USA’s Competency to Stand Trial Problem

A December 2017 article, entitled: “Colorado to spend $20 million to relieve ongoing backlog of mental competency evaluations; critics say problem was foreseeable,  in the Denver Post newspaper and recently reprised highlighted what has been a national crisis in the psychiatric inpatient care delivery system for at least the past decade.

Colorado’s problem has continued to balloon up so persistently that the article stated: “[the]State can’t keep up with monthly court orders for competency evaluation, which jumped from 146 to 215” swamping the entire state hospital bed capability. And as has happened in every other state, the regular emergent psychiatric admissions to the state’s public psychiatric hospitals were delayed, creating the all too familiar backups of patients in ERs statewide. And it must be remembered that almost all referrals for admission to state psychiatric hospitals are true emergencies.

A guard is reflected in a ...
Helen H. Davis, Denver Post file

A hallway at the Colorado Mental Health Institute at Pueblo, Denver Post file photo.

Judge Marsha Pechman of Washington state began fining Washington in the fall of 2017 $1500 daily after she found the state in contempt for not being able to deliver adequate care for the ITP patients. Her fines later escalated as she found the CEO of the Western State Hospital and the state mental health agency in contempt, to over $50M in total fines last year. By the time Judge Pechman began to levy the fines against Washington, its statewide monthly judicial orders, mirroring Colorado’s almost exactly were averaging 291 in-jail evaluation orders.
The issue is that most states in the USA continue to be flooded with mandated admissions of inmates from state judicial systems for psychiatric evaluations. These types of admissions are variously termed ITPs or incompetent to proceed to trial patients and other arcane terms derived from states’ laws designations. Washington state has struggled mightily more than most states with this issue so much that a Washington state judge has fined the state over $50M in the past two years because of the delays in care for other patients who had ended up warehoused for weeks to months at a time in general hospitals all over the state.
The Governor of Washington, Jay Inslee, who has been working at a furious pace with the Washington state legislature, recently announced new plans to try to have regional, non-state hospital-based forensic evaluation centers in different parts of the state by 2022 to handle all the ITP case needs. This is innovative in that most states do not have such a system.
In decades past, states had “forensic centers” that were designated the proper facilities to handle such cases. In the states that had such, their capacities were usually not increased from levels of the 1960’s. One such notable and nationally recognized center was and still is Michigan’s Center for Forensic Psychiatry south of Ann Arbor Michigan. Another has been the infamous Massachusetts facility Bridgewater state hospital’s forensic unit. Its heyday has long passed, and it has been the site of repeated scandals for a good decade and is not such a good example…
Nationally some of the forensic facilities were phased out as such units were incorporated into state psychiatric hospitals’ physical plants. But overall, the bed needs were not increased to keep up with population growth for over 50 years, hence the ‘sudden’ swamping of these facilities in whatever form they existed nationally.
Additionally, the impetus of the legal system has been to increasingly become scrupulous about ensuring inmates’ rights are protected to assure access to mental health evaluation and treatment. Issues of below average intelligence, organic mental conditions and medical conditions affecting legal issues such as the ability to know right from wrong, judgment, impairment of any sort at the times of commission of crimes, were more readily identified than ever in the past.
Also, it likely has become the standard of practice in the world of legal defense representation, to adequately refer to such psychiatric review whenever there is a question such an issue may exist with any defendant.
All these factors have fed into the current national crisis of explosion of need for such forensic psychiatric services at all levels and not just in infamous trials involving serial killers or cases involving the rich and famous.
All states who currently fall short of providing these mandated services will have to face the coming necessities of funding for such services along with all the other inadequacies of social, educational and human services gutted over the last 30 years. How all this will play out will in no small part shape the political and social policy debates in this country for decades.
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Progress at Western State Hospital in Washington State: A Good Example for Other Beleaguered Hospital Systems?

Western State (psychiatric) Hospital has been in operational distress for more than a year now and following the travails of this facility and its staff from the line ward workers and behavioral care technicians, nurses and professional staff has been quite sad and discouraging for anyone interested in mental health reform and service delivery policy.

Continue reading “Progress at Western State Hospital in Washington State: A Good Example for Other Beleaguered Hospital Systems?”

Washingston State Hospital System Fined

IN a very recent story of less than a week ago, entitled: “Washington accrues almost $7.5 million in contempt fines,” written by Martha Bellislea of the Associated Press published in many major newspapers across the country, the sad story of the travails of Washington’s Western State Hospital continues to showcase the plight of a number state public psychiatric hospitals.

 

Continue reading “Washingston State Hospital System Fined”

Does It require a killling to get a state hospital admission still…?

In yet another unbelievable horrible tragedy, a chronically mentally ill man in Washington state was finally admitted after a few months of court orders by a judge, a fine of the state mental health department to the tune of $2,000per  day and ceaseless and desperate advocacy for inpatient psychiatric treatment for their relative.

I must confess that in the above first paragraph, I did a little dishonest thing, an intentional literary device. I implied that it only after all those pushing and shoving well placed and well-intentioned efforts, did this man get the help he needed. No, those efforts were the unsuccessful prelude…

This middle aged man murdered his elderly father and THEN he was admitted to the state hospital. The article, “David Altman finally gets a bed at Western State Hospital,” makes for a very sad read. As I read it for the first time, the old colloquial phrase, “a train wreck in slow motion,” came to mind.

This tragedy is even worse in a way than the Gus Deeds tragedy in Virginia over two years ago. In that ‘case,’ Gus Deeds was a mentally ill psychotic young man in his early 20’s. His mental illness was known to the family and well managed as the father, a Virginia state legislator, is a Ph.D. clinical psychologist. He also saw the warning signs of spiraling psychosis and immediate need for acute inpatient psychiatric admission. Under the then peculiar obstacles in Va’s state hospital admissions procedures a bed could not be found for Gus and he was released from an emergency after four days. Within 1 or 2 days as I recall, he had tried to stab his father to death and then ended up suiciding.

Clinicians around the country  years ago began warning of these kinds of tragedies in the 1990’s. I remember joining the shrill and desperate warnings in those days at various levels of my own participation in state and then in my younger days, the national organizations as we advocated for our patients. I recall realizing along with many others that our estimates and assumptions about the weight of our influence in the ‘halls of power,’ were vastly self-deluding. ‘We’ were not only not listened to, but I recall as those in power and frankly zealots in the new wave of the then growing world of mental health restructuring, viewed us as psychiatric Luddites, old fogies who were no longer ‘with the program’ so to speak. Mental health professionals were viewed as stumping to preserve their own positions of power or whatever and our warnings were not only resented but also labeled as being rather like Chicken Little shrieking “the sky is falling!” As we continued our dissent and disturbingly factual predictions of what kinds of tragedies that reductions in training programs, inpatient, and outpatient resources would produce, we began to be denigrated, ignored and accused of holding up progress. Well, truly not to gloat utilizing families’ incredibly sad tragedies to do so, I must state the obvious, “We are not Kansas anymore,” and the predictions a generation of mental health professionals repeated over and over that fell on deaf ears, have to come to occur and confirm not how smart us mental health nags and gadflies were, but that those actions were to have dire and tragic consequences and for the last decade or more we have seen them materialize in front of us.

But on an optimistic note, we have turned the corner I firmly believe. The growing number of bills in legislatures at the national and state levels are now openly addressing and discussing the issue of the failures of mental health reform. Pieces of legislation are looking at many of the correct entre’ points for cultivating solutions: increasing training funds for all types of mental health professionals, financial incentives to go into the traditionally underpaid careers with loan forgiveness programs and other responsible incentives, starting up new training programs, restoring services, and spending monies by states and the nation even (gasp) talking of ‘enhancing revenue streams,’ (read new modes, methods of taxes, horror of horrors) to make any and all of these corrective measures possible.

Corrective legislation will have to be written to facilitate the immediate and easier mobilization of emergency psychiatric admission and legal mandated involuntary psychiatric hospitalizations to help to stem these kinds of horrific tragedies and save lives. And the balance of the rights of the person so involved will have to be redrawn in a different conceptual framework so that it is not virtually impossible to hospitalize someone who is psychotic and dangerous as it still is in some venues.