Five No-Cost Changes To Improve Care For Mental Health Patients In King County
There are two pathways through the Mental Health world; voluntary and involuntary commitment. The involuntary path is ITA court which includes detainment by court approved ‘Designated Mental Health Professionals’ (DMHPs), the voluntary path includes the Criminal Justice Department’s Mental Health Court as well as other public and private programs.
The following five changes will drastically reduce costs and improve both the quality and quantity of mental health services available to residents of King County.
#1 Enforce Least Restrictive Orders (LRA)
When a court releases a patient from custody on a Least Restrictive Alternative Order (LRA) the patient is still under the jurisdiction of the court and must comply with specific court-ordered requirements during the duration of the hold (usually 90 days).
Under an LRA, a patient is only being released from custody because they agree to an order containing a specific written set of behavioral guidelines with which they agree to comply. This usually includes counseling appointments and medication.
The problem is that there is currently no monitoring and no consequences for violating the order. The result is mental health patients immediately violating the LRA and circulating through the system over and over again. To resolve this:
• Have a specific contact point for family, friends or others to report LRA violations
• Followup with an intervention, arrest, an ITA commitment, if court ordered LRA conditions are violated – as patients are told.
#2 Don’t Release DMHP Designated Danger Risks Without A Trial or Hearing
When a person is detained by DMHPs for being a ‘danger to themselves or others’ they should not be released on technical or legal grounds prior to a courtroom hearing. As an example, patients are released prior to a hearing if an involved ER doctor does not communicate with the DMHPs effectively. This can be simply because the ER doctor is in surgery or has gone home for the day. The patient is then sent back out on the street immediately, with no hearing, in the same mental state, ‘a danger to themselves or others.’
To resolve this:
• Eliminate any option for a defense attorney to find legal loopholes allowing the patient to be released prior to trial once detained by DMHPs.
• Eliminate Substitute Senate Bill 5456, which requires a DMHP performing a civil commitment investigation to consult with an examining emergency room physician prior to a commitment. While the intention of this bill was to enhance care, a result has been that patient’s defense attorneys often use it as a loophole to get their mentally ill patients released prematurely.
#3 Eliminate Immediate Stabilization-Release Policy
When a person is involuntarily detained by the DMHPs they are often medically stabilized and released during their initial three day detention. This is the beginning of the system breakdown. Typically, a person who is involuntarily committed does not follow up with medication, counseling or other treatment once they are released. When they are released prematurely the cycle repeats over and over again at great risk and expense.
When a patient is detained by the DMHPs it is not a pleasant experience. They are grabbed off the street or from their home by strangers and police officers, then handcuffed, tied to a gurney, put in the back of an ambulance and taken to a mental health hospital against their will. The process alone is traumatic.
The mental health facility then issues medication which often stabilizes the patient in 24 to 48 hours, thereby qualifying them for release.
The ‘stabilized’ patient typically walks out of the facility, stops taking the medication and is right back where they were only days ago, only worse, as their trust level has gone down, their caretaker now has less influence and all parties are now at greater risk.
#4 Eliminate Single Person Gateways
Many mental health programs and facilities have only one designated person, often called an evaluator or intake manger, who makes all of the program admission and release decisions. While it may provide a level of consistency, it can also cause capricious roadblocks when that person’s perspectives, prejudices, or personality creates a barrier to appropriate treatment for a patient.
This can also be the case when a prosecutor with no mental health expertise is assigned a case and thereby given virtually absolute power over the patients options, which may not be appropriate for a patient with a mental health challenge.
#5 Create A System Of Program Coherence And An Ombudsman
Right now the person in my care is responsible be in compliance with and answer to seven different courts and programs; Superior Court, Municipal Court, Mental Health Court, CCAP, Sound Mental Health, PACT, his Defense Attorney, the Prosecutor, and the Department of Corrections.
While each program may be clear about the scope and requirements for their specific program, trying to navigate the often conflicting requirements of all these programs is a daunting task with severe consequences that I have not yet figured out.
Resolution would involve eliminating redundancy between programs and courts, creating a coherent interdepartmental process specifically for those with mental health needs, and creating an Ombudsman Office to help those with mental health challenges find resolution for their specific challenges so they can navigate their way through the often arduous journey back to health.
In 2015 Washington State was 48th on the list for quality care of the mentally ill. Last year we dropped to 51st – last place; the worst place in the country to get mental health help, yet we spend more money on mental health services than most other states. There is no reason a prosperous county like ours, in a prosperous state like Washington, can’t move to the top of the list, even without any additional resources.
Whenever lack of services becomes an issue the justification I always hear is lack of adequate budget. While it appears that demand for adequate mental health services far outstrips supply, streamlining existing resources, enhancing the ineffectiveness of the courts, and treating patients effectively the first time through will significantly increase both the quality and quantity of mental health services provided without any increase in budget.
Although there are many efficiency changes that could be made, the fundamental problem we face is with the courts. In an effort to insure the inalienable human rights of the mentally ill, they have consequently denied them services, obstructed the ability of friends and family to help, and put the general population at risk.
Treating Patients Effectively The First Time Through Is The Answer.
As I converse with family members in courtrooms, emergency rooms, mental health hospitals and NAMI classrooms, one topic always comes up, a discussion of how long these family members have been at this, how hard they have struggle year after year, how many times they have been to court, how many times their loved one has been dragged from their homes, and how badly they wish they had never put them through this for no result. Yet, desperate caretakers know of no other alternative.
What if he had received adequate follow-up treatment or wasn’t released for technical glitches? What if he had received the help he so desperately needs five or even ten years ago instead of being trashed by the system over and over again? Between the delays in his care and the systemic abuses he is so much worse off for participating in these programs. There are hundreds, if not thousands of King County residents in the same situation.
Had the LRA been enforced the first time it would likely have spared both of us, the County and the State all sorts of unnecessary expense and massively improved the quality of our lives as well as allowing significant funds for other mental health patients.
The most expensive cost per client is for housing. While housing is necessary in many instances, it is expensive, overburdened, and not always necessary. Rather than incurring the ongoing and expensive cost of providing housing, many, if not most of the patients needing mental health services have a family, friend or relative who is currently providing housing and doing their best to take care of their loved one on their own. This is often an arduous, if not impossible task without assistance. Why not give them a little boost that will help them be successful rather taking on the entire task bureaucratically at enormous expense.
Without increasing the budget, many times more clients could be served by using existing resources effectively. That number increases exponentially when you consider that each person attempting to get help cycles through a dysfunctional system over and over again rather than being treated effectively the first time and moving on.
I expect that $1,000,000 has been spent on the person in my care over the past ten years with no effective treatment, numerous premature releases, and no positive results. This is not because he is a particularly difficult patient, but because, like everyone else, he goes through the ineffective system over and over again without getting any help.
Money alone doesn’t solve the problem, effective help does.
• Legal community making mental health decisions is entirely inappropriate
• Reasonable intake system – no waiting until threats or damage – Joel’s Law
• Provide humane activities/life in mental health hospitals (ping pong & puzzles?)
• Consistent relationships with service providers
• Immediate specialized appeal process
This outline was presented to the King County Counsel, 2016.