By Paul Kiefer

As Washington lawmakers grapple with the shortcomings of the state’s behavioral health system, Sen. Manka Dhingra (D-45, Redmond) is sponsoring a bill that aims to open beds in the two state-run psychiatric hospitals, Eastern and Western State, to provide short-term mental health treatment beds for people with serious behavioral health disorders to stabilize so that a court can decide whether they need to be hospitalized long-term, a process called civil commitment. Neither hospital currently provides any short-term beds; instead, they provide long-term treatment, mostly to people accused of crimes who have been deemed incompetent to stand trial.

The bill would require the state hospitals to admit patients who need to undergo the two weeks of mental health evaluations and treatment needed for a civil court to decide whether they belong in long-term care. It does not set aside a specific number of beds for this purpose.

Across Washington, short-term psychiatric beds are hard to come by, especially for people with a record of violent crime. To fill the gap, Washington courts send hundreds of people each year to regular hospitals, which usually aren’t equipped to provide the level of mental health care that a psychiatric hospital can; some patients with severe behavioral health disorders even end up in emergency room beds, and others are turned away, often into homelessness. In September 2021 alone, King County courts committed 361 people to non-psychiatric hospitals.

Dhingra’s bill would prioritize opening beds at state hospitals for people whose criminal records would make it difficult to place them elsewhere.

The proposal sparked pushback from mental health advocates, who argue that the bill would only make it more difficult for the state’s Department of Social and Health Services (DSHS)—the agency that runs the two state hospitals—to manage its backlog of patients who either need to get into the hospitals for long-term, court-ordered treatment or who are sitting in the hospitals waiting for housing after their treatment ends. Advocates also say that hospitalizing people who need short-term treatment in large institutions far away from where they live works against the state’s larger goal of treating people with behavioral health disorders in their own communities.

In Dhingra’s view, Eastern and Western State Hospitals should help meet the demand for short-term treatment—especially for people that other hospitals refused to treat because of their criminal record. “The hospitals are already seeing this group of people,” she said. “They don’t get the treatment they need in the civil system; they then commit felonies and wind up at Western State. We should take them in when they first come into contact with the civil system instead of waiting for them to commit a felony.” Using the state hospitals may be a temporary solution, Dhingra added, until more local psychiatric beds open; since 2016, DSHS has been investing in small, community-based treatment facilities across the state, but that effort hasn’t met the demand for beds.

Some mental health advocates and DSHS itself, however, say Eastern and Western State Hospitals stopped handling short-term treatment for a reason. During a hearing on the bill last week, DSHS Assistant Secretary Kevin Bovenkamp told lawmakers that opening the hospitals to short-term patients again “moves us in the wrong direction.”

“We worked for years to shift the focus towards getting people places to recover in their own communities,” said Laura Van Tosh, an advocate who previously spent time as a patient at Western State Hospital. “If this plan goes through, it will upturn all those efforts. The last thing we want to do is put more people in the state hospitals.”

From Van Tosh’s perspective, while the bill might get people into psychiatric beds faster, a short stay in a large state hospital is far less useful in a patient’s recovery than treatment in their own community. “From where I stand, this doesn’t seem patient-centered, and it doesn’t seem focused on recovery,” she said. “It just seems like a mechanism to get homeless people off the streets and keep them in hospital beds for who knows how long.” People experiencing homelessness are more likely to be civilly committed, and people who have been civilly committed are more likely to become homeless after they are released

Todd Carlisle, an attorney with Disability Rights Washington, told lawmakers that opening new civil beds at the state’s psychiatric hospitals may not actually solve the problem Dhingra’s bill aims to address. Although a 2014 settlement agreement in federal court created a one-week deadline for transferring people with serious behavioral health disabilities from jails to a hospital, the wait time to get into Eastern or Western State is already more than 30 days for many people waiting to be transferred from county jails. These delays have cost the state millions of dollars in contempt fines.

Meanwhile, Carlisle added, patients cleared for discharge at Western State wait an average of more than 200 days to be released—a consequence of a shortage of re-entry housing for people with criminal records, among other factors.

Not all mental health advocates agree that smaller, local psychiatric hospitals are the right solution to the shortage of short-term treatment beds. Jerri Clark, who founded the advocacy group Mothers of the Mentally Ill after her son died by suicide, argues that the smaller treatment facilities aren’t usually able to take care of patients with the most serious behavioral health disorders. Clark’s son cycled through jails and treatment facilities as he dealt with bouts of psychosis.

“I found it alarming that the treatment facilities where my son was detained had such limited staffing, and I learned later that federal law limits the size of those treatment facilities,” she said, referring to a federal law capping the number of patients at psychiatric facilities that rely on Medicaid. “Even if we built a lot more of those local treatment facilities, they might not be able to keep enough staff to treat someone who needs really intensive care… I’m not saying that Western or Eastern State Hospitals are perfect, but they have medical resources to build on that don’t exist elsewhere.”

Dhingra has proposed two other bills that would expand involuntary outpatient psychiatric services in both civil and criminal cases, which she hopes would relieve some of the pressure on the state hospitals, though both bills outline routes for patients to transfer from outpatient care to state hospitals if their mental health deteriorates. Disability Rights Washington and other advocates also raise concerns about those bills, arguing that coercing people into mental health treatment and about creating new paths into inpatient psychiatric treatment at the state hospitals that could exacerbate the existing shortage of bed space.

“The floodgates of institutionalization will be opened,” Van Tosh said.

Dhingra argues that the state has to address the failures of the state’s mental health treatment system. “People opposed to this bill might be skeptical of systems change,” she said, “but we need efficiency and effectiveness that we don’t have right now.”