The front lines of mental health start in a person’s mind and body. Depending on the day, external stressors, resources or medication, that landscape gets smoother or rockier to navigate.
But it doesn’t end there.
The front lines shift and intersect in many environments: It can be a classroom or office, a hospital or church, a jail or shelter. Ultimately what begins as a personal experience ripples through a whole community, affecting not just the person experiencing mental health issues but their families, friends and neighbors.
And while we all have mental health (just like we have physical health), some live with mental illness, a wide range of conditions spanning mood disorders, addiction, PTSD and more.
It’s estimated over a million Washingtonians — or about 1 in 5 people in the state — have mental illness. That is likely an undercount, and calls for behavioral health crises steadily climbed since the COVID-19 pandemic began.
On the front lines to serve people with mental illness are about 12,500 people in King County, including substance use disorder counselors, behavior technicians and analysts, and a dozen other roles credentialed through the Washington Department of Health. About a quarter of them are social workers. Together with nurses, medical assistants and other health care staff, they work daily to care for people with mental health needs in Seattle and across the Puget Sound region.
While triage nurses and doctors in the emergency department treat trauma wounds, clinical social workers and psychiatric nurses are looking for signs of a mental health crisis. That could mean people who are perhaps eating or sleeping less, experiencing suicidal ideation, or psychosis, when they hear or see things that aren’t there. Patients are brought in by family and friends, on gurneys via ambulance, or by law enforcement. Some come in alone and willingly, others alone and involuntarily.
And while hospitals are a key part of the front lines, when it comes to mental health the needs are everywhere and anywhere. Luckily, the people working to help others are also close by. Here’s what some of them want you to know about their jobs, what they struggle with, and what keeps them going through it all.
Rachelle White, Harborview Medical Center
A social worker’s job includes evaluating patients as they come into the emergency department, asking questions about their mental health history, their housing status, and whether they’ve had recent changes in their life. They check in with the person’s family or friends, and come up with the next steps, whether that’s a referral to another treatment center or an overnight stay at the hospital.
“Really the job of the social worker is to think about how to make sure that this person is safe, and that we create a safe and reasonable plan,” said White, a supervisor at Harborview Medical Center who oversees 25 social workers in the emergency department.
Harborview is one of the only hospitals in the Seattle area with a specific psychiatric emergency services unit, or PES, as White calls it. It has 10 beds, where patients ideally stay for no more than a couple hours before being discharged or transferred to an inpatient facility like Fairfax Behavioral or Overlake Medical Center. But inpatient beds are limited. Some patients are considered complex cases and facilities won’t accept them.
“There’s also like a million pieces of that puzzle,” White said. “If somebody does require hospitalization, you have to know the systems, the different facilities. How do we get authorization from the insurance company?”
Sometimes patients leave against medical advice.
“It is complex. You have to really be thoughtful. To know when to say, ‘That’s not gonna work.’ When to be more concerned about a person,” White explained.
Silvia Riley, MultiCare Behavioral Health
“We don’t have weapons, we don’t have sirens,” said Riley, a director of crisis services at MultiCare Behavioral Health. “But we are available 24/7, holidays and weekends.”
During the day, Riley works with about 15 staff including designated crisis responders, care coordinators and clinicians. At night, it dwindles to just two people. The MultiCare team is contracted to respond to behavioral and mental health emergencies for the 900,000 residents of Pierce County. They sometimes ride along with law enforcement and have the ability to bring patients to the emergency room, whether voluntarily or through an involuntary commitment.
To be committed, a person in crisis must be 13 or older and a threat to themselves, others or property. Or they must have a grave disability and be decompensating: They stop eating or taking care of themselves or their home.
The bar for commitment is high, “And it should be,” Riley believes. “People have rights. This is my bread and butter, but I’m the first one to say civil detention, it’s not the answer.”
Riley, who has worked in mental health services for 30 years, recalled past health and safety violations at Western State Hospital and the impact on institutionalized psychiatric patients. For her, the strength of mobile teams is that they can divert people from two key places: jail and the ER. Instead of detoxing in an emergency room bed or being charged with crimes, Riley wants patients to be able to access treatment. Funding is limited, though, and she said fragmented services pose yet another barrier for her clients.
Dae Yang Kim, Sound
Every morning Kim gets a referral list.
Every person on it is involuntarily committed to a hospital in King County and is usually at one of the most vulnerable points in their life.
Kim, a clinician with Sound, a behavioral health provider, first meets with the highest priority cases (for example, people who are not already connected to outpatient services) and tries to discuss options: what services people are eligible for, how to get home if they have one, and sometimes whether clients even want care.
The responses run the gamut: “Some of them are violent. Some of them are friendly. Some of them are very lethargic and can’t really speak. Some of them are manic and can’t really remember the conversation the next time you go,” Kim said.
Kim doesn’t take the spectrum of reactions personally: Involuntary hospitalization can be traumatizing, making people lose trust in providers and overall more skeptical of treatment.
Kim works to build relationships, visiting a couple times a week until the client is discharged, sometimes meeting with them for up to 90 days through what’s called the transition support program. Sound’s team has six clinicians in this program, with around 18 clients each. The clients are sometimes in transitional housing, on the street, in hospitals or in the general community.
Sometimes the plans the clinicians make with their clients fall apart.
“You kind of make plans and goals, and then — boom — once they get out, you can’t really find them,” Kim said. Without addresses or phone numbers it’s hard to track people down.
Other times clients don’t get access to care because all the hospital beds are prioritized for COVID-19 patients, and in rare and heartbreaking situations clients die.
“I’ve had clients that I go to check on in the ER, and the front desk told me they passed away,” Kim said. “It’s just kind of a surreal moment. You got to just kind of learn to live with that and just keep pushing.”
Genevieve Ameling, Virginia Mason-Franciscan Health
On an average day at work, Ameling, a clinical social worker at Virginia Mason Franciscan Health, gets a handful of patients; some might be experiencing suicidal ideation, others could be intoxicated and exhibiting psychosis-like symptoms.
“Emergency departments become de facto detox facilities because there isn’t anywhere else to send people in that moment,” says Ameling.
Every shift she waits for at least one person to come down from a methamphetamine high before she can screen them for behavioral disorders. It can take hours for the person to metabolize the drug, if not a full 12-hour shift. People can be talkative and excited, and sometimes patients try to take their clothes off because they are too warm (excessive sweating is a side effect of the drug). At times it’s necessary to restrain them physically or chemically with antipsychotic medication.
In the past, Ameling sent people on Medicaid to two different detox centers in Seattle. One shut down at the start of the pandemic, and the other is still open but only Monday through Friday, 8 a.m. to 4 p.m.
Unfortunately patient needs don’t always align with those hours. And if patients are also experiencing homelessness, it’s hard to come up with a treatment plan. According to a 2020 survey documenting homelessness in King County, job loss was the reason most often cited for homelessness, followed by drug and alcohol use, and mental health issues. When those same people were asked to self-report if they’ve dealt with a psychiatric or emotional condition like depression or schizophrenia, however, 54% also said yes.
Ameling’s 10 years in crisis mental health work has transformed her into a housing-first advocate, and she sees it as a vital step in the recovery process.
“If you want people to get better, if you want our community to get better, you need to provide housing.”
Winnie Agwazim and Freyton Castillo, Downtown Emergency Service Center — Crisis Solutions Center
When Agwazim, project manager for the Downtown Emergency Service Center’s mobile crisis team, goes into the field to serve clients, she is armed with nothing but her partner, a pen and clipboard.
In 30 minutes to an hour, she tries to intervene in an acute crisis, whether she’s on the street with someone or in a home. The goal is to make sure a client is safe enough to be moved to DESC’s Crisis Solutions Center, where they can get a place to sleep and eat, do laundry or shower. Or the client can be taken to the emergency room, if they choose.
Lately, the work has been more challenging. When Agwazim got a call recently, what should have been a standard 20-minute response became a two-hour interaction trying to get a client to sit in a car so they could be transported to Harborview.
“The police just refused to help,” she said, frustrated. Since new police reform legislation went into effect, setting standards for when police can use force, social workers and behavioral health staff have noted law enforcement is less likely to intervene.
“They’re just choosing to misinterpret that (law),” she said. “I actually had to tell a police officer, ‘Someone is going to get hurt.’ And he said, ‘Yes, that’s true.’ Somebody doesn’t have to get hurt for us to change things.”
Housing is another challenge, said Castillo, program manager at the Crisis Solutions Center.
The facility has 46 crisis beds for all of King County and demand is always higher than supply. COVID restrictions mean beds have to remain spaced out and programs that would offer food or clothing have shut down or lost volunteers. While DESC would like to provide housing within a two-week period, it can’t guarantee that; instead it has another team that works with clients over a 90-day period, setting them up with a caseworker and therapist and building support networks with church groups or community organizations.
“It’s trying to serve folks that are slipping through the cracks, but still gives them access to services before they even get to that [crisis] point, or after they get to that point,” says Castillo.
The theory is that it takes a village to make and keep someone healthy after a mental health emergency.
For her part, Agwazim sees the work as her duty to give back.
“I believe in doing good because somebody has helped my whole family somewhere,” Agwazim said, thinking of her family in Nigeria.
“I’m hoping to make a change in someone’s life.”