The Mental Health Project is a Seattle Times initiative focused on covering mental and behavioral health issues. It is funded by Ballmer Group, a national organization focused on economic mobility for children and families. The Seattle Times maintains editorial control over work produced by this team.

LAKEWOOD, PIERCE COUNTY — If there is an apt symbol of Washington’s strained mental health system, it’s Western State Hospital. 

Each year, hundreds of people who are in mental health crisis or struggling with severe mental illness are ordered to the sprawling campus in Lakewood in hopes treatment there will help stabilize or manage their conditions. 

Now, Washington’s largest state psychiatric hospital is in the middle of not only a massive physical face-lift but also a dramatic shift in approach, as the hospital transitions to focus more on forensic patients, who arrive via jails and prisons, rather than patients committed through civil courts.

After Western State lost its federal certification — and much-needed funding — Gov. Jay Inslee set out to “re-imagine” the state’s mental health system in 2018. This is the first step of many more to come over the next decade.

But overhauling a behemoth like Western State is challenging, as legislators, the state Department of Social and Health Services, and others will tell you. Competing interests and rising costs are exacerbating an already daunting task. Most recently, state agencies have been challenged by local officials in the city of Lakewood, who see their town becoming a hot spot for behavioral health facilities with or without the town’s approval.

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As a key part of its plan, Western State wants to build a new 350-bed hospital tentatively set to break ground in summer 2023. The new $612 million project will supplement an existing forensic hospital, bringing the total number of beds for forensic patients to 530 by 2029.

At the same time, the wards for patients admitted through the civil courts are winding down, with many of those patients placed into smaller, long-term facilities across Washington like adult residential care. There, the goal is for people to live with fewer restrictions, closer to family and friends, and with supportive services.

Hospital administrators plan to reduce the number of civil patients housed at Western State by about 180 over the next year, to make room for more forensic patients. But that raises the question: Where exactly will people go?

Patients who enter Western State Hospital tend to have complex backgrounds and need high levels of care. They’re often recovering from substance-use disorders or have been homeless. For those who also have a criminal record or a history of violence, it’s especially hard to find a community-based care facility that will accept them. 

“As Washington moves through this transformation, this change, it’s going to be difficult,” said Mark Thompson, CEO of the Gage Center of Forensic Excellence at Western State. “It is hard to have people who potentially could have symptomatic episodes in our community, but it’s where they need to be. It’s the ethically and morally right thing to do.”

Focus on forensic 

There’s a seemingly never-ending demand at Western State: Even as the state has poured billions of dollars into mental and behavioral health in recent years, the hospital is struggling with a growing waiting list of people from the criminal-court system who are in need of competency and restoration services.

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Competency exams are court-ordered mental health assessments, in which a psychologist assesses whether a detained person understands what’s happening and can assist their attorney. If a person is found incompetent to stand trial, they are typically ordered to restoration treatment, which can involve medication and group or individual therapy, as well as education on the legal system. It’s estimated that around 17% of people in jail have a serious mental health disorder.

According to DSHS data, in mid-December 365 people were waiting for forensic services at Western State. That’s a nearly 60% increase from January 2020.

Between October 2020 and September 2021, the wait time between a referral for restoration to an actual offer of a bed at Western State was about 40 days on average across Washington counties, according to a DSHS report to the Legislature. Some areas, like Grant County, saw a 90-day wait. Meanwhile, people’s conditions deteriorate in jail while they wait for services.

This is an enduring problem in Washington: In a 2015 federal court ruling known as the Trueblood decision, the state was ordered to provide competency evaluations within 14 days of a court order and restoration services within seven days.

Though 88% of evaluations from the past year are meeting that 14-day mark, according to a report from DSHS last month, restoration treatment is still taking weeks more than it’s supposed to. Only 13% of restoration services were completed on time in 2021.  

“Unfortunately, it does not look much different than it did in 2015 when we won that case,” said Kimberly Mosolf, an attorney and the director of the treatment-facilities program at Disability Rights Washington, which was a plaintiff in the Trueblood case.

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“I get calls from the defense attorneys all the time, frustrated on behalf of their clients, families calling us,” she added. “It’s really frustrating to be now going on seven years into a federal court order and to not see improvement.”

Mosolf’s organization “fought like hell” against building the new hospital at Western State, she added, advocating instead for programs to help people sooner, before they end up forced into hospitalization through the criminal legal system.

Hospital officials are trying to follow court orders to get forensic patients evaluated and treated, but they’re up against many challenges. The COVID-19 pandemic aggravated the hospital’s already overburdened systems, officials say, from the processing of initial paperwork to evaluations and having enough physical space to offer a person a room amid social-distancing requirements. 

Staffing is also a persistent issue — when staff-to-patient ratios fall short, it has an impact on the safety of both workers and patients, which then contributes to a cycle of low morale and a negative perception of the hospital. As of December, Western State was 69% staffed, and in need of more nurses and psychiatrists. 

Western State’s history

For decades, the 216-acre campus has faced concerns ranging from funding to patient escapes and assaults on staff. Most recently, the hospital was on thin ice with federal regulators in 2015 — the same year as the Trueblood court ruling — due to staff shortages and safety issues.

Lawmakers and Inslee poured in hundreds of millions of dollars to try to save the hospital’s certification, even entering into a rare improvement plan with federal regulators. But in 2018 after years of failing inspections, the hospital received a major blow when it lost $53 million of federal funding — a little under 20% of its annual budget — from the Centers for Medicare & Medicaid Services.

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The following year, hospital officials withdrew from a separate national accreditation program. (Eastern State Hospital in Medical Lake, the state’s other major behavioral health facility, remains federally accredited.)

Mental health resources from The Seattle Times

In response to those troubles, state lawmakers and Inslee conceived a plan to “modernize and transform the state’s mental health system” that essentially splits Western State into two sections and winds down the number of civil beds. The new facility for forensic patients is expected to be finished between 2027 and 2029.

To make room for the new hospital, several old facilities will be demolished. New features will include pods for eight to nine people with their own social spaces, therapeutic designs that will allow staff to engage and monitor patients, and an enclosed outdoor courtyard. 

Officials also plan to continue using the existing forensic facility, which is newer than much of the campus. Thompson said they hope to get both the brand-new facility and the existing one recertified by federal regulators, to restore some federal funding. 

Future of civil patients 

As the hospital shifts its focus to patients from the criminal-court system, it still plans to maintain some space for people referred through civil courts. Those patients are generally sent to Western State under Washington’s Involuntary Treatment Act, when a designated crisis responder has filed a petition saying the patient is a threat to themselves, others or property, or they’re considered gravely disabled and worsening. Sometimes, people on the forensic side of the hospital are also transferred to the civil side. 

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By around 2029, hospital officials expect to reduce the number of civil beds at the hospital from about 470 to 200. Civil patients are expected to receive care at community-based facilities instead.

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If you or a loved one are transitioning from Western State Hospital into community care, we’d like to hear your story. How has it gone for you? What challenges are you facing? Email us at mentalhealth@seattletimes.com.

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For some families who already have had a difficult time finding community facilities that will accept their loved ones, the shift at Western State raises questions about how many options will be left for them.

Kaaren, whose son has been treated at Western State at least four times over the past two decades, knows what happens when people no longer have the support and structure the state hospital affords. “Every time he comes out of Western State, he’s balanced and doing really well,” she said. “But then the support system falls apart.” 

The Seattle Times is using only her first name for privacy reasons. Her son is diagnosed with bipolar disorder with psychotic features. He’s also a registered sex offender and has cycled in and out of jail and homelessness, often unmedicated and sometimes dealing with substance-use problems. 

Kaaren’s son has found moments of stability. Back around 2010, he was successfully checking himself out of Western State on day trips through a program called PALS, Program for Adaptive Living Skills. That program housed around 26 people in a dormlike setting, bringing people together who would otherwise rarely be accepted in other settings due to their complex backgrounds. But PALS ended in 2011 due to funding cuts.

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Since then, her son has struggled to find community-based facilities that will accept him or work with his needs. She remembers he was discharged to a residence in Seattle’s Capitol Hill neighborhood twice but was too sick one time and brought back to Western State. The second time, he was kicked out of the facility. 

Most recently, he spent nearly two months at Harborview Medical Center, awaiting a civil bed. In early March, he was finally transferred to Eastern State Hospital, four hours from his family. 

Meanwhile, Western State is already winding down the civil side; it hasn’t taken civil-commitment patients from the community for the past couple of years. One ward is expected to close at the end of this month, meaning about 30 people will need appropriate housing.

DSHS says it has a staff of 34 navigators at Western State who are helping patients find spots at community facilities, if needed; other housing; or to reconnect with family.

The agency has not shared where patients end up, citing privacy laws, but says people can typically be discharged to group homes, assisted living facilities or a friend or family member’s house.

The exact demand for civil-commitment beds is hard to quantify, but one forecast presented to the state Legislature last fall said the hospital would need 410 more civil beds by 2027. Currently, about 100 new beds are planned among four facilities by DSHS and the Washington State Health Care Authority, in addition to other beds at facilities like a new behavioral health hospital being built at the University of Washington, but these plans all have different timelines. At the earliest, a 16-bed DSHS facility in Thurston County will be open at the end of this year.

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At one point, new adult-care facilities in Auburn and Burien were proposed, but some members of the community pushed back against their construction. Ultimately, neither were built.    

Local impact 

There also remains a major roadblock for Western State’s construction: Lakewood has yet to approve the hospital’s master plan. Last August, city officials sent a letter to DSHS asking for more information about the state’s plan to discharge civil patients and challenging them to consider placing the new hospital somewhere else.

“It’s a very unfortunate way to say it, but Lakewood is not interested in being the mental health capital of the world,” explains Jim Kopriva, the city’s spokesperson. “It’s become clear Lakewood has an unfair concentration of behavioral health capacity.” 

City residents are conflicted. While some want to support people with mental illnesses, others worry about racial-equity issues, including the disproportionate number of Black and Native people who are involuntarily committed at Western State.

Others don’t want the facility bringing in more people, period, and are nervous about how close the new facility would be to surrounding parks and schools. There’s also the fear that Lakewood and the nearby town of Steilacoom will end up caring for released patients.

“We have 135 adult family homes and about 18 to 20 applications for new ones every year,” Kopriva said. “We’re clearly accommodating. We just expect that other communities should begin to pick up the slack and follow our lead.” According to DSHS data, Lakewood has the state’s second-highest concentration of adult family homes, only behind Lynnwood.

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Though Western State is a major employer, it also has consequences that affect the community at large.

For example, when patients escape from the campus, it’s the responsibility of local law enforcement to secure the community and bring the patients back. In one 2016 case, a patient suspected of first-degree murder escaped Western State along with another man. An investigation from The Associated Press that same year found 185 instances of patient escapes over a 3½-year period.

DSHS plans to resubmit its master plan to Lakewood officials in the coming weeks.

Kopriva recognizes the urgency; he worked for DSHS during the first year of the pandemic.

“[A Western State patient is] a human being just as much as you or I,” he said. “They need a place that will actually serve them.”

Seattle Times staff writer Joseph O’Sullivan and researcher Miyoko Wolf contributed to this report.