For people in mental health crisis, what comes after police response?

Cops are only one part of a larger system that more often treats the symptoms than the cause.

Mariah Andrignis, right, a social worker from Downtown Emergency Service Center who contracts with the Seattle Police Department to help with crisis response, works with Officer Sandlin Grayson while speaking with a witness at the scene of a fatal stabbing in front of Seattle Fire Department's Station 5 along Alaskan Way in downtown Seattle, Aug. 6, 2020. (Matt M. McKnight/Crosscut)

Last January, Peter began to doubt that anyone knew how to help his stepson.

The hard lesson started in a bar, where police arrested the stepson, M, for hitting another man. The incident followed days and weeks of M flashing a psychosis that seemed to be worsening. Since he had arrived from Washington, D.C., for a visit in January, M’s behavior had caught the eyes of the neighbors who were growing intimidated by the young man down the street.

The victim in the bar was disabled and, when M punched him, it triggered a seizure. Peter acknowledged that M was a threat to others and likely himself as well.

But Peter also knew that the root of M's action was a disorder that could send him to dark and confusing places. Was some sort of intervention necessary? Yes. But the one he received tossed M ricocheting down through a system that only deepened his crisis — a system well-tuned to respond to the emergency at hand, but less prepared to stop the next incident from occurring. For M, what followed his arrest was weeks of isolation, intermittent treatment and, eventually, a sudden release. Another arrest followed just days later.

"The system failed over and over again in the last six months," Peter said.

It can take near-total decompensation before anyone steps in to intervene in a human crisis — and then it's almost always the police. After a summer of protest, the cops' role in these moments is under sharp scrutiny.

But the police response is just one part of a broader system largely geared toward treating symptoms, not causes.

After police show up for someone in crisis, what most commonly follows is a handoff into a confusing — and expensive — amalgamation of the legal and behavioral health worlds. Advocates for people suffering from mental illness insist more must be done. 

The current system, which runs through hospitals, is not jail, but it's not true mental health treatment either. It more closely resembles an emergency room, except it’s mandatory and for behavioral health crises. When the emergency passes, the authority of that system ends, which can drop someone like M into an abyss. 

More often than not, those who enter into this world will cycle through repeatedly. In 2017, 57% of people committed had been through the system at least once before, according to a 2019 King County audit. This number, the audit concluded, suggested stability was not being maintained after an individual returned to society.

Given the choice, advocates and attorneys prefer hospital commitment over jail for their clients.  But it's nevertheless a potent symbol of how few opportunities exist between no treatment at all and treatment of last resort.

"The system we have set up offers very stark choices," said Kim Mosolf, an attorney with Disability Rights Washington. "You either get not a whole lot, or you get way more than you bargained for…. Finding a better balance in there, we have not done that yet in Washington state."

In the weeks that followed the incident at the bar, M was passed from the jail, to the hospital, back to the jail, into psychiatric treatment and then to the streets, his condition worsening along the way. What treatment he received for his psychosis stretched only far enough to satisfy the legal system that he no longer needed to be detained against his will — a wholly lower bar than whether any of his symptoms would return in the future. They would. 

For Peter, it was all baffling to watch. Unlike with an emergency room, there was little easing back to normalcy for M — just one drop into nothing.

"A more comprehensive mental health treatment system could have intervened in the last six months and prevented this cycle from happening over and over again," Peter said.

After 911

At a time of protests and political standoffs, one tenuous point of agreement has emerged among activists, politicians and even the cops: Police should respond to fewer behavioral and mental health crises.

But filling that role requires an understanding of what happens when cops do respond.

In the more than 10,000 crisis contacts made by the Seattle police last year — calls that may not involve a crime, but instead a behavioral health or substance use issue — officers ended up sending subjects to a hospital against their will nearly 40% of the time, according to department data. That was by far the most common end result of crisis situations — much more so than referrals to a case manager, arrest or even doing nothing at all.

Officers take this step when they've decided a person is an immediate threat to themselves or others, or are seen to be gravely disabled. By sending them to the hospital, an emergency situation — a man stepping into moving traffic, for example — can be mollified, at least for a moment.

"When you see an individual that's clearly struggling and managing through day to day life, it becomes difficult when we look at it and it's like there's not criminal activity — an arrest or citation is not a good option," said Seattle Police Sgt. Eric Pisconski. "So officers are looking to other options. Where can we go with this person?"

When someone is sent to the hospital, the system they enter looks to be mental health treatment. They can be held under Washington's Involuntary Treatment Act for an initial 72 hours and between 14 and 180 days, if an evaluator determines it's necessary and a court agrees. 

But because commitment is involuntary, its underpinnings are also legal. There's a prosecuting attorney who argues for why the person should be held and a defense attorney advocating for the person’s liberty. A judge oversees the whole thing, often from a courtroom inside Harborview Medical Center.

The system's goal is stabilization through treatment — enough so that the person is no longer deemed an immediate risk to themselves or others. What it's not, however, is long-term treatment.

"The [Involuntary Treatment Act] is very clear that no one is held simply because they have a mental disorder," said King County Superior Court Judge David Steiner. "Otherwise our hospitals would be extremely full."

When someone is turned out of the system, despite continued struggles with mental illness, that can create confusion and frustration for families like Peter’s, as well as those who refer the individuals into the hospital.

Pisconski said that, of the roughly 4,000 people police send to the hospital every year, only about 10% to 15% are actually held for extended treatment. It's not uncommon for officers to see the person they committed at the beginning of their shift walking down the sidewalk by the end of the shift, he said.

Victoria Van Nocken, the head of specialty courts unit in the Seattle City Attorney's Office, said she routinely sees reports on people who were found to be suffering from mental illness — a box checked on a form — but nevertheless did not qualify for commitment.

"Anecdotally, I have seen some really, really mentally ill people come through," she said.

Judge Steiner said this is how it must be; anything more restrictive could present a serious infringement on a person's civil rights. "We don't charge people or incarcerate people because of the risk of crime," he said. "We don't involuntarily commit people because of a risk that they might do something."

Kelli Nomura, administrator of the King County behavioral health and recovery division, said crisis evaluators are always hoping to find a less restrictive alternative to commitment. Much of that is based in recent history, in which people struggling with mental illness were overly institutionalized. 

“We always approach it with the intention, the hope, that we're going to find a less restrictive option for the individual, because the last thing we really want to do is put someone in the hospital against their will,” she said. “We want to be able to provide that service and support in a voluntary way in the community.”

At the same time, hospitals cannot hold someone against their will purely out of concern that there's nothing waiting for them on the outside, said Allie Franklin, behavioral health service administrator at Harborview Medical Center. The balance, then, is between depriving someone of their liberty and the fear of what that liberty might mean for an individual. 

“As long as we are involuntarily committing people, we need to have a system in place to protect their rights,” said La Rond Baker, special counsel for affirmative litigation and policy with the King County Department of Public Defense. “But that system alone is insufficient to actually really resolve an individual's problems.”

And so, with limited options for seeking mental health treatment in the region, hospital commitment is sometimes the only hope, for better or worse. 

Emily Katz, a nurse with the Downtown Emergency Service Center, said that when she provides testimony in the courtroom for why a client should receive that treatment, she'll sometimes focus on physical ailments, like infections or injuries that could grow worse, rather than the person’s debilitating mental illness.

"What I really want to write is this person isn't eating," she said. "They're not OK. I'm not necessarily thinking they're going to die any second, but I'm very concerned about their well being, so please do something.”

She knows the person is suffering because of his or her psychiatric state and that society should do something. “But what I have to say, because I know this is what will win the argument in a court hearing, is not exactly what feels truthful to me," Katz said.

Preventing returns to the hospital

M’s experience in King County highlights how fluidly mental health and criminal legal infrastructure overlap. He was moved between the jail and the hospital several times; at one point he was incarcerated for seven weeks. He was "mostly unmedicated, in a profound psychosis, and in solitary confinement," said Peter, his stepfather. With only remedial medical care from the jail's staff, what had been a bad state spiraled further. "During the time that M was in jail, he called me whenever possible, expressing violent and delusional thoughts," he said.

Peter eventually succeeded in getting M returned to the hospital on a 14-day commitment, this time in a Kirkland facility, where he received treatment to help him stabilize. But throughout his stay, he continued making irrational calls to family. Peter said it was the worst he's ever seen M in 16 years.

And then, M's time was up and he was released. Peter said he learned this only when he heard that M showed up at his brother's house in San Mateo, California. The family had an emergency meeting and decided to send him back to Washington, D.C., where he had a strong support network. But 72 hours after he was discharged in Kirkland, he was arrested again on the other coast.

In a strange way, the arrest was something of a relief for Peter. "It may have been just as likely that he would be dead in the morgue," said Peter. "Or somebody else would be injured or dead."

This question of what comes after the hospital is central. Franklin, the Harborview behavioral health service administrator, said the hospital works with providers and peer advocates to offer "step down" services. Someone can also agree to a voluntary commitment in a hospital.

But there's broad agreement that the region needs more services to fill the gaps before and after a hospital commitment.

"We need to have something better in our community that a person doesn't have to sink so low to meet the criteria for ITA [the Involuntary Treatment Act] and inpatient treatment but can get substantial help prior to reaching that low," said Anne Mizuta, senior deputy prosecuting attorney with the King County Prosecuting Attorney’s Office. And when they leave, there needs to be something to ensure they don’t return. 

Peter agreed.

“There's a bigger safety net that's needed,” he said, pausing between each thought, “because of the fragility and significant invisible trauma of psychosis. In my experience, psychosis is not much different from traumatic brain injury, and the recovery is slow and delicate. We just don't have the systems that provide those resources.” 

Participants in King County’s 2019 audit noted that some people frequently return to the commitment system “without receiving treatment that would reduce their likelihood of having a new case." 

That’s especially true of Black and homeless individuals, who are both disproportionately likely to be committed to begin with and even more likely to return repeatedly. 

Twenty percent of people with three prior commitments were Black and 41% of those with three prior commitments struggled with homelessness. 

In this way, the system's success will always be limited so long as a person's larger needs go unmet, said Dr. Cyn Kotarski, of the Public Defender Association. "ITA is focusing on medical stability and leaving out all the other factors that have to play in in order for that stability to be maintained, including housing and actual access to supportive therapy," she said.

Many of the same programs receiving attention as possible alternatives to police response — including the Law Enforcement Assisted Diversion program and the Downtown Emergency Service Center’s mobile crisis team and crisis solutions center — are also geared toward providing the kinds of services that could keep people from returning to the hospital. 

But at the same time, COVID-19 is further damaging King County’s behavioral health system. Revenue from a sales tax that funds services has decreased, spurring one of the county’s largest providers, Sound, to start laying off workers. In May, a 60-bed facility, El Rey, closed its doors

In the months since he was arrested in King County, M has returned to the hospital four times in four different places across the country, a clue that no matter where he was, mental health treatment is complicated.

Peter's tired. His family is tired. M is still struggling, still cycling in and out of hospitals and the criminal system. Peter understands that there's no easy answer, especially for someone like his stepson, who presents a genuine risk to society. 

But he also believes that the current response, such as it is, is falling short.
 

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