Each year, Washington sends thousands of residents to forced treatment at psychiatric facilities.
They’re taken from their homes and locked in sterile, sparsely furnished rooms. They’re often compelled to take powerful medications. And they can’t leave until the medical facility or a judge says so.
The state sends people off for this type of treatment, not on criminal charges but under the state’s Involuntary Treatment Act — a set of laws meant to treat people who are so mentally ill they’re deemed dangerous to themselves or others.
The system was developed not to punish people, but to provide vital care to those in dire need of treatment. Even as many lawmakers and medical professionals view it as a necessary avenue for mental health care, it raises ethical questions about when it’s acceptable to strip someone of their civil liberties.
This is just one of the dilemmas plaguing the involuntary treatment system, according to many who work in the medical and legal services surrounding it.
Patients often leave traumatized and may end up back there within a few months. The most ill people often don’t even get into treatment. And some patients and advocates argue the law is fundamentally flawed, pushing instead for services that intervene earlier and prevent people from needing forced treatment at all.
Lawmakers, health officials and the governor have all said they’d like to revamp the involuntary treatment system.
But many of the changes proposed in these discussions have already been passed into law over the last decade, aimed at fixing the cracks in the system. The state has laws on the books to lower the threshold for committing people, expand treatment for people with substance use disorder and improve community-based treatment options.
They’ve all sat underused or not used at all.
Top of mind
Involuntary commitment has long been a point of concern for state and local officials: Over the past few years, lawmakers have introduced bills to make changes to the way people can be committed, or expand the law to include substance use disorder.
The Seattle City Council listed it as a legislative priority this year. During his campaign last fall, Gov. Bob Ferguson named improving aspects of involuntary treatment among his behavioral health priorities.
Despite attempts at reform, little has actually changed.
Even as laws have been passed to ease the hiccups in the system, communities throughout Washington have struggled to implement them. Many require more staff, more space for patients or coordination between state and local agencies.
Washington’s involuntary treatment system has always been complicated. Since 1973, state law has allowed a person to be involuntarily committed if they pose a danger to themself or others. They can either be deemed “dangerous” — posing a risk of violence, self-harm or property damage — or “gravely disabled, failing to meet their own health and safety needs.
While other states allow psychiatrists or law enforcement officers to evaluate someone for treatment, Washington has a unique system: The only person who can initially hold someone is a designated crisis responder — a mental health professional employed by the county government specifically for involuntary treatment cases.
The system costs the state millions of dollars — $63.7 million last year for bed and court costs — and detains thousands of people a year. Last year, around 3,100 people were involuntarily committed for at least 14 days, according to the Health Care Authority. More than four times that many were initially detained.
And despite the financial investments, involuntary treatment often doesn’t work the first time. According to data from the Health Care Authority, one-fifth of the 3,100 people committed in 2024 had been involuntarily committed just the previous year.
Clarifying the rules about who needs commitment, as well as building out community facilities to house people closer to home, could help ensure those who need treatment are getting it, and use the laws that have been passed.
The biggest barrier?
“Money,” said Rep. Lauren Davis, D-Shoreline. “One word.”
Davis said with Washington’s large budget deficit, lawmakers are hesitant to make any significant changes to the law that would make it easier to commit patients. A lower threshold would likely mean more people coming into the system, which in turn would cost more. One bill introduced this session that would have relaxed the commitment standard for people with substance use disorder didn’t make it to a hearing.
“You change one word of that criteria (to make it easier to commit someone), and it’s almost like $10 million per word in terms of the fiscal note,” she said.
A group of attorneys, mental health professionals and law enforcement officials from around the state is now spearheading a “listening tour” it hopes will inform recommendations to legislators for the next session. The “ITA task force” is traveling the state and interviewing people who have gone through involuntary treatment, as well as those who work in it, to identify broad complaints.
The first meetings in Whatcom County found, according to members of the committee, that people want to see improved coordination and communication between social services and other programs that intersect with the law, especially as a person is being transitioned in or out of commitment. Other common requests include addressing barriers to care and improving preventive care, so people don’t need to be committed in the first place.
Civil liberties at stake
As the state grapples with how to get people needed treatment, it must also consider what’s being taken away.
Forcing a person into mental health treatment used to be much easier, with fewer measures for accountability. In the late 19th and early 20th centuries, widely available hospitals and asylum beds meant people could be committed for almost any reason, such as being gay or because family members wanted them locked away.
As awareness of abuse and neglect in asylums grew, lawmakers nationwide began to increase protections.
Washington’s civil commitment law requires authorities to consider the least restrictive forms of treatment for patients, and mental health facilities must petition the court any time they want to extend a patient’s stay.
But lawmakers haven’t yet figured out a system that balances individual rights and safety, according to many mental health advocates and people who live with serious mental illness.
Advocates have also noted that people of color, especially Black people, are disproportionately institutionalized.
Many who’ve been through the system argue involuntary treatment should be used sparingly, if at all — and instead say the state should be putting its resources into services like outpatient care that prevent people from getting to the point where they need their rights taken away.
Washington has taken some steps toward building these kinds of “upstream” services, said Laura Van Tosh, a mental health advocate who has been civilly committed in the past. Examples include the five crisis and stabilization centers being built in King County after voters passed a $1.25 billion property tax levy.
Van Tosh also noted that former Gov. Jay Inslee emphasized finding resources for new community mental health beds that could keep people in their communities.
“The point is that people are not stuck far away in the state hospital in the hinterlands, but they could actually have family and other people closer to home,” she said. “Or they could just be closer to home so they could reintegrate back into society.”
Matt Sanders, the interim director of the King County Department of Public Defense, also called for more options to address mental health issues, such as crisis centers and mobile crisis response teams.
“This overreliance on the ITA system signals a need for us to really invest deeply in intermediate solutions,” he said. “It’s not only going to be better for individual autonomy and civil liberties but also public safety, family dynamics and community building.”
The current system, he said, cycles patients through but is rarely in their best interests, and often causes friction between patients and others who want to help them, such as their families.
Sanders acknowledged the lack of places for people to go once they’re released from treatment. Without housing and other services, they can deteriorate more quickly.
But ultimately, he said, patients should have the opportunity to decide what they want to do.
“I think it’s important to advise them and give them all of the information that is relevant to the decision,” he said. “And what you’ll find is that maybe if you’re a family member, or even a friend, you may say, stay in (the mental health facility). But then give the client the agency to decide. And a lot of time, what you’re going to find is that the client wants to be out of that cage.”
Conflicting systems
Many mental health advocates say involuntary treatment should be a last resort. But when it is an option, they say, it must be a viable one.
Anna Nepomuceno, the policy director for Washington’s chapter of the National Alliance on Mental Illness, said candidates for involuntary treatment are unlikely to seek help on their own, putting them at risk for self-harm, or committing a crime that lands them in the state hospital while they await court hearings.
Rather than a rejection of the system, she said, flaws with the Involuntary Treatment Act should prompt improvements.
“I don’t think there should be black-and-white between yes and no ITA,” she said. “I really think there just needs to be improvements made throughout the entire system.”
So far, efforts to change the system have failed to gain traction.
The obstacles? Resources and coordination, lawmakers say.
For example, a lack of resources — a limited number of psychiatric beds — has stymied a law passed in 2020 that allows more people who are “gravely disabled” to get care. The law, introduced by Sen. Manka Dhingra, D-Redmond, expanded the definition of “grave disability” to mean someone has deteriorated from safe behavior, not just routine functioning.
Expanding that definition would allow more people to be committed if they show signs of not being able to care for themselves. A person’s regular behavior may be concerning, Dhingra said, such as someone with a severe mental illness frequently going off their medications or not eating or bathing. The wording change would allow the state to consider whether that person’s behavior is objectively harmful, rather than whether it’s an escalation of their regular behaviors.
But because the state was facing a serious shortage of mental health beds, lawmakers added a last-minute caveat: Patients could only be detained under the new criteria once the state reduced the number of involuntary treatment patients it was lodging in nonpsychiatric facilities like emergency departments — a process known as “single bed certification.”
The new law stated that if the state had fewer than 200 civil patients per month in nonpsychiatric beds, it could begin using the broader criteria for commitment. It has never met that number, and the law has never been used
Dhingra said she’d like to see the state drop that restriction. As of now, she said, the state doesn’t have a sense of the true need for psychiatric beds because many people who have “severely deteriorated” are prevented from getting treatment.
With the state’s tight budget and the uncertainty surrounding Medicaid rates, Dhingra said, that change is unlikely to happen soon.
In the meantime, she said, more mental health beds are needed — as well as people to staff them.
Reaching the right people
The state passed another program in 2015 that could have helped alleviate the bed shortage — as well as offer people treatment in a nonhospital environment.
Assisted Outpatient Treatment is a form of involuntary commitment that takes place outside a hospital — people may be required by law to take medication, or see a psychiatrist, but they can stay at their home or a community facility that’s less restrictive than a hospital like Western State. It can be used either in lieu of institutionalization or after a person leaves residential treatment. But most counties haven’t implemented the program — either due to a lack of staff or difficulty coordinating a program.
Pierce County has an active program, and a few others, including King and Snohomish, are working to launch theirs.
But not every county has the resources or inclination.
“There have to be organizations set up to have the space and to have the capacity to take on those patients and their needs, and be accountable to the court as well,” said Aleksandra Letts, a King County prosecutor involved in the task force that’s collecting recommendations for reforming the system.
Davis, the Shoreline lawmaker, said another big challenge is locating patients who might benefit.
“How the heck are you going to find the person if they’re experiencing homelessness, if they’re in active addiction, or they’re not likely in one particular location?” Davis said.
She said the program would likely be most effective for patients who are leaving jail or stepping down from a more restrictive setting.
Others are more wary of the program, both for its continued impact on patients’ civil liberties and the lack of clarity about what role the program actually serves.
Kim Mosolf, a civil rights attorney who previously worked with civil patients, said the program is often touted as a “panacea,” a way for people to avoid restrictive inpatient treatment. But those who end up using it most have already gone through long-term institutionalization and may be stabilized to a point where they’re amenable to treatment — making the point of forced treatment moot.
Mosolf said to reach people who aren’t as easily accessible, such as those living on the street, the program should offer more intensive services, such as monitors and housing.
“It’s going to take a lot of support and services for those folks,” she said.
Another law passed in 2016 would expand the reach of involuntary treatment — but lawmakers say it’s been rarely used due to a lack of beds and a lack of coordination between different agencies.
In 2016, Washington passed a law allowing people to be committed for substance use disorders, broadening the scope of involuntary commitment beyond mental illness. “Ricky’s Law” was used nearly 900 times between October 2023 and September 2024 to commit people to secure withdrawal management facilities, state data shows.
While that’s an increase over the previous couple of years, Davis, who sponsored the bill named after her close friend Ricky Klausmeyer-Garcia, said in December that the law is still “wildly underutilized.”
There are many points where the system can break down, Davis said.
If someone ends up in the emergency room with a substance use disorder, hospitals won’t always call a designated crisis responder to evaluate the person — as that prolongs the person’s stay in the emergency department, Davis said.
A crisis responder could decide a person doesn’t need to be detained. They could be detained, but a facility may not accept them. Or a court evaluator may decide a person should be released after their initial detention, even if family members or others argue they still need treatment.
And a shortage of beds for substance use disorder patients makes using the law all the more difficult. In 2023, Washington had just 65 secure withdrawal management and stabilization beds, which provide direct treatment for involuntarily detained patients with substance use disorders.
Davis added that many people who work in the system are still adjusting to the idea of treating substance use disorder as a disease that can be addressed by treatment, rather than a moral failing.
“There’s stigma issues,” she said, recalling that once when she tried to get Klausmeyer-Garcia detained, a designated crisis responder balked at the idea of dealing with substance use disorder.
Dr. Paul Borghesani, the medical director of psychiatric emergency services at Harborview Medical Center, said it’s hard for clinicians to assess a person’s qualifications for Ricky’s Law because they don’t have the power to invoke it — that authority rests solely with designated crisis responders.
“That makes it very confusing for the clinicians because since they’re not empowered to make that decision, they actually don’t really know when to use it, and the subtleties and nuances of when it might be appropriate,” he said.
Often, he said, designated crisis responders will ask ER doctors to let a person metabolize, or allow the effects of drugs or alcohol to wear off before referring them for evaluation. Once that happens, a person is often no longer a danger to themselves or others because their behaviors are tied to intoxication.
“All of a sudden, we’re in a situation where they’re no longer really appropriate to just refer for general detainment under the ITA laws. And this is exactly what Ricky’s Law was trying to do, is give an option for clinicians to refer while the patient was still intoxicated, with the understanding that their intoxication was what was causing them to be a danger to themselves or others,” he said. “That’s a really hard nuance to understand.”
Borghesani said he’d like to see emergency room doctors educated more on the overlap between mental illness and substance use disorder.
"Speaking the same language”
Trying to ensure existing laws come to fruition is one of the biggest challenges lawmakers and others in the mental health system are still trying to work through.
They’re doing so while wrestling with two systems that are often at odds.
While medical professionals may make recommendations about what these patients need, those needs are playing out in a system with public defenders and prosecutors, who are wrestling with questions of public safety and patients’ rights.
“It’s still a contentious process, even though it’s supposed to be set up to be a therapeutic court process,” said Letts, the prosecutor.
Those in the ITA task force say there are opportunities for policymakers and officials who implement the laws to go through all of the puzzle pieces together.
Letts said she hopes the listening tour will help bring some of those groups into the same room.
“If you have a handoff, pass the baton from the policymaker for the implementers and the groups along the way,” she said. “So that everyone’s speaking the same language and the expectations are the same.”
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