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August 11, 2014 at 5:45 AM

With the end of psychiatric boarding, a new mental health crisis decades in the making

The state Supreme Court’s opinion on Thursday invalidating psychiatric “boarding” has thrown Washington’s already-messy mental-health system into chaos.

An estimated 350 very ill people across the state are currently being warehoused in emergency rooms, usually without treatment, because the state hasn’t funded enough psychiatric beds. State and county mental-health managers are scrambling to suddenly find beds for them. If they don’t, the patients could be cut loose, with potentially dire consequences, particularly to themselves.

King County mental health director Jim Vollendroff told me Friday morning eight people were in limbo. “We’re scrambling for those,” he said.

What’s disturbing is that Thursday’s ruling, In The Matter of The Detention of D.W., seemed to catch the state by surprise, with no advance planning. The state Department of Social and Health Services and Pierce County lost this case before a Pierce County Superior Court Commissioner, a judge and at the Court of Appeals. Their thin legal argument contended that patients were better off in ER beds, even untreated, because they were “warm and dry.” The result at the Supreme Court was an unequivocal 9-0 ruling with a simple message: if the state is going to detain some in psychiatric crisis, it must treat them.

It’s also useful to remember the history of how Washington got to this point, returning to the inhumane warehousing of very sick people. “We’ve underfunded the mental-health system for decades, and it’s now coming to haunt us,” said Victoria Roberts, deputy director of the Department of Social and Health Services’ mental-health division.

This bad scenario has been building since 1979, the year of Washington’ involuntary-treatment law. Justice Steven Gonzalez, who wrote the Thursday Supreme Court ruling, summed up the history:

By 1981, Western State Hospital, which at the time acted as an evaluation and treatment center, was filled to capacity and refused to accept more patients until it was ordered to by this court. Overcrowding has continued.

Pierce County sued the state for discharging still-sick patients from Western State Hospital from 2001 to 2004, in some cases dumping vanloads of people off at Tacoma homeless shelters. Other lawsuits followed. The state loses, settles, promises reform. Rinse, repeat.

Washington neglected to fully fund the county-based outpatient mental-health system or the state-run psychiatric hospitals. On inpatient side, Between 2000 and 2010, Washington reduced beds certified to take involuntarily committed patients by 36 percent – a net decrease of nearly 200 – and plunged to near-last in the nation for access to psychiatric beds per capita.

At the same time, the Legislature, squeezed by the recession, also stripped $90 million from preventative outpatient care. More than $57 million alone was cut in the 2009-2011 budget.

The result was obvious: The number of people in psychiatric crisis jumped, particularly in King County. The involuntary treatment law says that people deemed so sick – that they’ll likely hurt themselves or others – must be held in a facility able to treat their illness and restore them to health.

But without enough beds, the state turned to a little-known administrative rule, called “single bed certification.” It was intended to allow involuntarily committed patients to be temporarily held in hospitals not certified to treat their mental illness, but able to provide medical care not available at standalone psychiatric facilities, such as dialysis.

The grim truth is that “single bed certifications” became a patch on a system full of holes. Instead of assuring intensive medical care, boarded patients often got little treatment at all. The number of “single bed certifications” nearly tripled since 2007, to 3,412 last year.

The Supreme Court described it accurately: “warehousing.” But the high court isn’t the only one that’s found Washington’s access to inpatient treatment contemptible. King, Pierce and Snohomish county judges have ruled DSHS in contempt in criminal cases where Western State Hospital is supposed to restore defendants’ competency. Currently, an estimated 100 defendants are backed up in county jails, sometimes for months, waiting competency restoration ordered by both the law and by judges.

Now that boarding has been declared illegal, and the mental health system is in an imminent crisis, Washington is at a fork-in-the-road moment.

The state Legislature – and particularly Speaker of the House Frank Chopp – has prioritized better mental-health funding in the past two budgets. Chopp has quietly convened a small task force and chipped away the budget and policy backlog, adding operational funding for about 50 beds, as well as new preventative care teams.

But many of those beds haven’t materialized because operating funds don’t build buildings, and opening a psychiatric facility is expensive. The state Senate’s Majority Coalition did a disservice to families with mental illness last session by not passing a capital budget, which included $11.2 million help build new facilities. Had the budget passed, Friday’s crisis have would have been smaller.

More mental-health investment must not be crushed by the $2 billion budgetary iceberg of the education-funding McCleary decision, due next year. If it does, Thursday’s In The Matter of the Detention of D.W. will be just the beginning of court oversight of Washington’s mental health system.

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Comments | Topics: dshs, mental health


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