Very thoughtful article. It's kind of shocking to see how slowly our local government is, in responding to the facts on the ground. Alan Evans of Bybee Lakes has been saying for years, "If you put a sick person in a house, you get a sick house." Also, everyone who works with the acutely ill people on the streets knows that most are not able to advocate for themselves; they are doing well to survive, much less make the right decisions about their health and security. Outreach professionals tell me that of every 100 people they connect with and offer services to, 95 decline because they prefer to continue their current life on the street. If we leave it in their hands, we will never be able to restore livability for the public at large.
Your article reminds me of the fatality a few months back of a man who was extremely psychotic, hanging knives out his windows, and when the police arrived ended up dead before he could be transported to a hospital. Housing first was always a way of warehousing the severely mentally ill. The culture in our city seems to minimize the severity of those suffering with severe mental disorders and underestimates the necessity of a good civil commitment capability. We have a systemic problem with the unavailability of hospital beds for those who are severely mentally ill, going back 20 years when emergency rooms started having to keep patients for days at a time, because of a lack of beds. The medical community has largely avoided this population because the laws governing hospitalization are impractical, lead to wasted efforts, and unreasonably focused on the right to refuse treatment in the face of obvious need for it. The recently passed HB2005 is an improvement from years of an overreliance on the "imminent dangerousness" standard. But it is administratively burdensome and takes too long to institute. It also defers the immediate decision of civil commitment for weeks, disregarding the liberty interests of those with severe mental disorders in the meantime.
A stronger criminal justice system and a stronger mental health system are necessary to improve neighborhoods and help the severely mentally ill homeless. Jail, followed by treatment under a civil commitment statute, for those who break public laws, rather than treatment in place of jail is a better balance. When is the city going to stop bending over backwards to accommodate those whose illnesses and choices defy ordinary and reasonable social conformity? It is going to take a politically savvy person to build up community support for effective and relatively short-term hospital care. A good place to start is to get judges deciding commitment in hospitals instead of in their usual chambers. A public emergency demands some creativity and innovation. Psychiatrists will jump to work in a system that can provide reasonable patient outcomes but will say no to a system that releases people back on the street after 3 days who will just go back to their old ways. Also, the police will be much more likely to go to the trouble of taking people to hospitals if they know there is a reasonable chance of not being such a bother to communities and or so obvious destructive to their personhood.
The real obstacle isn’t whether long-term psychiatric stabilization is clinically necessary—it clearly is—but whether Oregon’s public institutions are even capable of building and running the infrastructure required. Nothing in the past two decades suggests they can. A meaningful civil-commitment system requires physical facilities: secure inpatient units, subacute beds, step-down residential programs, 24/7 medical staff, transportation protocols, security, and administrative oversight. That translates into multiple buildings, each with specialized design requirements, and a workforce that doesn’t currently exist in Oregon in sufficient numbers.
Expecting state or local government to execute this efficiently is unrealistic. These are the same institutions that cannot reliably manage basic shelter operations, permitting, procurement, or oversight of their nonprofit partners. The idea that they could design, build, staff, and competently operate a multi-tiered psychiatric system—at scale, on time, and within budget—does not square with observable performance. Even outsourcing the work doesn’t solve the problem, because competent outsourcing requires contract-writing expertise, cost controls, and enforcement capacity that Oregon governments also lack. Without that, private operators can overcharge, underperform, or both.
So the usual policymaker question—“How much will it cost?”—is almost beside the point. The deeper issue is that there is no evidence Oregon’s governing institutions can deliver the system they claim to support. The gap between clinical necessity and governmental capacity is so large that simply proposing long-term civil commitment, without confronting who is supposed to build and operate it, verges on fantasy.
That’s the real dilemma: we need long-term stabilization for the most severely ill people, but we have hollowed-out institutions that cannot credibly provide it. Until that mismatch is acknowledged, the system will continue producing exactly the failures we see now.
Since I live in Oregon, I would love to see short term civil commitments maximum of six weeks, a substituted judgment consent for those committed, and commitment hearings with 12 hours of admission to the hospital, and dispersed units in all general hospitals with a percentage of hospital beds devoted to mental health hospital care. Nationally, though, there is a need for formulation of an ideal system which would require not only a change in civil commitment law, substantial revision of legal precedents, along with the further integration of mental health into hospital care delivery. I believe this was always the intention of communities following largely emptying state hospitals, that is, to have adequate acute care units for those who are non-compliant or decompensate. But it is one that cities and communities largely have ignored. Now we are paying the consequences of years of neglect and underestimation of the social costs of untreated mental health disorders. Forced psychiatric care has become a civil rights issue and as such has degraded a reasonable societal adjustment to balancing the liberty interests of the severely mentally ill with the rights of citizens for safe, civil, and beautiful public spaces. A new approach would be to clarify that issue up front where the judge can see just how ill many of those people are when they come into the emergency room. It is the failure of the judiciary to be assertive in managing societal versus individual rights in this area, which has hamstrung efforts to provide proper and reasonable treatment to very sick people and also right for communities to advocate for their community interests independent upon the interests of the patient.
I bring a realistic voice to the discussion of what could be achieved if people wanted to pursue a good system. I am not in favor of funding much of what we have. Our state hospital, with 680 patients, costs us 480,000 dollars per year, per patient. 76 percent of the people housed there are for competency to stand trial or are on a guilty but mentally ill status. Only 24 percent are there on civil commitments unrelated to legal charges or convictions. The deflection center is a waste of money. The housing first movement, another waste of money which will put my grandchildren in a much worse situation and form a permanent underclass of citizens. The nonprofits have largely been grifting off the taxpayer and achieved little. I don't like my tax dollars going to handing out needles to drug addicts either. Nor should the city by allowing PPOP to do so.
Perhaps the first step is to cut out all the programs that are not functioning well or are counterproductive like housing first and needle distribution. Second step is to recruit some lawyers to get behind significant changes in civil commitment law. HB2005 will likely lead to little improvement. Hospitals and clinicians will get behind a system that will produce substantive changes in patients admitted. They will not flock to the revolving door treatment model we have currently. Getting a legal basis for civil commitment that balances the liberty interests of the severely mentally ill, with neighborhood, family and humanitarian interests will rapidly lead to change and investment.
Change is coming on this issue. Wasting resources on ineffective programs and watching our city continue to deteriorate and seeing much of the same in many other places, will drive it eventually. We will get a strong criminal justice system and a strong mental health system when we accept fully the suffering associated with not having these systems in place.
Brave words that I'm willing to bet no one in the peacock caucus, DSA followers or anyone else will read or take to heart.
Kevin Dahlgren has been preaching this for years, with local media totally ignoring him (when someone should have hired him). Meanwhile, Candace Avalos is all over Bluesky trying to grab $-millions to keep people from "falling out" of rentals and into homelessness--with nary a word about WHY they're "falling." This is the caliber of our local leadership--which ensures that Homelessness Inc. will go on making Big Bucks from the feral.
The idea that any pol will support taking the clearly incompetent/mentally ill off the streets is ludicrous. If Mr. Perkins has any ideas what to do about that...well, we're listening. (He might start with "Get rid of the 25-percent 'winners' nonsense.")
A missing dimension in this conversation is the belief system that underlies how Multnomah County and many of its contracted nonprofits approach homelessness, addiction, and untreated mental illness. The recurring pattern that Dick Perkins describes—treatment gaps, deterioration of housing units, rising vacancies, and shrinking affordable stock—is not simply the product of poor planning, administrative drift, or insufficient funds. It is the predictable result of an ideological commitment to placing people directly from street conditions into permanent housing while avoiding any mandatory expectations related to sobriety, psychiatric stabilization, or engagement with treatment services.
Within much of the homeless-services ecosystem, addiction and chronic psychosis are framed primarily as consequences of structural oppression rather than as conditions requiring active rehabilitation. This framing treats interventions such as detox, medication compliance, and behavioral expectations inside supportive housing as forms of coercion that risk “re-traumatizing” already marginalized individuals. As a result, the system has evolved toward an absolutist, non-contingent version of Housing First—one that preserves the housing component but systematically strips away the parallel treatment and stabilization that the original model assumed.
When supportive housing is delivered without expectations and without adequate clinical backup, the consequences are predictable: untreated tenants struggle to maintain stable tenancies, units suffer costly damage, evictions rise, and sober or treatment-seeking residents avoid buildings that feel unsafe or chaotic. Providers then face unsustainable operating losses, reinforcing the very scarcity of affordable housing that the policy is intended to relieve. These outcomes are not random; they flow directly from a philosophical stance that treats structure, accountability, and conditional services as inherently suspect.
For that reason, the barrier to reform is not only technical or financial—it is conceptual. As long as key actors in county bureaus, nonprofit leadership, and activist networks hold the view that requiring treatment or stabilization constitutes an oppressive act, efforts to rebalance resources toward treatment-first approaches will be resisted. Effective change will require either a shift in these underlying assumptions or a shift in who holds institutional authority. Until then, Portland’s system will continue producing outcomes that align with its governing worldview rather than with the practical needs of the population it aims to serve.
I firmly believe there will no no assumption shift occurring. Therefore, we need a shift in institutional authority. Voters in this city really need to get a clue and actually “show up” to vote.
I think the future will see a continued shift in perspective, one which you point out as very necessary. Finding excuses for people who make mistakes, and then rewarding them for those mistakes, will no longer be the default position of most citizens who are discouraged and worn out with the status quo. Realism when it comes to mental health care, both what it can deliver, and what it can't, will come to light. Public policy and law can move forward based on it and things will get better. But when? "Structural repression" will be replaced by different words. Perhaps three words would be better for the next thirty years. How about "reasonable social conformity"?
I think, after rereading this that some additional comments, about a path forward for the city. Before we start planning and spending on what we think people will need in the future, we should consider the big shift in emphasis that this piece asserts. Let's put the horse before the cart, provide good solid and competent care based initially on short term psychiatric care in general hospitals. After one to six weeks of civil commitment time, they can go to shelters and follow up at their local community health center outpatient clinic. Building out housing for people can have the unintended consequence of incentivizing great public expense. It isn't beyond reasonable that a person might suppose having a serious drug habit might just get him or her or they or them, free housing? It is better to equivocate a bit with individuals, to ensure that they are putting their best foot forward and making genuine efforts to be productive and participatory in a quest to be personally responsible. There is a tremendous amount of variability between people and what their intentions and motivations and capacities are. We can't just sort them like a deck of cards, all the hearts in one place, the clubs in another. It is a huge task that requires a strong, capable and balanced workforce that isn't afraid of defeat. To include the severely mentally ill, have confidence in them, and reasonable expectations of them is much better than to warehouse them.
Very thoughtful article. It's kind of shocking to see how slowly our local government is, in responding to the facts on the ground. Alan Evans of Bybee Lakes has been saying for years, "If you put a sick person in a house, you get a sick house." Also, everyone who works with the acutely ill people on the streets knows that most are not able to advocate for themselves; they are doing well to survive, much less make the right decisions about their health and security. Outreach professionals tell me that of every 100 people they connect with and offer services to, 95 decline because they prefer to continue their current life on the street. If we leave it in their hands, we will never be able to restore livability for the public at large.
Your article reminds me of the fatality a few months back of a man who was extremely psychotic, hanging knives out his windows, and when the police arrived ended up dead before he could be transported to a hospital. Housing first was always a way of warehousing the severely mentally ill. The culture in our city seems to minimize the severity of those suffering with severe mental disorders and underestimates the necessity of a good civil commitment capability. We have a systemic problem with the unavailability of hospital beds for those who are severely mentally ill, going back 20 years when emergency rooms started having to keep patients for days at a time, because of a lack of beds. The medical community has largely avoided this population because the laws governing hospitalization are impractical, lead to wasted efforts, and unreasonably focused on the right to refuse treatment in the face of obvious need for it. The recently passed HB2005 is an improvement from years of an overreliance on the "imminent dangerousness" standard. But it is administratively burdensome and takes too long to institute. It also defers the immediate decision of civil commitment for weeks, disregarding the liberty interests of those with severe mental disorders in the meantime.
A stronger criminal justice system and a stronger mental health system are necessary to improve neighborhoods and help the severely mentally ill homeless. Jail, followed by treatment under a civil commitment statute, for those who break public laws, rather than treatment in place of jail is a better balance. When is the city going to stop bending over backwards to accommodate those whose illnesses and choices defy ordinary and reasonable social conformity? It is going to take a politically savvy person to build up community support for effective and relatively short-term hospital care. A good place to start is to get judges deciding commitment in hospitals instead of in their usual chambers. A public emergency demands some creativity and innovation. Psychiatrists will jump to work in a system that can provide reasonable patient outcomes but will say no to a system that releases people back on the street after 3 days who will just go back to their old ways. Also, the police will be much more likely to go to the trouble of taking people to hospitals if they know there is a reasonable chance of not being such a bother to communities and or so obvious destructive to their personhood.
The real obstacle isn’t whether long-term psychiatric stabilization is clinically necessary—it clearly is—but whether Oregon’s public institutions are even capable of building and running the infrastructure required. Nothing in the past two decades suggests they can. A meaningful civil-commitment system requires physical facilities: secure inpatient units, subacute beds, step-down residential programs, 24/7 medical staff, transportation protocols, security, and administrative oversight. That translates into multiple buildings, each with specialized design requirements, and a workforce that doesn’t currently exist in Oregon in sufficient numbers.
Expecting state or local government to execute this efficiently is unrealistic. These are the same institutions that cannot reliably manage basic shelter operations, permitting, procurement, or oversight of their nonprofit partners. The idea that they could design, build, staff, and competently operate a multi-tiered psychiatric system—at scale, on time, and within budget—does not square with observable performance. Even outsourcing the work doesn’t solve the problem, because competent outsourcing requires contract-writing expertise, cost controls, and enforcement capacity that Oregon governments also lack. Without that, private operators can overcharge, underperform, or both.
So the usual policymaker question—“How much will it cost?”—is almost beside the point. The deeper issue is that there is no evidence Oregon’s governing institutions can deliver the system they claim to support. The gap between clinical necessity and governmental capacity is so large that simply proposing long-term civil commitment, without confronting who is supposed to build and operate it, verges on fantasy.
That’s the real dilemma: we need long-term stabilization for the most severely ill people, but we have hollowed-out institutions that cannot credibly provide it. Until that mismatch is acknowledged, the system will continue producing exactly the failures we see now.
Since I live in Oregon, I would love to see short term civil commitments maximum of six weeks, a substituted judgment consent for those committed, and commitment hearings with 12 hours of admission to the hospital, and dispersed units in all general hospitals with a percentage of hospital beds devoted to mental health hospital care. Nationally, though, there is a need for formulation of an ideal system which would require not only a change in civil commitment law, substantial revision of legal precedents, along with the further integration of mental health into hospital care delivery. I believe this was always the intention of communities following largely emptying state hospitals, that is, to have adequate acute care units for those who are non-compliant or decompensate. But it is one that cities and communities largely have ignored. Now we are paying the consequences of years of neglect and underestimation of the social costs of untreated mental health disorders. Forced psychiatric care has become a civil rights issue and as such has degraded a reasonable societal adjustment to balancing the liberty interests of the severely mentally ill with the rights of citizens for safe, civil, and beautiful public spaces. A new approach would be to clarify that issue up front where the judge can see just how ill many of those people are when they come into the emergency room. It is the failure of the judiciary to be assertive in managing societal versus individual rights in this area, which has hamstrung efforts to provide proper and reasonable treatment to very sick people and also right for communities to advocate for their community interests independent upon the interests of the patient.
I bring a realistic voice to the discussion of what could be achieved if people wanted to pursue a good system. I am not in favor of funding much of what we have. Our state hospital, with 680 patients, costs us 480,000 dollars per year, per patient. 76 percent of the people housed there are for competency to stand trial or are on a guilty but mentally ill status. Only 24 percent are there on civil commitments unrelated to legal charges or convictions. The deflection center is a waste of money. The housing first movement, another waste of money which will put my grandchildren in a much worse situation and form a permanent underclass of citizens. The nonprofits have largely been grifting off the taxpayer and achieved little. I don't like my tax dollars going to handing out needles to drug addicts either. Nor should the city by allowing PPOP to do so.
Perhaps the first step is to cut out all the programs that are not functioning well or are counterproductive like housing first and needle distribution. Second step is to recruit some lawyers to get behind significant changes in civil commitment law. HB2005 will likely lead to little improvement. Hospitals and clinicians will get behind a system that will produce substantive changes in patients admitted. They will not flock to the revolving door treatment model we have currently. Getting a legal basis for civil commitment that balances the liberty interests of the severely mentally ill, with neighborhood, family and humanitarian interests will rapidly lead to change and investment.
Change is coming on this issue. Wasting resources on ineffective programs and watching our city continue to deteriorate and seeing much of the same in many other places, will drive it eventually. We will get a strong criminal justice system and a strong mental health system when we accept fully the suffering associated with not having these systems in place.
Brave words that I'm willing to bet no one in the peacock caucus, DSA followers or anyone else will read or take to heart.
Kevin Dahlgren has been preaching this for years, with local media totally ignoring him (when someone should have hired him). Meanwhile, Candace Avalos is all over Bluesky trying to grab $-millions to keep people from "falling out" of rentals and into homelessness--with nary a word about WHY they're "falling." This is the caliber of our local leadership--which ensures that Homelessness Inc. will go on making Big Bucks from the feral.
The idea that any pol will support taking the clearly incompetent/mentally ill off the streets is ludicrous. If Mr. Perkins has any ideas what to do about that...well, we're listening. (He might start with "Get rid of the 25-percent 'winners' nonsense.")
A missing dimension in this conversation is the belief system that underlies how Multnomah County and many of its contracted nonprofits approach homelessness, addiction, and untreated mental illness. The recurring pattern that Dick Perkins describes—treatment gaps, deterioration of housing units, rising vacancies, and shrinking affordable stock—is not simply the product of poor planning, administrative drift, or insufficient funds. It is the predictable result of an ideological commitment to placing people directly from street conditions into permanent housing while avoiding any mandatory expectations related to sobriety, psychiatric stabilization, or engagement with treatment services.
Within much of the homeless-services ecosystem, addiction and chronic psychosis are framed primarily as consequences of structural oppression rather than as conditions requiring active rehabilitation. This framing treats interventions such as detox, medication compliance, and behavioral expectations inside supportive housing as forms of coercion that risk “re-traumatizing” already marginalized individuals. As a result, the system has evolved toward an absolutist, non-contingent version of Housing First—one that preserves the housing component but systematically strips away the parallel treatment and stabilization that the original model assumed.
When supportive housing is delivered without expectations and without adequate clinical backup, the consequences are predictable: untreated tenants struggle to maintain stable tenancies, units suffer costly damage, evictions rise, and sober or treatment-seeking residents avoid buildings that feel unsafe or chaotic. Providers then face unsustainable operating losses, reinforcing the very scarcity of affordable housing that the policy is intended to relieve. These outcomes are not random; they flow directly from a philosophical stance that treats structure, accountability, and conditional services as inherently suspect.
For that reason, the barrier to reform is not only technical or financial—it is conceptual. As long as key actors in county bureaus, nonprofit leadership, and activist networks hold the view that requiring treatment or stabilization constitutes an oppressive act, efforts to rebalance resources toward treatment-first approaches will be resisted. Effective change will require either a shift in these underlying assumptions or a shift in who holds institutional authority. Until then, Portland’s system will continue producing outcomes that align with its governing worldview rather than with the practical needs of the population it aims to serve.
I firmly believe there will no no assumption shift occurring. Therefore, we need a shift in institutional authority. Voters in this city really need to get a clue and actually “show up” to vote.
I think the future will see a continued shift in perspective, one which you point out as very necessary. Finding excuses for people who make mistakes, and then rewarding them for those mistakes, will no longer be the default position of most citizens who are discouraged and worn out with the status quo. Realism when it comes to mental health care, both what it can deliver, and what it can't, will come to light. Public policy and law can move forward based on it and things will get better. But when? "Structural repression" will be replaced by different words. Perhaps three words would be better for the next thirty years. How about "reasonable social conformity"?
I think, after rereading this that some additional comments, about a path forward for the city. Before we start planning and spending on what we think people will need in the future, we should consider the big shift in emphasis that this piece asserts. Let's put the horse before the cart, provide good solid and competent care based initially on short term psychiatric care in general hospitals. After one to six weeks of civil commitment time, they can go to shelters and follow up at their local community health center outpatient clinic. Building out housing for people can have the unintended consequence of incentivizing great public expense. It isn't beyond reasonable that a person might suppose having a serious drug habit might just get him or her or they or them, free housing? It is better to equivocate a bit with individuals, to ensure that they are putting their best foot forward and making genuine efforts to be productive and participatory in a quest to be personally responsible. There is a tremendous amount of variability between people and what their intentions and motivations and capacities are. We can't just sort them like a deck of cards, all the hearts in one place, the clubs in another. It is a huge task that requires a strong, capable and balanced workforce that isn't afraid of defeat. To include the severely mentally ill, have confidence in them, and reasonable expectations of them is much better than to warehouse them.