April 1, 2019

People with a history of mental illness are given little or no voice in how the behavioral health system functions.

The behavioral health workforce is underpaid and overworked. And too often the workforce doesn’t reflect and struggles to understand the diverse cultural communities they serve.

Panel of mental health experts applaud incoming county mental health director Ebony Clarke

State and local agencies, despite a mandate to improve the lives of those who are most vulnerable, often fail to coordinate or often even communicate — creating confusion, inefficient and ineffective use of resources and devastating service gaps.

But change is already coming.

New leaders at the top of the County’s Health Department and its Mental Health and Addiction Services Division bring expertise in behavioral health and a commitment to inclusion. State reforms may ensure better connections between service providers and governments. And planned legislation would give the public better access to care.

A panel of experts gathered for an Oregon Health Forum last week to discuss not only the challenges of a system created to care for the region’s most vulnerable residents but also the possibilities for transformation that lie ahead.

“In terms of leadership and accountability, I’m optimistic, and I can’t remember a time when I have been optimistic about this system,” said Multnomah County Commissioner Sharon Meieran, who spearheaded a systematic review of the county’s mental health system. “The tide feels like it has turned.”

Peer support

Agencies have long coordinated advisory boards made up of clients who use their services. But people recovering from mental illness and addiction argue that’s not been enough. Peers recovering from mental illness argue they are best positioned to help craft the programs intended to support them.

Kevin Fitts, a member of the Oregon Mental Health Consumer Association, says peer support will improve services, decrease cost of mental health care

“You don’t make a decision about women’s reproductive rights with 49 men and one woman at the table,” said panelist Kevin Fitts, a member of the Oregon Mental Health Consumers Association.

Nonetheless, that’s usually how policy has been made. But that can change.

Fitts said employing people in recovery as peer supports and navigators will improve clients’ outcomes while also cutting pharmaceutical and hospital costs. And agencies should promote recovery programs that allow clients to create community. It’s also more cost effective than relying solely on licensed professionals.

“If we want to reduce cost, we as a community need to support the development of natural relationships,” he said. “Friendships with meaning and consequence. Paid friends don’t meet your needs on the weekends.”

Braunwynn Franklin, a peer support provider for 12 years, said she felt marginalized and like she was being talked down to when she visited providers. “Especially if you’re a person of color, we feel less than, and that keeps us from accessing services,” she said. Working with peers just feels different — empathetic and compassionate — and that grows into a sense of community.

Mental Health and Addiction Services is seeking to create a peer-held leadership position to address a priority recommendation from an August 2018 analysis of the County’s mental health system.

Multnomah County is also moving forward with a mental health resource center for people experiencing homelessness who are living with mental health challenges. The project would be crafted in partnership with regional peer-run nonprofits, and include a day center managed by peers, a transitional shelter and transitional housing.

The county is also backing House Bill 2831, which would provide financial support for peer respite centers to support individuals with mental illness who experience acute distress, anxiety or emotional pain. The bill would require the Oregon Health Authority to adopt criteria for peer respite centers that receive funding and to monitor compliance.

Workforce

Stacy Chamberlain, the Oregon director for the American Federation of State, County and Municipal Employees, said the union represents more than 5,000 behavioral healthcare workers across the state, including at Multnomah County and also at many local nonprofits, including Cascadia Behavioral Healthcare and Central City Concern.

The union surveyed its members in 2017 to identify weaknesses in the system. The results were stark, yet unsurprising. People working in behavioral health are too often thrust into an unsustainable profession: high caseloads and intense emotional work, coupled with low wages and few opportunities for advancement or continued education.

“While they’re mission-driven, they don’t have the funding to live,” Chamberlain said. “People burn out after two years.”

The Oregon Legislature could offer some relief. House Bill 3279 would ensure parity among providers of addiction services and mental health treatment. Currently, addiction service providers are paid less than mental health providers.

Workforce issues are particularly challenging for providers of color, said Ebony Clarke, appointed last week as director of the County’s Mental Health and Addiction Services Division. Hiring a diverse staff and delivering culturally responsive services is doubly challenging in a system created largely by white people in a largely white region.

“We have to ask, who created the policies,” she said. “Why do we think we can create a system that meets the needs of communities of color when there are no people of color in the room?”

Without diverse, culturally aware leadership, Clarke said, supporting and retaining a diverse staff is impossible. And agencies, in turn, lack credibility in communities of color.

When staff of color aren’t passing their employment probation periods, Clarke said, “oftentimes organizations say the issue is the person of color, when the issue is the white manager or supervisor who doesn’t know how to support a person of color.”  

Instead of assigning mentors to help people of color navigate a white system, Clarke said, agencies should train white managers on how to support a diverse staff.

Panelists Ebony Clarke, left, along with Jeffrey Eisen, Sharon Meieran and Kevin Fitts talk about the shortcomings and opportunities in behavioral health

In her new role as division director, working with newly appointed Health Department Director Patricia Charles-Heathers, she’s poised to test the waters.

“We are in a time of opportunity,” Clarke said. “We have this opportunity to ride the wave of transformation.”

Shared vision

Commissioner Meieran campaigned on mental health reform when she ran for the Multnomah County Board of Commissioners. In her first two years as Commissioner for District 1, she spearheaded a review of the mental health and addiction services system, culminating in the 2018 report that lists more than 70 recommendations for change.

Topping that list is the need for a shared vision.

“We’re working on programs without looking at what our overall system of care should look like,” she said.

Other panelists agreed.

“There was a point in Commission Meieran’s system analysis that caught my eye. A comment that said organizations serving people with mental health concerns are ‘frenemies,’” said Dr. Jeffrey Eisen, chief medical officer for Cascadia Behavioral Healthcare. “There’s a culture of competitiveness and a lack of friendliness. In an underfunded system, agencies are competing for funds.

“But what we’re doing is much bigger than any one organization. This is in need of change. The true test of leadership is the ability to take your hat off and consider the bigger, broader needs of the population we collectively serve.”

Eisen and others will have that opportunity in the coming months as Meieran’s office launches the next phase of the mental health system analysis. The office will call on community and government partners, along with peer advocates, to prioritize needed changes. And that will begin with a shared vision that can be translated into action.

Peer advocate Fitts said he looked forward to seeing that action, and he encouraged the public to hold government accountable.

“Remember, none of these people are responsible for the system they inherited,” he said, gesturing to the panel. “But they are the future architects of the system we hope to have five or 10 years from now.”