beautiful place. We have kept our outpatient services staffed and grown our Child and Adolescent Outpatient program, including expanding our consult/liaison service to Doernbecher, Unity, and Randall Hospitals. We have kept our Intercultural Psychiatry Program and African American centric outpatient programs intact, and we have expanded our adult outpatient clinic and provide measurement-based care in all our programs. Our training programs for residents and fellows in Psychiatry are full, expanding, and vital to providing next generation care to patients.

Yet it isn’t enough. I know that, and my colleagues around me know that. It is so very complicated, all the care needed for our population, that we only touch the surface of this problem. What we know is that we only touch a very small percentage of the population needing help. And to do better, we need to be connected better with all other existing resources.

Consider the consequences of not making these connections early on in a patient’s recovery. Let’s suppose that our 50-year-old friend, Jack in Klamath Falls who has a drinking problem, is discharged from a stabilization center without any follow-up care. Jack picks up where he left off and resumes drinking. Jack loses his job. Mary leaves him. He loses his home. And now Jack is desperate. He breaks into a liquor store one night to stock up on alcohol but is arrested down the street before he gets too far, having passed out in front of Safeway clutching gallon jugs of his favorite drink – Jack Daniels. Sadly, his behavioral health problem has now crossed paths with the justice system.

Jack’s thrown in jail, charged with breaking and entering and will stand in front of a judge the next Monday morning. The kind judge will say to him, “Your problem isn’t that you’re a criminal; it’s that you’re a drunk”, to which Jack does not disagree. But she can’t just drop the charges, so she orders Jack to a treatment program. Jack would like to comply, but he can’t – it’s simply too difficult to get into a commodity so precious and scarce. It takes more energy than he has to figure out the right program for him when he hears the word “no” the first time. Things escalate and Jack ends up in jail again and again and again until the charges are so serious – let’s say that Jack accidentally kills somebody in the commission of his latest robbery – that he is now bound for the Oregon State Hospital to restore back his capacity to aid and assist in his own defense of a serious felony after he shows up in court in a psychotic stupor.

This scenario plays itself out day after day, month after month, time after time in Oregon. However, in Oregon, the system is set up to fail its patients and workforce, and it fails spectacularly when the only thing this drunk from Klamath Falls gets is an expedited stay at the Oregon State Hospital, along with a criminal record. The destruction of his life, loss of his partner, loss of his work, loss of his home, loss of his self-respect, and loss of his simple dignity is complete because he didn’t get the necessary treatment at the time when he was ready to make a change. If this story sounds far-fetched to you, it’s not. It’s based on someone I love when I was the exasperated relative trying to support a loved one getting help from a disorganized system.

I can hear somebody say, “Well, he didn’t try hard enough back at the beginning of his problems.” Anybody in this situation in this state knows that you must be bloody fixated on understanding a system so mind-boggling complex that it would take a Type A genius to navigate a path towards success. The proof of that is visually seen on the streets of our largest communities and even in the far reaches of rural counties. There are tens of thousands of homeless people, broken, drug-addicted, sometimes psychotic, living in rank conditions and cycling through the justice system and our hospitals, waiting for the day when somebody will reach out to them and show them a better way to cope with the lot in life handed to them.

Not only are the people needing help losing hope of ever finding it, our behavioral health workforce is losing hope as well. We have lost a significant portion of our workforce at all levels and they’re leaving because they aren’t satisfied with a job by doing the one thing they’re motivated to do – help people heal.  

The only hope I have right now, and this is both the saddest sentence I’ve ever written and the truest statement I’ve ever made, is that we can as doers and fixers try to make visual for policymakers the brokenness of all these connections. We must help the existing programs find each other to make these connections on behalf of patients. We must give the workforce some hope so that they are confident that they can help Jack and his family. Through the Oregon Behavioral Health Coordination Center, we want to show the caregivers a simplified roadmap on how to connect patients to the help they need. It seems simple in concept. In reality, the back-end mechanisms to make it simple are very, very complex.  

To be completely transparent, at the beginning it will be a mess with more visualization of brokenness than actually helping anybody. But once you get me and all of my ilk around the state who really want to stick to this and make this solution work right, the hope is that we will fix one thing, and then another thing, and then two more things, until we cobble together a coherent picture of where all the points of light are and how to get the right people towards them when they need it most. That’s the hope, at least. And…

I’m sticking to this hope.

*Names changed to protect privacy.