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June 11, 2016; Seattle Times

Taking on leadership of a key institution in the midst of an inadequate and uncoordinated system where advocacy efforts sometimes appear at cross-purposes is not for the weak of heart. Having been hired into the position in April, Cheryl Strange is very new in the role of CEO at state-owned Western State Hospital in Lakewood, the largest psychiatric hospital in the state of Washington. But because she has defied the court to keep a patient with dementia on the wait list for admission rather than have him “jump the line” and enter ahead of those with greater need, she may be facing jail time.

Pierce County Superior Court Commissioner Craig Adams, who has a history of demanding that the system perform better on behalf of patients, ordered the man be admitted to the 800-bed facility, and Strange will have to go to jail on Wednesday if she does not admit him. Nevertheless, Strange refuses, saying to do so would require her to skip over other prospective patients on the waitlist who are in worse shape.

The patient in question was, in April, ordered by the court to be detained for two weeks but has never been admitted to an acceptable mental health facility. In May, the patient was again ordered detained—specifically at Western State, and this time for 90 days—but still no space was made available and he continued to be held under a “single-bed certification” at a general hospital where, though sometimes restrained, he has received medication, behavior management, and speech therapy, according to court testimony.

The practice of holding patients in emergency rooms or other inappropriate settings, known as “psychiatric boarding,” was found unconstitutional by the state supreme court in 2014, when patients were being held in hospitals in virtual limbo for extended periods, often in hallways or bound to their own beds. New state law has made the restriction less strict recently, but Commissioner Adams said the state doesn’t allow a patient to be boarded in a hospital for more than one 30-day stretch.

“To leave anyone stranded in single-bed certifications is a disservice and a violation of their constitutional rights,” said Adams.

Still, Strange declares she won’t admit the man, saying that the patient is stable in the current arrangement. “I will not override that [waitlist] to place somebody to avoid going to jail,” she said. When asked if she will report to jail, Strange said, “I will.”

In a statement Friday afternoon, Carla Reyes, an assistant secretary at Washington’s Department of Social and Health Services, defended the hospital’s “clinical judgment.”

“Our waitlist must be managed so that people with the most serious mental illnesses, and no other place to get treatment, are admitted,” Reyes, whose agency oversees Western State, said in prepared remarks. “We cannot increase civil admissions until we have staff who can provide the quality of care that leads to recovery.”

Strange would certainly have her reasons for trying to maintain systems so that they make coherent sense. Western State has been the source of controversy for years, and no one thinks the task of turning it around will be easy. Assaults on staff, severe worker shortages, and patient escapes have plagued the institution. Its accreditation is at risk, along with $64  million in annual federal funding. The Seattle Times describes some of the conditions that need to change:

Getting right with the federal regulators means dealing with the chronic staff shortages that bedevil front-line workers such as nurses, psychiatrists and counselors. About 170 of those jobs are vacant right now, including roughly one in four psychiatrist positions.

Meanwhile, the state in the last fiscal year approved workers’ compensation claims for 135 assaults on Western State staff members, costing a total of 5,957 work days.

After accumulating four warnings from the Centers for Medicare & Medicaid Services, the hospital recently signed an agreement with a 13-month plan for changes to be made.

This is one of many stories around the country of an inadequate mental health system in profound disarray. Prisons and jails are standing in as institutional homes for overwhelming numbers of people with mental illness.—Ruth McCambridge