Homelessness Observations Reflection

Continuity of Care.

The first time I saw him he was walking around the shelter with another man. His hands were buried in the pockets of his hoodie and his gaze was fixed on the ground. He looked shorter than his actual height because he was slouching.

He and the man walked laps around the shelter while they talked. His expression was hard: Eyebrows furrowed, jaw tight, lips curled into a slight frown. He moved across the tiled floor like a sleek fish gliding through the water.

“Hi,” I said, introducing myself. “Do you mind if we talk for a few minutes?”

His companion kept walking as he coasted to a halt. His stony expression softened; his eyebrows raised and wrinkles appeared at the outer corners of his eyes as he smiled.

“Sure. Thank you.”

He and I walked laps around the shelter for the next few days. His father beat his mother, his brother, and him. At the age of 11 he found his mother’s body after she committed suicide. His father disappeared for days at a time. When he returned, his speech was slurred, clothes were dirty, and exhalations were thick with malt liquor. He stopped attending school. He ran away from home. He slept in alleys and underneath bridges. The police picked him up on a variety of charges: Theft. Drug possession. Criminal trespass.

The second time I saw him he lying on a mat in the shelter. The stiff blanket was not long enough to cover his entire body; his feet with their long toenails poked out.

He pulled the blanket off of his face and replied, “Heroin. Couple days ago.” Pulling up a sleeve, he showed me the collection of tiny bruises on his arm. He closed his eyes. Beads of sweat collected on the pale skin of his forehead.

“I’ll be done kicking dope tomorrow.” He pulled the blanket back over his head.

The third time I saw him he was sitting on the floor in the shelter, his arms hugging his knees.

“I don’t make many promises. I promised her that I won’t kill myself. I keep the promises I make, so I didn’t do it. I really wanted to.”

He accepted the invitation and got up. He and I walked laps around the shelter. He had yet to talk with her, though he planned to see her tomorrow. The last time he used heroin was over six months ago, but he was also in jail for four of those months.

“You didn’t use anything in jail?”

He shook his head.

After a pause, he said, “You know, I’ve seen you downtown. You were with a guy, so I didn’t want to bug you.”

“Is that where you’re staying these days?”




The fourth time I saw him he was standing on the sidewalk outside of a methadone clinic. The hood of his sweatshirt was pulled over his head and baggy jeans covered his long legs. His hands were buried in the pockets of his sweatshirt. The other man made a joke; he chuckled and wrinkles appeared at the outer corners of his eyes as he smiled.

I crossed the street. He was with a guy and I didn’t want to bug him.

The fifth time I saw him he had already passed me. Without realizing that I was reviving an old habit, I wrapped the long white coat closed as I looked over my shoulder.

“Smith!” the officer barked. “Stay where you are. Turn around.”

He stopped, turned, and looked up. We saw each other.

“Go back to your cellblock, Smith.”

He moved across the concrete floor like a sleek fish gliding through the water. Before he passed me, he nodded in recognition. I nodded back.

We both kept walking. I sighed.

Education Medicine Observations Policy Seattle Systems

A Primer on Psychiatric Boarding.

The Washington State Supreme Court recently stated that “psychiatric boarding” is unconstitutional.[1. You can read the court’s opinion here. It’s a fairly easy read.] I agree with and support the court’s decision. “Boarding” is a terrible practice.

To be clear, though, the consequences of this decision may be undesirable.

Some background: In the state of Washington, the only people who can hospitalize individuals against their will for psychiatric reasons are “designated mental health professionals” (DMHPs). Police officers can bring people to emergency rooms against their wills and physicians and other professionals can evaluate people who show distress. A DMHP, as an agent of the state, makes the ultimate decision whether to detain someone against his will.

Let’s be clear about this: Being hospitalized against your will is stressful, upsetting, and frightening. The state is taking away the rights and freedoms from an individual. Civil liberties? Gone. It is a big deal. No one enjoys the process.

In order for a DMHP to hospitalize someone against his will, a person first must show evidence of a “mental disorder”.[2. A finer point about “showing evidence of a mental disorder” is that there should be some proof that hospitalization is an effective treatment for the mental disorder in question. This is why some people go to jail and not to the hospital. This path can lead us into the weeds.] Having a mental disorder alone, however, is not reason enough to hospitalize someone against his will. At least one of the following three criteria must also apply:

  • He is a danger to himself. (Consider a man with major depression who was found nearly unconscious; a noose made of bedsheets was around his neck.)
  • He is a danger to others. (Consider the woman who is walking across the highway multiple times because she believes that God wants her to proselytize to the drivers.)
  • He shows “grave disability”, or is unable to meet his basic needs. (Consider the man who has not eaten any food in nearly two weeks because he believes that all food is actually composed of his internal organs.)[3. If you think that none of these scenarios ever really happen, I encourage you to go volunteer at your local emergency room.]

Thus, at least two people–the person who wanted the individual to go to the hospital and the DMHP–were concerned enough about the individual to believe that he needed to be in the hospital to get care.[4. For now, let us put aside arguments that psychiatric hospitalization is never helpful or indicated. Some people believe that psychiatric hospitalization is a veiled form of incarceration.]

That “to get care” part is the crucial point when we talk about “boarding”.

People who are involuntarily detained in Washington are only allowed to be hospitalized in certain facilities (or certain beds). Facilities submit an application to the state to become a “certified” place where they can treat people who are hospitalized against their wills.[5. Indeed, there are psychiatric hospitals in Washington State that are not certified to treat people who are hospitalized against their wills.] These places can be entire buildings (called “evaluation and treatment facilities”, or “E&Ts”, here). They can also be specific beds within a hospital, usually on psychiatric wards.

There has been concern if “inpatient psychiatric capacity is sufficient to meet [a] potential increased demand” for involuntary hospitalizations. All certified beds are frequently occupied. Most people who are referred for involuntary hospitalization are not in psychiatric hospitals; they are in hospital emergency rooms.

There are medical centers (and, by extension, hospital emergency rooms) in Washington State that do not have any psychiatric providers on staff.

Thus, DMHPs have been hospitalizing people against their wills, but no certified treatment beds are available. These detained individuals therefore are admitted to hospital emergency rooms or random hospital wards while they wait for certified beds to open up.

If the hospital does not have psychiatric providers on staff, that means these detained individuals don’t receive any psychiatric care. People could wait hours, days, or even weeks before they are transferred to a certified facility to receive formal psychiatric services.

In the meantime, these individuals are often physically restrained to their beds. There might not be enough hospital staff to fulfill the state’s mandate that they remain in the hospital against their wills.

Sometimes these individuals receive doses of sedating medication for multiple days in a row. (Imagine you work in an emergency department. Someone who is detained in your emergency department will not stop screaming obscenities at other patients. He also tries to spit at everyone. He has also tries to punch the nurses whenever they walk by.)

This isn’t treatment. (Remember, the state ordered that this person be hospitalized against his will to get care.)

Thus, you can now see why the state supreme court decreed that it is not okay to “board” psychiatric patients. People who are detained against their will, by the state’s definition, need treatment. “Boarding” isn’t treatment.

This is why I agree with and support the court’s decision.

However, now that you know that there aren’t enough certified psychiatric beds in the state, you can guess what undesirable consequences might come from this decision.

The detained individual in the emergency room who yells and tries to punch all the nurses? Now he might end up in jail on charges of assault. Jail is not a therapeutic environment. Some jails do not offer any psychiatric services. Incarceration, like boarding, is not treatment.

Detained individuals might instead be released into the community if no certified beds are available at that time. Someone else–another police officer, another family member–might try to re-refer them back to the hospital a few hours after they were released. This results in a cycle in and out of hospitals and other institutions. That isn’t treatment, either.

Hospitals that have certified beds may feel pressure to discharge people more quickly due to the heightened demand. These individuals may not have recovered “enough” and may return to the hospital much sooner than anyone would like.

Another potential consequence is that those individuals who seek hospital services on their own–perhaps in an effort to avoid involuntary hospitalization–may not be able to get into a hospital at all. Those detained against their wills may occupy all of the certified hospital beds.

My understanding is that the state is considering various ways to work with the new law: This includes increasing the number of certified beds, creating different options to divert people from hospitals, and reducing the amount of referrals for involuntary hospitalization.

I don’t understand why some hospitals don’t employ psychiatrists.[6. Psychiatric services are not “revenue generators”, so I suspect this is the reason why some hospitals don’t hire psychiatrists.] If a pregnant woman about to have a baby shows up at an emergency room, hospitals have staff available with the expertise to manage her care.

Why isn’t this the case with psychiatry?