Western State Hospital in Lakewood
OLYMPIA — After Joshua Stuller began wrestling with mental-health issues, his stepfather discovered journal entries in October 2015 that included threatening language and some names. He called a mental-health crisis line, hoping a professional could help his son.
Instead, police appeared and arrested Stuller for the journal entries, according to him and his stepfather. Prosecutors charged Stuller with attempted murder.
The arrest dropped Stuller into the criminal and legal vortex that often substitutes for Washington's mental-health system.
He spent 13 months in solitary confinement in Chelan County's jail, according to a lawsuit he filed against the county. The jail denied Stuller adequate mental-health treatment and failed to properly manage his medications, according to the lawsuit, causing "severe emotional and psychological suffering."
In jail, Stuller says, he waited more than a month for a competency exam to determine whether he was fit to stand trial -- a length of time that violates the Constitution, a federal court ruled earlier that year.
After pleading not guilty by reason of insanity to reduced charges, Stuller went to Eastern State Hospital. There, workers found the right mix of medications to stabilize him, he said, and he earned his release last year.
"What's happened to me must not happen again," Stuller, now 30, told people gathered Friday at a mental-health advocacy event in Olympia. "It's traumatic."
Stuller's appearance in Olympia comes at a key moment. State lawmakers and Gov. Jay Inslee have vowed to overhaul Washington's mental-health system and fundamentally shift psychiatric care toward community treatment and prevention.
It's a gargantuan task filled with numerous challenges. Chief among them: a severe shortage of mental-health treatment beds and qualified workers, as well as the state's largest psychiatric facility, Western State Hospital, deemed so troubled that it lost federal certification and funding.
Under the proposals by Inslee and lawmakers, many state hospital patients would be moved to community placements. Short-term crisis and detox centers and outpatient programs would treat people before they got too sick. Residential housing, with staff or case managers, would care for people with chronic mental illness and dementia.
Perhaps 1,000 beds could be added. The price would easily top $1 billion in the coming years.
"My hope, really, is that in the next couple years, you're going to see the demand for long-term inpatient state beds go down because we're able to help people earlier on," said Sen. Manka Dhingra, D-Redmond. "That's the hope."
With the regularly scheduled legislative session ending April 28, lawmakers and Inslee have just weeks to commit to a historic blueprint for caring for some of the state's most vulnerable residents.
Clock is ticking
It would be the most ambitious comprehensive statewide overhaul by any state in recent memory, said Lisa Dailey of the Treatment Advocacy Center, a Virginia-based nonprofit.
"It's a recognition that radical changes were needed to help Washingtonians attain a working" system for people suffering from mental illness, Dailey wrote in an email.
And it's overdue. Despite pouring nearly $1 billion into mental-health spending in recent years, lawmakers and Inslee have struggled to turn the system around. For years, a shortage of psychiatric beds has left people with severe mental-health diagnoses, such as schizophrenia, to languish in emergency rooms and jails.
Court orders in 2014 and 2015 condemned each of those practices. The lawsuit that focused on the jail detentions, known as the Trueblood decision, cost the state $83 million in fines.
Then federal regulators last year decertified Western State Hospital, costing Washington $53 million in annual funding. The approximately 850-bed hospital in Lakewood has been dogged by poor federal-inspection reports detailing health and safety issues. Families have complained about the treatment of relatives there, while hospital workers have suffered gruesome assaults.
The state hospitals are a crucial chokepoint in a struggling system.
Many of the people in limbo are waiting for beds to open up at Western State or Eastern State, in Spokane County. Others, involuntarily committed by civil courts, can't leave Western State because there are no beds in the community.
Democratic and Republican lawmakers working on mental-health issues -- along with the governor -- broadly agree on a plan. But as they craft final budget agreements in the coming weeks, they must reconcile differences among separate proposals from Inslee and lawmakers in the House and Senate.
They must decide which projects to build first, and where. They must agree on how many should be run by private or nonprofit groups, and how many -- if any -- should be run by the state.
They would have to commit serious money in the upcoming 2019-21 state operating and capital-construction budgets. As always, mental-health funding competes for dollars with education programs and other needs, along with wariness or opposition by some lawmakers for raising taxes.
Some of that tension surfaced last week. The governor's budget office released letters highlighting concerns that the Democratic House and Senate proposals don't provide enough funding for parts of the plan.
Even with funding, the plan could take six or 10 years to complete.
But with Washington already years into a crisis, some state senators want to move more quickly.
Sen John. Braun, R-Centralia has sponsored Senate Bill 5537, which would ask voters to approve $500 million in bonds outside Washington's constitutional debt limit to accelerate the projects.
That would allow lawmakers to use those funds, as well as the capital-construction budget. One-third of the Senate has signed on, including Democratic budget writers.
"We need to be prepared to go directly, once we have spent some money planning ... to go right into funding and building those things," Braun said.
The plans
The various proposals, which would set Washington on a remarkable building boom, include:
--Creating a 150-bed psychiatric teaching hospital at the University of Washington. It could admit state hospital patients while training badly-needed psychiatric medical staffers.
--Funding psychiatric beds at community hospitals in Auburn, Everett and Yakima, including roughly 75 beds for state hospital patients.
--Funding for specific community facilities in Seattle, Spokane, Bremerton, Sedro-Woolley, Centralia, Island County or the Jamestown S'Klallam tribe.
--Providing tens of millions of dollars in competitive grants to build community mental-health projects. Tens of millions more could go in the state Housing Trust Fund for supported beds to help with affordable housing for people with mental-health issues.
--Planning for a new forensic facility at Western State Hospital for patients coming through the criminal courts.
--Providing hundreds of millions of dollars in the state operating budget for other private and nonprofit services.
--Funding the federal court settlement in the Trueblood decision, for which Stuller has been advocating. To implement that, Senate Bill 5444 would speed up competency evaluations for defendants in jail by adding staff and provide diversion and outpatient restoration services.
--Implementing other bills or provisions intended to better recruit and retain psychiatric workers.
Most patients committed by the civil courts are sent to state hospitals, because they would likely pose serious harm to themselves or others. Under some proposals, the hospitals then would be refocused to primarily handle patients coming from the criminal courts.
The plan won't be easily realized.
New community facilities can take years to site and build, and they could be delayed by community opposition, a scenario that recently played out in Lakewood.
Only predesign money is included for the new Western State forensic hospital -- meaning that project could be years away.
A shortage of qualified workers could delay facilities from opening. For example, staff shortages that helped trigger poor inspection reports stopped an expansion at Western State Hospital in 2015.
The proposed University of Washington teaching hospital is geared toward boosting the availability of trained psychiatrists, nurses and others. But it will take a few years to be built and fully operational.
The shortage is "a significant challenge, not just within our organization, not just within our state, but nationwide," said Tim Holmes, president of behavioral health at the MultiCare hospital system. "And it's not just with psychiatrists, either; we're seeing it with a variety of professionals and paraprofessionals."
Legislators are betting on hospitals like MultiCare to quickly replace some civil-commitment beds being eliminated at the state hospitals.
The proposed operating budgets would fund patients being sent to community hospitals. The capital-construction budgets provide dollars for at least three specific hospitals.
The House and Senate plans give money to help MultiCare build a new psychiatric hospital on its Auburn campus. It would include 60 beds for long-term involuntary commitments -- the types of patients leaving the state hospitals.
It would house an additional 60 short-term psychiatric beds, and another dozen or so beds for crisis stabilization services, which Holmes described as like a psychiatric emergency room.
Providence Regional Medical Center in Everett gets some funding for a 24-bed psychiatric unit, including six beds for long-term psychiatric care, according to Kim Williams, chief executive officer for Providence Health & Services Northwest Washington.
There's already space in a building, but refurbishing for psychiatric care means replacing all the windows, doors and bathroom fixtures to meet safety requirements.
"We're going to have to take it down almost to the studs, essentially," Williams said.
The proposals also fund six long-term psychiatric beds at Virginia Mason Memorial Hospital in Yakima, according to a hospital spokesman.
Daunting challenges
A report commissioned by the Legislature highlights just how far Washington has fallen behind in psychiatric care.
Released in January, the report by Public Consulting Group compared Washington to five other states: Oregon, Colorado, Illinois, Massachusetts and Minnesota.
It found that Washington lags behind those states for inpatient and residential mental-health beds per 100,000 people.
To get up to par, Washington would need to create roughly 1,540 treatment beds of various types, according to the report.
That number excludes the hundreds of civil-commitment beds needed to replace those state hospital beds being wound down.
Within Washington, the report highlights the inability of communities to treat people with mental-health issues.
Six of Washington's 39 counties -- Clallam and Jefferson on the Olympic Peninsula, and Okanogan, Chelan, Douglas and Grant, east of the Cascade Mountains -- don't have any community hospital psychiatric beds.
Those four Eastern Washington counties also lack evaluation and treatment beds, often used for short-term involuntary commitments.
Washington has only 36 beds in facilities that care for people with special needs, like dementia. None of those beds are in King, Pierce or Snohomish counties.
There are only 53 beds in triage facilities for short-term detox and stabilization, according to the report. None are found in King, Pierce or Thurston counties.
"At this point, we need capacity so much that whatever types of beds people put in, we're not going to be at a place in two years where we are over-bedded," said Rashi Gupta, a senior policy adviser for the governor.
