State must improve care for homeless with mental illness

In news about homelessness in Seattle and the region, very little is said about the responsibility of the state of Washington for those living on the streets who are mentally ill–about 20 to 25 percent of the total.

Homelessness has elements that are a local (and federal) problem, such as untreated drug and alcohol addictions, not to mention housing. But for serious mental illness, the buck largely stops at the state. Article XIII, Section 1 of the state Constitution declares the state shall provide institutions “for persons who are mentally ill or developmentally disabled.”

Frequent physical assaults on staff at Western State Hospital in Lakewood should drag the state’s failure into the spotlight. Early this year the U.S. Department of Health and Human Services withdrew $53 million of federal funding at Western after repeated attempts to get the state to improve patient care.

More recently, after assaults on staff by out-of-control patients, nurses and attendants at Western held public protests to demand change. The response of the governor’s spokesman was to pledge a “full review.”

But we have been reviewing the situation for decades. The problem goes back to the 1970s and deinstitutionalization as a reform enacted in the aftermath of a few striking cases of improper treatment of the confined mentally ill and the powerful, but dated, film, “One Flew Over the Cuckoo’s Nest.”

Decentralized care for some cases might have made more sense if it had been balanced with adequate community facilities and with better leadership at state hospitals. But deinstitutionalization and voluntary commitment has not worked well for many cases, as we see in accounts of violence perpetrated by mentally disturbed people and especially by the frequent and expensive trips to local emergency rooms by individuals who have descended into dire hardship and disease. Death on the streets is more common than the public probably realizes.

Nationally, the number of homeless people with serious mental illnesses continues to grow and is variously estimated at around 250,000, of which 140,000 are considered “seriously mentally ill.” Another 390,000 mentally ill reportedly are in jails or prison, according to Mental Illness Policy Org.

The New York Times recently covered the release of a patient, after 19 years of involuntary treatment, who had pushed a young woman onto the tracks of a subway train. It was hoped that his case–which led to New York’s pioneering “Kendra’s law”–would greatly improve treatment. But the Times’ report shows New York officials neglected to follow up the law with vigorous enforcement. The problem is partly that bureaucratic and legal procedure are cumbersome and often are so slow as to make them unproductive.

The same is true of Washington’s Assisted Outpatient Treatment (AOT) legislation. Many attorneys and social work officials contend that individual civil liberties are abridged in an involuntary commitment under almost any but headline circumstances. Effectively, a person has to assault someone or demonstrate an intention to kill or hurt himself. In the end, some longtime reformers charge that civil liberties have become an excuse for humanitarian deprivation.

Eleanor Owen, of Seattle, helped found the Washington Advocates for the Mentally Ill (WAMI) 40 years ago. She states today that “The mentally ill homeless situation here and around the state is the result of years of shifting funds from staffing and training at Western State Hospital to communities and jails and prisons.”

State Sen. Steve O’Ban, R-Lakewood, whose district includes Western State Hospital, believes the stat’s failure to provide proper management and training to care for those with dangerous mental illness is the “next McCleary.” He refers to the Supreme Court ruling that forced added state support for education. O’Ban contends that the Legislature, with new revenue coming in this year from the economic expansion, should make funding mental health its top priority in the 2019 session. He also advocates a stronger form of legal guardianship to help family members get their loved ones health care, even if, because of mental incompetency, patients decline assistance.

“People need to ask, ‘What would you want for your own son or daughter if they were out on the street and delusional?’ Most people would answer that they want effective compassion,” O’Ban states. “They want them off the street and into the treatment they so desperately need.”

The problem is as much state mismanagement as weak funding, O’Ban says. Reform legislation passed in the State Senate in recent years has been buried in the House or Vetoed by Gov. Jay Inslee. Instead of bolstering Western’s care, the Tate is considering how to close its “non-forensic” beds and send the cases back to community facilities.

Or, one suspects, to the street.