Judge hopes to close Western State Hospital's revolving door

Staff writerMarch 14, 2013 

One woman, S.B ., is 44. She stabs a hole in her abdomen, over and over. After surgeons close it, she picks the wound open and stabs it again with any knife she can find. She swallows metal, including razor blades.

Another woman, B.P., is 26, a convicted sex offender, institutionalized since the age of 14, prone to assaulting those who care for her. She’s a bureaucratic asterisk: Three years ago, the state classified her as a sexually violent predator, citing her repeated threats to attack children if released. One year ago, the state removed the predator label; B.P. said she no longer felt the predatory impulses, but she kept assaulting her caregivers.

Both women share a common problem: They spin through a revolving door at Western State Hospital in Lakewood that never seems to stop. Collectively, they’ve been in and out more than two dozen times – most recently in January and February, when hospital leaders released the women despite court orders to the contrary.

Following the releases, the women promptly slipped back into habits of self-mutilation and assault, triggering new petitions for commitment.

Wednesday, Pierce County Superior Court Commissioner Craig Adams wedged his foot in the revolving door.

“I’m kind of reminded of the children’s game of hot potato, where no one wants the potato,” he said. “I think the treatment these two women have received is shameful.”

That was the rhetoric. Adams followed up with a technical ruling: Hospital leaders can no longer shuffle diagnostic categories to justify a practice known informally as “straight release,” meaning a return to the community with limited mental-health treatment.

The ruling followed a hearing Adams called to settle a question: Why were the two women released from Western State?

Answers were anything but simple. After hearing them, Adam drew a line between two legal phrases – “grave disability” and “likelihood of substantial harm.”

Until Wednesday, the two women fell into the first category.

According to multiple diagnoses, they’re mentally ill – “gravely disabled” – but in the eyes of the state, they don’t have the right kind of illnesses to justify extended treatment at Western State. They have personality disorders, but they know the difference between reality and fantasy.

The distinction is critical: In simplistic terms, not recognizing reality buys a likely ticket to Western State. Patients with personality disorders are different; as a matter of policy, mental-health experts nudge such patients toward less restrictive treatment in the community.

Those factors drove the recent releases of both women, according to testimony at Wednesday’s hearing. A parade of witnesses testified. First came Dr. Brian Waiblinger, the medical director at Western State.

Waiblinger knew about S.B., the mutilator.

“She’s one of the worst ones I’ve seen, frankly,” he said. “She is a very difficult to treat. She definitely has a severe disorder.”

S.B. had received treatment in the past, Waiblinger said. Sometimes it worked, sometimes it didn’t. She’d been released to a group home and stabbed herself again, reopening the old wound.

That was predictable, Waiblinger said; and S.B. retained the right to come back to the hospital if she wanted. She was a voluntary patient.

Adams, the court commissioner, asked a question. S.B. had been diagnosed with other disorders as well as a personality disorder, correct?

Waiblinger said that was true.

Adams listed more diagnoses, and mentioned S.B.’s lengthy history of self-mutilation. Did that make her a good candidate for release into the community?

“Whether she is injuring herself here or out in the community, she’s going to injure herself,” Waiblinger said.

Adams’ question was a lure. S.B. had been diagnosed as “gravely disabled,” which allowed a straight release under hospital policies – but the diagnosis didn’t include an assessment of another factor - “likelihood of substantial harm” to self or others. That factor would require a conditional release, which meant more direct therapy, treatment and contact with mental-health professionals.

Waiblinger said the “gravely disabled” factor represented standard practice. The hospital had always done it that way.

Other witnesses discussed B.P.’s case. Like S.B., she had multiple diagnoses of mental illness in addition to a personality disorder. Unlike S.B., she also had a lengthy criminal history that included sexual assaults.

At one point, a team of mental-health professionals had suggested releasing B.P. to a homeless shelter, according to statements at Wednesday’s hearing.

One witness was Barbara Sussex, a clinical manager at Telecare, a mental-health evaluation and treatment center overseen by OptumHealth, the private company that contracts with the state to provide mental-health services for Pierce County.

Sussex knew the stories of both women.

“It’s a long road for them, given their history, given their emotional and behavioral ways that they act out in the world,” she said.

Sussex said the “gravely disabled” factor set a high bar for B.P.’s entry to Western State.

Eula Garrison, an assigned defense attorney, represented both S.B. and B.P. at the hearing. She asked Sussex whether release into the community was wise.

Sussex answered slowly.

“(B.P.) is a young woman who has never really functioned in a community,” she said. “She doesn’t know how to be out in the world. She is like a child. Putting her in the community would be a danger – to herself and perhaps to others. She needs a lot of work, a lot of help.”

Sussex said Telecare officials discussed referring B.P. to Western State, but they also knew admission was unlikely. B.P. ended up at the group home instead.

The witnesses were finished. Three attorneys offered arguments to Adams.

First came Ken Nichols, a deputy prosecutor who handles petitions for involuntary commitment. Typically, he argues for keeping patients in detention. Wednesday, he defended the decisions to let them out, arguing that the mental-health professionals have the discretion to make clinical decisions. The court couldn’t supersede that authority.

“It’s not the fault of the system,” Nichols said. “I don’t think you can find fault. The court has to basically step back and let the professionals do what they do.”

Eric Nelson, an assistant attorney general for the state, spoke next. Like Nichols, he typically argues for detaining patients. Wednesday, he had to take a different position.

“All of us have a concern about the revolving door,” he said. “In general it’s something to be discouraged. (But) we also need to give people the opportunity to recover and exercise their liberty. It’s always a balancing exercise between those competing tensions.”

Garrison, the defense attorney, spoke next. She stood at the ferry dock last year when B.P. was released from the Special Commitment Center on McNeil Island. She has visited S.B. in the hospital and seen the wounds. She said the two cases were the hardest in her dossier.

Like the other two attorneys, she argued in reverse. Typically she advocates for less restrictive treatment – the duty of a defender. This time she argued against the system of releases that spin the revolving door. Other Western State patients – men – had personality disorders, she noted, but the hospital accepted them.

“This is something that amounts to what we used to call hysterical females,” she said. “We have a personality disorder that is attributed to just women. The protocol ends up being a way to dump people on the street. I do know that my clients have been wronged. I don’t know what the remedy is for that.”

Adams had an answer. By law, the hospital had to take “likelihood of serious harm” into consideration. If that factor was present, the proper procedure was a conditional release instead of a straight release. It didn’t mean automatic entry to Western State – but it meant a higher level of treatment.

“I think that’s what the law says,” he said. “What is important is both women were mentally ill. I disagree that it is not the fault of the system, when we set up a system that has no accountability.

“I heard Dr. Waiblinger say we’ve always done it that way. Just because we’ve always done it that way is insufficient for me.”

Sean Robinson: 253-597-8486
sean.robinson@thenewstribune.com

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