Getting 'downstream' treatment dollars diverted 'upstream'

A class-action lawsuit would force Washington to provide "evidence-based treatment" for children with mental illnesses. The goal is to head off big problems by letting families remain together.
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A class-action lawsuit would force Washington to provide "evidence-based treatment" for children with mental illnesses. The goal is to head off big problems by letting families remain together.

Last week the advocacy group Disability Rights Washington filed a class-action civil rights lawsuit against Washington State on behalf of children and youth suffering from mental illness. The complaint cites the state’s failure to provide home- and community-based services that would effectively address these children’s health needs.

Susan Kas, staff attorney for Disability Rights Washington, said in a telephone interview that the intent of the lawsuit is not to recover financial damages but to change the way mentally ill youngsters in the public health system are served, by bringing Washington into compliance with federal law. “In return for billions of dollars in federal money, the state agrees to provide certain services,” Kas told me. But according to the lawsuit, the state Department of Social and Health Services (DSHS) spends federal money on practices deemed ineffectual by the Department’s own studies since at least 2002.

Children in the public system who are diagnosed with serious mental illnesses are too often taken from their homes and placed in residential facilities. “Instead of creating more trauma for kids and spending money on institutional care that’s the most expensive kind of care but not nearly as good” as home- and community-based, family-centered care, Kas said, "the state should let children remain with their families” wherever possible and organize services around them. “The fiscal policy behind the federal funding is that if you treat kids correctly when they’re young, you can prevent their conditions from becoming chronic or severe. It’s a financial investment in the future of these children, that in the long run actually saves public money,” she said.

Dr. Eric Trupin, Director of the UW Psychiatry Department’s Division of Public Behavioral Health and Justice Policy, which oversees the Evidence Based Practice Institute, provided some clinical perspective on improving the treatment of childhood mental illness. “We know so much more about effective mental health interventions with children and families than we did 20 years ago,” he told me. “It’s a shame we’re so slow to implement what we now know: that psychosocial interventions which include intensive skills-based work with families lead to better outcomes than earlier approaches ever did.”

Such interventions are also cheaper, when considered from a long-term perspective. “If you can teach a family how to reduce a child’s symptom or how to help a child manage his or her behavior, it’s incredibly cost-effective, Trupin said. “The challenge is convincing policymakers to shift the balance to effective practices rather than continuing to fund the current practice of institutionalizing kids, where the outcomes are so much poorer.”

To its credit, the Washington Legislature has taken significant steps during the past decade to improve care for children with mental illnesses. In 2000 it established Family Integrated Transitions, a UW pilot program that builds in-home collaborations with families to help juvenile offenders return to their communities with less conflict and recidivism. Further, Trupin told me that two years ago the Legislature provided funding for the Evidence Based Practice Institute at the UW, which he co-directs. “The state has aggressively supported expanding the use of evidence-based treatment” in the public mental health system for children, he said. But true reform “depends on keeping kids out of foster care and institutions” except where absolutely necessary for the safety of the child or other people.

So more steps need to be taken. Eleanor Owen, founder and interim executive director of the National Alliance on Mental Illness (NAMI) Greater Seattle, as well as a co-founder of the parent NAMI and of NAMI Washington, agrees with the purpose of the lawsuit. “We’ve created a system of mental health care that benefits, instead of kids and families, vested interest groups far from where the challenges originate,” she told me. “Although families can often identify problems their kids are having, we don’t put effort or money into early intervention. We don’t provide needed care upstream; we build everything downstream.”

For example, Owen said, the Legislature spends vast amounts of money on “downstream” housing for people who can’t qualify as tenants because they have prison records. But they have prison records because of belated, poor treatment of the mental illnesses that led them to offend in the first place. With effective early intervention, she said, people with psychiatric disorders can learn to build productive lives, saving the state millions of dollars every year over the long term. “It’s not rocket science,” she said, “just good public policy.”

The class-action complaint is the first lawsuit filed in this state on behalf of children and youth with mental illnesses. If successful, it will force DSHS to allocate its federal resources more effectively by revising its public mental health policies according to sound principles based on current psychiatric research, and keeping more of Washington’s families intact.


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