There are 100 of them in there. They cannot get out. They've done their time. They are not free to go. They are Western State Hospital patients, well enough to be discharged from the psychiatric wards but, as a practical matter, unable to leave the grounds. You probably don't know them; you don't hear about them. They are nameless and faceless, held hostage by a mental health system that doesn't work and a society that doesn't care.
SEATTLE WEEKLY2004 MENTAL-HEALTH COVERAGE
• One suicide too many (1/14/2004). MORE
• Mentality challenged in Olympia (3/3/2004). MORE
• Give them shelter (5/5/2004). MORE
• Mental-health purgatory at Western State Hospital (8/11/2004). MORE
• Psyched out and fighting for normalcy. (11/17/2004) MORE
If you were a prison inmate who had served your sentence and yet you couldn't get out of jail, society wouldn't just care—it would be outraged. There's a similar situation at Western State, in Steilacoom in Pierce County—the most notorious of Washington institutions—but the public outcry is missing. Two years ago, a new state program enabled stabilized patients to leave the hospital and, with help, make their way in the real world. But then this freedom train stopped, and 100 people were left in limbo. State and local health officials know there is an effective way to release them, one that's fast and cheaper than keeping them institutionalized. But they are afraid to act.
Twelve of these 100 patients are former prisoners; the rest have never been accused of any crime. They have rights. But, being mentally ill, they are screwed. Freedom is the creed of this country, but it mostly applies to these patients in the abstract.
One man for whom freedom has worked is a 53-year-old schizophrenic named Wei Li. He was in Western for six years. He's now in a progressive program run by Highline Mental Health in West Seattle, and he's proving to be a very determined patient. He knows the difference between in there and out here, despite the many challenges to piecing his life back together.
"More better," says Wei Li, whose mother tongue is Cantonese, of life out here.
The reason more patients—including the 100 in Western limbo—aren't winning the freedom Wei Li enjoys is that the Legislature and state and local mental health officials have created a system with knots that Hercules couldn't cut.
For society, the convenience of keeping people like Wei Li locked up is easy to justify. They're nuts. They're a menace. They can't live amongst us. We've long regarded the institutionalization of mental patients as a joke: "You're going to Western State," goes the giggling putdown of children and adults. So no one much cares about what goes on behind the low stone wall around Western's grassy hospital grounds or inside the graceful, early 1900s brick buildings. Plenty has. Rape. Torture. Murder. Seclusion for weeks and months strapped to a bed in leather restraints. Forced prefrontal lobotomies. Walking zombies. Frances Farmer.
The main entrance at Western State.
(Kevin P. Casey)
You went in and you didn't come out, and few gave a damn. Until the 1950s, Western patients' remains, unclaimed by families, were buried in a nearby graveyard. Names did not appear on markers. Instead, they got a number. Three thousand numbered graves lie near the Western campus today. No lie.
On occasion, journalists and citizen groups reported on deplorable conditions at Western. Lawsuits and spotty reforms followed. It took many decades, but Western made the shift from warehouse to hospital. Today, its wards—units, in Western's parlance— resemble hospital wings at a low-budget medical center. The cinderblock walls are painted gray. Patients get bedrooms with a dresser, desk, and mattress.
But our attitudes on the outside have not changed. Even in 2004, families forget about relatives in there. Why should the rest of us give a damn? They are crazed, unable to live in society, right?
But in the 21st century, something's different: Medications and behavioral treatment for schizophrenics—the hospital's core population—are far, far better than in decades past when doctors used cold baths as a treatment. People can improve. They can "recover," as many in the mental health field now call a patient's progress from the depths of illness to reintegration into society. They can live in society, and they should not be held without prospect of release.
A few years ago, the Legislature and state mental health officials hammered out a plan to downsize Western. It costs $425 a day to hold a patient at the hospital, but it would cost one-third that to house them in a group home or halfway house and offer a reorientation program like the one at Highline. Indeed, over the past two years, patients who previously would have had little chance of being freed were released through a state program called Expanding Community Services (ECS). Seventy adults and about 100 geriatrics tasted freedom for the first time in years via ECS. Among the adults, only five have returned to Western—a far cry from the regular recycling of patients.
But that gate has slammed shut. State and local officials have put the exodus on hold until late 2005 at the earliest. And so a hundred people wait in Western, able to leave but with nowhere to go. Many of the 70 adults who got out had been in a special unit at the hospital called the Program for Adaptive Living Skills (PALS). It exists to prepare patients for freedom. But, in practical terms, it's as restrictive as Western State Hospital proper. This is crazy. Convicts get out of prison when they've served their time, with nowhere for them to go. Level 3 sex offenders—considered the most likely to reoffend—get a better shot at freedom than Western patients.
That might make sense to you somehow, but even the U.S. Supreme Court doesn't buy that logic.
Wei Li, a 53-year-old schizophrenic, begged to be released from Western State.
(Kevin P. Casey)
'Please Get Me Out of Here'
Inside Western one day last fall, Wei Li shuffled up to a woman named Ravenna Candy. She is a therapist for that innovative program at Highline Mental Health. It takes long-term Western patients, the hard core of the chronically mentally ill, moves them into three- or four-bedroom homes, and gives them appropriate medication, intensive training in living skills, and a strong dose of behavioral therapy. Candy was there to assess other patients. Wei Li wasn't on her list. But Wei Li knew she was his ticket out of PALS, out of Western, back to see his mother. He knew the gate could be opened.
He lowered himself to his knees and put his hands together. His hair is black and brush-cut. He bowed. "Please, lady, please. Get me out of here."
He was one of the harder cases at PALS. Wei Li had been in and out of psychiatric hospitals since he was an adolescent in Canton during the Cultural Revolution and since coming to this country in the 1970s. He was needy for human contact while at Western, to the point of grabbing people just to touch them, to remind himself that there was something else at the end of his hands. His family had largely left him in his bedroom in a small tan house on Mercer Island from the late 1980s until, after many hospitalizations at Western, Harborview Medical Center in Seattle, and Overlake Medical Center in Bellevue, Wei Li was most recently committed to Western in 1999. He had not seen his mother since then.
Still, Candy was impressed by his desire. On Dec. 1, 2003, she drove Wei Li to Burien, where Highline Mental Health manages the homes for the former Western residents, under the flight path of Seattle-Tacoma International Airport. Wei Li had not been outside the wall surrounding Western for four years. The man could barely walk. He moved into a two-story house with vinyl siding and a cathedral ceiling, got his own room and his own bed with a real box spring and mattress. A nightstand. A dresser. A metal folding chair. A semblance of normalcy.
He also got a case manager named Kim Brown. She knows all about Western and the road back, having been involuntarily committed there for three months in 1997. After she came out, Brown got a psychology degree from the University of Washington and devoted her career to helping people like her.
At first, you have to work to understand Wei Li. His Cantonese accent is still thick. The medications he takes—mostly the so-called atypical antipsychotics, designed to quiet schizophrenia's hallucinations and behaviors—make it harder still to understand him. His mouth is dry to the point where his tongue is white and grooved like a dry lake bed. You have to lip-read when you first listen to him.
When I met Wei Li in early June, he was still in tough shape. He shuffled slowly, hunched over like an old man too proud for a cane. He led me to his room and stood there in front of me. I didn't know what to ask him. I could barely understand the man. He blurted out that he bought his clothes at Value Village, $2 for a faded purple polo shirt and $4 for a pair of gray cargo pants. He wore knockoff Birkenstocks.
"I tell you something, sir," he said. "If I make mistake, I don't see my mother." He held out his arms, his wrists touching one another. He clenched his fists. He knew the score—a ride in a cop car to a psych hospital, his freedom gone.
I met other former Western patients at lunch that day at a nearby Highline Mental Health facility in Burien. One man had been in Western for 15 years. Another trembled constantly. Others walked as though they'd just been punched in the abdomen. Some of them own cars. They shop for secondhand clothes and food. They have friends who visit. Some have no one. Most of them live on about $500 a month in Social Security benefits, with which they pay for housing and food. A tough life. But all of them seemed very much in the present. Their faces were bright with recognition of the reality around them.
Wei Li was still struggling to get there. Later, I watched him shuffle along the dirt shoulder of the road leading back to his home. Brown walked alongside. Wei Li kicked up small clouds of dust.
Both Brown and Candy told me that he is a very determined man. I had my doubts as to how far that would get him.
The rooms are spartan, but conditions are better than in Western State's old "warehouse" days.
(Kevin P. Casey)
Free to Go, But Where?
Today, 100 patients languish in PALS in Western. Seventy-five percent are men, 25 percent women. Eighty percent are white, 10 percent African American, the remainder a mix of other ethnicities. The most common diagnosis is schizophrenia, but there are a few with bipolar disorder—manic depression—as well.
The program costs $5 million a year and is overseen by the Department of Social and Health Service's Mental Health Division.
Western State houses about 400 other adult psychiatric patients and approximately 200 geriatric psychiatric cases. There also are 240 mentally ill people in a new and very secure forensic unit—a prison to you and me. A court found them to be not guilty by reason of insanity, or they are being held in an attempt to get them competent enough to stand trial.
Regular Western patients are held on what is known as involuntary commitment. They have been determined to be a danger to themselves and others. A mental health commissioner from Pierce County Superior Court reassesses their commitments every six months.
PALS patients, on the other hand, are not held on involuntary commitment. Forty are in PALS "voluntarily." Sixty are on what's called LRA—least-restrictive alternative—an agreement with a court to undergo PALS treatment or be put on more restrictive hold as a regular Western patient.
All of the PALS participants enjoy a measure of physical freedom. They can walk through glass doors at the west end of the building anytime they wish between 6 a.m. and midnight, 2 a.m. on weekends. The LRAs, too, can make their way a quarter-mile to a gas station and buy potato chips and soda. Many also buy cigarettes. They have to smoke well away from the PALS building.
They walk in and out of those doors, sometimes to the Albertson's a half-mile to the east. The less mobile stay in their rooms. Others slump in chairs in front of televisions in a day room. High doses of atypical antipsychotics induce sleep, and very powerful dreams several times a day. A good number of patients I saw at PALS over a three-hour period also had that shuffle and a haunted look to them—mouths, faces, and eyes hardly moving.
It felt like a zoo for Homo sapiens.
The essential idea behind PALS is to get these patients—technically discharged from Western and medically stable—ready to live in what everyone in mental health circles calls "the community," where the rest of us reside. Some will be in PALS for perhaps three months. Others will be in PALS far longer. The current record holder has been there eight years. Some have been in Western and PALS for more than two decades.
Western and state officials say that 50 of the PALS patients have had some kind of criminal past and will be very difficult to place. Twelve of them were in Western's forensic unit. They are rapists and murderers. Each has served their sentence. The other 38 committed misdemeanors and low-level felonies. They were not charged with a crime, owing to their illnesses, and were sent to Western's adult units. Many mental health programs don't want them. Many are caught in Western and PALS for years longer than a common felon would be jailed for the same crime. Along with the 50 other patients, they are free to go. All 100 could walk out through the glass doors, catch a bus on Steilacoom Boulevard, and never return. About five people give it a go each year. They come back soon enough. They don't get treated in the outside world. They melt down. They are committed all over again.
The old hospital graveyard is marked with numbers instead of names.
(Kevin P. Casey)
PALS patients I spoke with know all about this cycle. That's why they walk back through the doors every evening like children at summer camp. They are free, and there is nowhere to go.
The system has them tethered. PALS is their shelter. It's where they get treatment. It's where they eat. It's where they have a sense of community. Should they leave, nothing as good as PALS awaits. They have to cooperate. They have to hope a bed becomes available in Tacoma or Seattle. Until then, they have to cool their heels and wait for the state to stoke the freedom train again.
It's a bizarre limbo. Some patients I spoke with can handle that. Some find it outrageous.
"Why am I here?" says Shawn Clark, who's been at Western and PALS for three years. "I'm ready to roll." He's still waiting to find a space at a group home in King County.
"It's kind of like the prison system," says Mike Dyer, a nurse at Western for 18 years. "We know these people would do best out in the community, but the community just doesn't want to deal with it."
Jacked Up On Meds
A few days later, I tagged along with Wei Li and Brown. We went to a strip mall restaurant in Burien. Wei Li likes noodles and sweet and sour pork, and plenty of it. After, we went to a neighboring Safeway. Watermelon was $3 a pound that day, and Wei Li couldn't afford it. "How about cantaloupe?" Brown said. She encourages him to eat plenty of fruit. "You need to eat healthy, Wei Li. Remember?"
"OK." Wei Li shuffled over to a bin of cantaloupes and picked up the first two he could reach. They were green and smelled a touch moldy. Brown put those back and taught Wei Li how to smell a ripe cantaloupe. We moved on. He bought oranges, a case of bottled water (hydration is crucial for people who take atypicals), a 12-pack pack of Diet Pepsi, and two bottles of Sunsweet prune juice, which he especially likes. He paid for it with his food stamps card. Then he demanded to go to a branch of U.S. Bank. Wei Li was convinced someone had stolen his checkbook. He had misplaced his check register.
"No one can get your money, Wei Li," Brown told him.
"Take me to bank." At the bank, he could barely slide his ID out of his wallet. The teller, behind an inch of Plexiglas, patiently explained to Wei Li that his account was safe. She gave him a new check register. "OK," he said. "OK."
Each time Wei Li got in and out of Brown's Honda Civic, I watched to see if he would remember to lock the passenger door. Half the time he did. Not bad, all things considered.
Still, I had my doubts. How far could someone like Wei Li come back from the ravages of mental illness and more than half a decade in Western? Brown says Wei Li didn't get much individual attention there. Wouldn't he just walk out of his house one night and stumble into the path of a car on Des Moines Memorial Drive in Burien? Aren't we subjecting him to yet another convoluted half-freedom, jacked up on antipsychotic meds—freed by the meds and at once imprisoned by them? How much of how you are supposed to behave in society could he remember from the days before he cracked?
The more time I spent talking with Wei Li, the more I became convinced that he wasn't a zombie like some of those he left behind at PALS. His world has texture to it. He likes country music. He owns one compact disc, John Denver's Greatest Hits, plucked from the $1.99 bin at Fred Meyer. His CD player cost $27. He showed me his radio. He listens to country music on that, as well. Without fail, he offers guests Diet Pepsi. He calls everyone "sir" or "lady." He bows. He smiles a lot at visitors. He still knows how to connect.
Once, he insisted on making me lunch. I accepted. Brown wasn't around, and I wanted to see if the result would be a nice meal or a mess on the kitchen floor. The noodles and snow peas were great.
"Do you want to see your mother?" I asked him as we sat at the house's small dining table.
"Yes," he said, smiling. His face tightened. "One day. That's all I want."
As difficult as his situation is, I didn't once hear him complain.
Later in June, Wei Li awoke at 2 a.m. one morning and was unable to use his right hand. He figured that he'd slept on it. His hand and fingers were still uncontrollable seven hours later. I was to visit him that morning and arrived as Brown, Candy, a nurse, and his psychiatrist, Barry Grosskopf, came through the door. Was this a pinched nerve or something else?
The nurse moved his hand through its range of motion. So did his doctor. Wei Li could not do this under his own power.
Wei Li looked helpless sitting on the edge of his bed. His mouth was open and his eyes did not blink. No one dared say it within his hearing, but this was a threat to his progress. You never know what's going to trigger schizophrenia's demons, uncork a patient's wild behaviors.
Andy Phillips, Western's new CEO, says that the bad old days are long gone.
(Kevin P. Casey)
His room smelled of mold and body odor. Brown opened the windows. I sat on the metal folding chair for five minutes, furious that life had kicked him yet again, then went out on the tiny front porch and smoked cigarettes with Brown. I asked her how she kept level when something like this happened with a patient.
"I try to stay positive," she said. She was quiet for a moment. "This is a setback."
Grosskopf walked by. "I'm afraid Wei Li may have lost the use of his right hand."
If that happened, I figured it was game over for Wei Li. But Wei Li is a determined man.
The Olmstead Ruling
In 1965, Congress passed the Community Mental Health Centers Act. It was intended to deinstitutionalize the mentally ill. This policy was in part spurred by antipsychotic meds like Thorazine and Haldol—considered breakthroughs at the time—and partly by a desire to treat patients far cheaper in the community. There were approximately 500,000 people in state mental hospitals around the country at the time. They were subject to the same kind of inhumane treatment as Western patients experienced in the old days. But lawmakers made a cruel mistake. They did not provide funding for housing, leaving deinstitutionalized patients to fend for themselves. Many ended up on the streets. Or back in state mental hospitals. Or in prison. Or dead.
At the behest of President Ronald Reagan, the government took another swing at deinstitutionalization in the 1980s. Cost savings, again, were part of the impulse, but with the active encouragement of groups like the American Civil Liberties Union, freedom was trumpeted as the prime mover. Once again, there were few provisions for housing or aftercare. The deinstitutionalized flooded the streets of urban centers.
By the early 1990s, there were 93,000 people in state hospitals. In 2001, there were 53,000, a halving in just one decade. Much of that decrease can be tied to medications far better than the old ones and behavioral treatments that, to varying degrees, worked for everyone except the most hard-core cases. Without these meds, only 20 years ago people like me—bipolar and suicidal, as I detailed in these pages last January—would have wound up cuffed and belted into the back of a police car on the way to a state hospital.
Now we're permitted to remain in society. We're still problem children, of course. But since we aren't hurting anyone, we only have to grapple with marginalization.
Former Western patients face higher hurdles. Try, for example, explaining a two-, five-, or 10-year gap in your life on a job application.
It's no accident that many of the mentally ill have been discharged over the past decade. Three forces combined to make freedom possible: the meds, better treatment in the community, and a Supreme Court ruling that stands with Brown v. Board of Education as a landmark civil rights case.
Medications for schizophrenics such as Thorazine had immense side effects. They often reduced the mentally ill to people with frozen faces and blocky gestures. Locked down psyches. Jerky motions and shaky limbs—tonic movements, as they are called. The meds prevented wild behavior but reduced patients to robots in the process.
In the late 1990s, a breed of kinder, gentler antipsychotics came into wide use for schizophrenics and some bipolars. Called atypical antipsychotics, the best known among them are Risperdal and Seroquel. Compared to Thorazine and Haldol, they hardly have side effects (aside from potential long-term problems such as diabetes, for example) and give patients some measure of freedom from the hallucinations and rage to which schizophrenia and bipolar are heir.
These drugs alone have set many state hospital patients free around the country.
Community treatment has gotten better as well. Group homes and halfway houses aren't the extension of the state hospital they once were (and in some cases still are). They provide shelter, ready access to meds, and regular therapy. The trouble with those settings, as some in the mental health field put it, is that they are too institutional, and a good number of people cycle back to psychiatric hospitals.
A more humane alternative is just now coming into vogue across the nation. It's called Assertive Community Treatment (ACT), and it could be an effective solution for the 100 hostages at Western. ACT was developed in Wisconsin in the early 1970s, after state hospital personnel there tired of watching patients bounce between hospitalization and the community. They tried putting patients in their own apartments and small homes. Gave them some sense of attachment to the broader world. Worked with them at fast-food restaurants and coffee shops and in their own residences. And stayed on top of them. Reinforced behavioral goals every day, not once a week. Gave one case manager five patients, not 60.
Several studies over the past 25 years show that ACT dramatically reduces the number of rehospitalizations. ACT is used at the Highline Mental Health program. It's been so successful that only one of 22 Western and PALS adult patients in the Highline program has returned to the state hospital in two years. These results mirror other programs nationally.
The new generation of meds and ACT are ways to deal with the practical effects of mental illness, schizophrenia in particular. How to get people housed and integrated into the community. How to keep them from running around naked on Interstate 5. How to give them back their lives, piece by piece.
But a landmark 1999 Supreme Court ruling kicked the door open even more. Called Olmstead v. L.C., it was the first time the rights of institutionalized mentally ill patients were carved into law. Two state hospital patients in Georgia, one of them identified as L.C., brought the case. Olmstead is Tommy Olmstead, the then– commissioner of the Georgia Department of Human Resources. Both patients were assessed to be treatable in the community but faced long waiting lists for group homes. That left them to wither in the hospital, partially free of illness but not of the institution. The court ruled that as long as patients could be treated better in the community and wanted treatment in the community, and it cost less to treat them in the community, they had to be released. What's more, the court found it unacceptable for states to claim that they didn't have the resources in the community to deal with all these people. These people had to be set free, pure and simple.
That ruling had important implications for Washington.
In 2002, the state took the first substantial steps to comply, releasing the 70 adults and about 100 geriatrics from Western and PALS into the state's ECS program. And then, that was all, with another 100 adults waiting for their chance to get out.
Wei Li with case manager Kim Brown: living with voices, but making progress.
(Kevin P. Casey)
Living With Voices
No one calls him just Wei, his given name. It's always Wei Li. It's two quick syllables, and it feels good to say it. Wei Li. Wei Li.
He hears it all the time. From Dr. Grosskopf and Kim Brown. From his radio. From the television. And, from the voices in his head. The ones that say, "We will kill you, Wei Li!"
Wei Li hears bad voices like those four times a day. They crumple him, and he folds into himself on his bed. Sometimes, his days are better—he hears the voices only twice. "Wei Li. Wei Li. Kill you!"
"They aren't real, Wei Li," Brown says, and she says it often—reinforcing behavior. "The TV is not talking to you, Wei Li."
"OK," Wei Li says. He smiles and lowers his head as if for a small bow and rolls his pupils up in his eye socket. "OK. You're my boss!"
"Wei Li, I don't control you. My job is to help you. You aren't a patient anymore."
He's buying the story for the moment: If you don't believe the voices are real, they won't come.
Some researchers say that schizophrenia will be cured in a decade with gene therapy. Wei Li doesn't have a decade. He has more immediate problems. The voices will hit again, within hours, of course. He'll think they are real, his regular tormentors making their scheduled appearances. Then, it's off on the scrambled brain narrative that's ruled his life from adolescence to middle age.
The voices and his occasional frustration at being so befuddled—he never gets angry, he's a remarkably gentle and polite man—aren't merely a medical issue. He'd been out of Western for seven months and still hadn't seen his mother. His brother-in-law, who runs the household for Wei Li's elderly parents, wouldn't let Wei Li visit his mother. Wei Li's sister had yet to come to Burien to see him. His brother-in-law visits every couple of weeks, along with Wei Li's father. They drive him to the International District. The two men buy him dim sum and Chinese noodles from a small market. On occasion, they take Wei Li to a barber shop.
They didn't want Wei Li near the family home until they could be certain he would be controllable. He was mostly there, despite clinging to the notion that President Bush speaks to him. I was around Wei Li repeatedly over a period of two months. Not once did I see him act badly toward anyone. He doesn't have a mean word in his mouth. But mental illness is a huge stain for some families, a blot on a good name. His family wanted to proceed with extreme caution. Wei Li wasn't going to see his mother anytime soon.
But hearing voices in Burien beats the hell out of hearing them in Steilacoom. "More better, more freedom," he says when asked about the difference between Western and Highline.
When I asked Wei Li what life was like back in the dimly remembered past, the details come out in small pieces. A stocking job at a Safeway in Redmond. A job assembling electronic parts somewhere else on the Eastside. Marriage to a woman from Canton. Taking the bus from Mercer Island to Redmond and back. He liked the trees behind his family's home. He's foggy on the when and where, but he knows that he was in and out of private psych hospitals and King County's principal psych unit at Harborview Medical Center. That's what Wei Li remembers—and that his wife divorced him while he was being held at Western.
The amount of crap that he's been through is startling. He still couldn't use his right hand beyond a weak squeeze in late July—he's on Medicaid, and Harborview didn't have time to see him until Aug. 9.
Otherwise, there often are little spikes on the register of hope. One morning, Wei Li and I sat on his front porch and watched airliners as they powered toward the runway at Sea-Tac. We turned it into a game—who could identify which airline. I worked with him on Alaska Airlines. He nailed that one. He is fond of the fur-trimmed Alaskan Native painted on the tail of Alaska's Boeing and McDonnell Douglas jets. We tried United Airlines, with the multicolored U on the tail. I wanted to see if it would cement in his mind.
A week later, we went back to the porch. I pointed north as a creamy jet approached. "Alaska," Wei Li said. And, as another jet glided over us, he said, "United."
Wei Li took a drink of Diet Pepsi. "Very good, sir."
Money, Time, and Meetings
In 2002 and 2003, the state's mental health officials had their act together. They were on the way to catching up to all the freedom they should offer in the wake of Olmstead, with the new medications and programs like the one in Burien.
But most of the patients released were geriatrics, classed as anyone over 60 years old at Western. In all the adult units at Western, there's a sad story around every corner and behind every door. But you can handle that. They are in their 30s and 40s. Presumably, they have some life left and could still spend much of it outside of Western.
It's the geriatric units at the hospital that will shake you up. A woman with drooping cheeks rolls her wheelchair slowly around the unit. She holds a Mylar balloon with an American flag on it. She has none of the freedoms that come with that flag. She and the other patients stare out a series of windows at terra cotta planters filled with bright flowers hanging on a fence topped with barbed wire.
About 100 geriatrics were released to nursing homes and long-term care facilities in 2002 and 2003. Seventy adults were released, as well, some into traditional group homes, others into more aggressive treatment. The adults mostly came through the PALS program. Some were in tough shape like Wei Li, others were already back to being "high functioners," as they are called in mental health circles.
Life on the outside includes walks in the park for Wei Li.
(Kevin P. Casey)
Then came the screeching halt. Only a trickle of patients was coming out of PALS, and those were typically patients who had been in Western on three- and six-month holds. State officials didn't want the freedom train to stop. Both the Department of Social and Health Services (DSHS) and its Mental Health Division wanted to close PALS by the end of 2004. They were confident they could place the majority of the remaining 100 patients. Western employees say they wanted to see the releases continue, too. It was more humane for the patients, especially given the newer meds and better treatment options in the community.
The trouble was that local mental health departments—known as RSNs, or Regional Support Networks—got spooked. Some of the PALS patients would be difficult to place, mostly those with criminal pasts. The local agencies argued that, due to budget cuts enacted by the Legislature, they would not have the funding to absorb them. They needed more money and resources, and lots of it, they said. They needed time to administer it all, and lots of that, too. And they wanted to have plenty of meetings.
State officials decided to stop the transition to community living until everyone could get on the same page.
Dennis Braddock, secretary of DSHS, says that the $5 million PALS budget could be shifted from Western to agencies like Highline. But he says he's hamstrung. Braddock says he cannot predict how the Legislature will resolve the state's Medicaid crisis next year. Will they cut funding again or increase it? Will they agree to pick up the tab for non-Medicaid patients who are falling through the cracks? Without knowing those answers, Braddock and Karl Brimner, director of the state's Mental Health Division, say they have no room to maneuver.
Still, the PALS 100 have an absolute right to freedom. By the time the Legislature and DSHS shake hands on an agreement and the discharges begin again, it will be late 2005, at best. More than a year. Sure, the bureaucracy has its needs. But weighed against someone's freedom, those needs are picayune.
Even the local mental health officials recognize that there is an imbalance here. They are careful how they admit that, however. I asked Amnon Schoenfeld, the director of King County's Mental Health Division, the RSN for the Seattle area, when the rights to freedom and liberty of the PALS patients trumped the bureaucracy. He paused. "Yes," he answered.
Disability law experts don't buy that.
"We'll give you services if you agree to stay at the hospital, that's what they are saying," says Ira Burnim, legal director of the Bazelon Center for Mental Health Law in Washington, D.C. He was on the legal team that brought the Olmstead case to the Supreme Court. "That's what Olmstead says is illegal. For this to take a year and a half is absurd."
"Does it violate their rights under the Americans with Disabilities Act?" asks Steve Gold, an attorney representing ADAPT, a disability advocacy group. Olmstead is based on the ADA, as it's known. "Sure it does, if they could live in their own homes or in group homes. The law doesn't say 'the least restrictive' but 'the most integrated.'" The real world instead of PALS.
Here's what's crazy about this: The state has the money to make this happen, and programs like Highline's are willing to take the PALS patients into their care. But nothing is happening.
'It's Not Rocket Science'
It would be easy to flay state and local bureaucrats over this stalemate. They are, after all, the ones in charge of the system. Journalists are supposed to rail against the lazy bureaucrat in such situations. To be fair, the system, designed to provide long-term care to the chronically mentally ill, has been so tangled for so long that, barring a global solution, it will be impossible to untie it.
"There are too many moving parts," said Braddock, when I asked how things had gotten so knotted up. And, with the Legislature cutting tens of millions of dollars in mental health services over the past four years (with more to come, possibly), it's not likely things will be different in the immediate future.
All the same, state and local officials should look at this as an opportunity to be creative. It's unacceptable to delay the release of PALS patients until late 2005. We don't have the right to revoke another 16 months of their lives. We have a social compact with these people like Wei Li. They are supposed to get out as soon as they are able. Someone has to find the will to do something.
One person who sees a better, faster way to get this done is David Johnson, CEO of Highline Mental Health. He says that it would take but two months to expand Highline's program and house another 20 to 30 patients from PALS over a six-month period. Other mental health providers could do it, too.
"It's not rocket science," he says.
Johnson says his program would take on ex-felons. In fact, there are already some in the Highline program, and there have been no problems.
And Wei Li himself ought to be example enough that discharging people from Western is worthwhile.
On a recent hot July day, he sat at a small dining table in his home across from Brown. He said that he still heard voices each day.
"Bad things I imagine in my mind," he said. "I can't control."
Brown looked at him for a moment. She has a sympathetic face and that day it was working overtime. She was angry that Harborview Medical Center had yet to examine Wei Li's hand, almost a month after it became unusable.
"The best thing is to make sure you have a good life anyway," she said. Earlier, she told me that Wei Li's future was hard to predict. He'd probably be unable to live with his family again. He is too much for them to cope with. As he improves, he might be able to hold down an assembly job for 10 to 20 hours a week, assuming he can find an understanding employer. Most likely, he'll always have to rely on public funding for housing, food, and medical care.
"OK," said Wei Li.
Later, we took Wei Li to Seahurst Park in Burien, along Puget Sound. The view across the Sound to Vashon Island and the Olympic Mountains is gorgeous. There is a path that runs under some hardwood trees along the seawall. It was cool under the trees.
Wei Li began to walk. He stopped and raised his arm, his splinted hand and wrist, and said "hello" to everyone who passed.
He walked quickly, with a regular stride. He did not kick up dust on the path. Brown and I let him walk ahead of us.
The next week, Wei Li saw his mother at his family's home on Mercer Island. He took her flowers. There were no problems.