Western State Hospital, a mammoth, 714-bed public mental institution, is one of Washington State’s two public hospitals for the mentally ill. Built in 1871 in rural Pierce County, Western State has long been controversial, with disability-rights groups claiming that its role in the state’s mental-health system is too large and local law enforcement claiming that it isn’t large enough. Today, as the state struggles to manage a backlog of mentally ill defendants in its county jails, the historic facility finds itself under fire again, with hospital staff and law enforcement accusing administrators of inappropriately discharging dangerous patients.
The latest controversy began in August, when 22 counties sued Washington for failing to evaluate mentally ill defendants in county jails. According to the counties, this failure crowded local jails with incompetent defendants, waiting for admission to Western State. Responding to disability-rights groups, the counties contended, the state had unfortunately “removed beds from and closed wards at Western State Hospital, long before replacement bed space was available, resulting in a decrease in capacity to perform its statutory obligations, including its obligation to . . . evaluate civil conversion patients.”
Then, in September, former Western State Hospital psychiatrist Laetitia Geoffroy-Dallery resigned, accusing the hospital of making discharge decisions that “endanger[ed] our patients, their families, and the community at large.” Mary Robnett, the Pierce County prosecutor whose county hosts Western State, seconded this assessment in a statement to local media. Robnett also claimed that Western’s administrators had failed to give her and other law-enforcement officers the statutorily required 30 days’ notice before discharging formerly incompetent defendants. In other words, maintained Robnett, some mentally ill defendants who were admitted to Western and restored to competence, and who were thus eligible for prosecution, were discharged without notice, potentially evading prosecution altogether.
The hospital’s inability to manage its admissions and discharge policies stems from Governor Jay Inslee’s mental-health reforms. Inslee proposed phasing down the state’s civil services—inpatient beds for people with serious mental illness who are not involved in the criminal-justice system—at its two public mental hospitals and focusing both campuses’ resources on criminal forensic patients.
Under the plan, approved by the state legislature in 2019, Western and Eastern State Hospital, the public hospital in Medical Lake, would serve almost exclusively patients involved in the criminal-justice system. The hospitals would restore incompetent defendants, house on a long-term basis those adjudicated not guilty by reason of insanity, and, according to the state department of social and health services (DSHS), treat only those adult civil patients with “the most challenging high-risk behaviors.” The other adult civil patients currently housed at Western and Eastern State would either be discharged into the community or placed in one of six new “community-based” hospitals—16- to 48-bed residential-treatment facilities located throughout Washington.
The new law represented a middle path between two competing visions of mental-health reform: that of disability-rights groups, committed to deinstitutionalization and the eventual closure of Western State; and that of local law enforcement, which wants psychiatric patients out of its jails and placed at the state hospitals. By increasing forensic beds and potentially reducing civil beds, Inslee sought to satisfy both camps.
Disability-rights advocates had pressured Washington for decades to wind down its civil footprint at the hospitals. Kimberly Mosolf, an attorney with Disability Rights Washington, whose organization sued the state over its large inpatient population in 2014, claimed that Washington was “violating people’s constitutional rights” by not discharging them from the hospital “in a timely fashion.” The potential decline in civil-bed space at large “institutional” facilities is consistent with disability-rights groups’ vision, which, as the New York–based civil libertarian Bruce Ennis once described it, is “nothing less than the abolition of involuntary hospitalization.”
Inslee’s desire to expand forensic services, on the other hand, may have been motivated by law enforcement’s complaints about the state’s forensic mental-health system. Western State’s administrators announced the construction of a drab, 350-bed forensic unit on the hospital grounds, built in a brutalist style that contrasts with the facility’s regal brick exteriors. The state claims that the new unit “will augment, not replace, the majority of the existing WSH structures,” and likely will expand the forensic services offered on grounds.
In practice, the rebalancing of civil and forensic beds has made it almost impossible to manage the state’s caseload, especially those “civil conversion” patients who committed crimes but are eligible for long-term civil commitment. The problems may multiply in the future, as the plan to treat most of the state’s civil patients in smaller settings, away from the rural campuses at Eastern and Western State Hospitals, takes effect. As other states have discovered, moving noncriminal patients out of state hospitals can, over time, result in a portion of those discharged patients deteriorating to the point of criminal behavior.
Washington has thus far acquired only two of Inslee’s six proposed civil units. But even if the state builds all of these “community-based” units, it may wind up with fewer total civil beds, meaning that some patients at Eastern and Western State today may not have beds in the future. DSHS told City Journal that Eastern and Western State house 192 and 287 civil patients, respectively. Most of the proposed “community-based” units will house 48 patients or fewer.
More fundamentally, even the most lavishly funded community-based mental-health programs have historically failed to treat people with serious and persistent mental illness. The economies of scale and physical plants available at large state hospitals like Eastern and Western State make long-term treatment possible for people whose conditions cannot be managed in a less restrictive environment; a small building downtown is not an ideal place to house a treatment-resistant schizophrenic for 180 days. The past 60 years of American mental-health care has proved conclusively that smaller, community-based settings, focused on prompt discharge at the expense of long-term stabilization, are inadequate for some people with serious, persistent mental illness. Sometimes, taking an unstable person out of his community for treatment is precisely what he and his community need.
Other states have already taken Washington’s intended path. New York cut more than 300 beds at its state hospitals between 2016 and 2021. In the past few years, the state has seen several high-profile incidents involving people with untreated psychosis variously injuring and killing strangers. Some of the perpetrators had been in and out of mental hospitals for decades. New York has learned that discharging civil patients to community-based hospitals, or out of institutions entirely, can lead some to decompensate—a few, like accused New York subway murderer Martial Simon, to the point of violence. Left untreated, civil patients can become forensic patients.
By downsizing the civil footprint and expanding forensic services at its state hospitals, Washington is running a similar experiment. Whether the results prove as tragic as New York’s remains to be seen. For some patients, better outcomes will likely follow. But others will almost certainly find themselves back on Steliacoom Boulevard, bound again for the century-old doors of Western State Hospital—this time, in orange jumpsuits.
Photo: T85cr1ft19m1n, CC0, via Wikimedia Commons