‘You have no control:’ Overcrowding at state psychiatric hospitals threatens care, safety

In her Ashland home, which is overflowing with knickknacks and pictures of horses and dogs, Traci Jones stretches her fingers out before her and shrugs.

She doesn’t know exactly how many temporary-detention orders she’s received, she says. But she knows it’s more than she can count on both hands.

For a little more than 10 years of her life, from her 20s into her 30s, Jones battled dissociative identity disorder, cycling in and out of psychiatric hospitals under the involuntary detention orders, called TDOs for short.

She was grieving the loss of a child and husband, trying to raise her surviving daughter and keep everything from crumbling around her, she says.

“My life was very much out of control,” she said. “I was a happy young mother and then all of a sudden I lost my daughter, I lost my husband, I lost my livelihood, I lost my ability to stay in my home, I lost any credibility.”

But the cycle was self-perpetuating. Once she had been the subject of multiple orders, she had a hard time convincing a magistrate or mental health assessor that her mind was sound, she said.

They worried she was a danger to herself.

TDOs are meant for people in crisis who pose a risk to themselves or those around them. They’re traumatizing, as Jones can attest. Their purpose is to involuntarily hold people for treatment.

Often, the patient is transported to the hospital by law enforcement officers.

But the system Virginia has built to care for those in crisis is itself in crisis. State hospitals are dramatically overcrowded, threatening the care patients receive and staff safety.

Everyone involved in behavioral health is feeling the strain, as community services boards — organizations that contract with the state to provide behavioral health care in their respective regions — scramble to find a place for patients to go for treatment and sometimes a place to live after they return.

At its meeting Tuesday, the Joint Subcommittee to Study Mental Health in the Commonwealth in the 21st Century will hear recommendations to address some of the challenges the state’s mental health system faces.

The group created a statewide TDO task force earlier this year, which submitted a report in November that says “the best long-term solution to psychiatric crises is strengthening the community-based system of mental health care.”

The stresses imposed by the orders are a reflection of structural problems within Virginia’s mental health system, advocates say. The state devotes a massive chunk of funding to the state hospitals while the vast majority of those with mental illness are seeking treatment in their communities.

TDOs start with emergency custody orders that anyone, even family members, can initiate that last for eight hours so a mental health clinician can make an assessment. Then a magistrate ultimately decides, usually based on the clinician’s assessment, whether or not to issue the order, under which a patient is transported to a facility for up to three days.

“You’re giving emergency therapists the right to take away somebody’s rights and freedom for up to 72 hours, which is a really big deal,” said Leslie Weisman, client services entry supervisor for the Arlington County Community Services Board. “It’s a huge legal decision that these staff have to make, and then, of course, it’s a life-and-death decision.”

‘A radical shift’

Since 2015, the annual number of TDOs in the state has increased slightly, with about 25,000 ordered every year, according to data from the Department for Behavioral Health and Developmental Services.

The most dramatic shift in recent years, though, has been where those patients end up, as increasingly they are admitted to state psychiatric hospitals after community services boards call every private hospital in their area without finding a bed.

Since 2013, the percentage of TDO patients sent to state hospitals has shot up by nearly 300 percent.

“The dramatic increase in the TDO admissions to Virginia’s nine state hospitals has created an unsustainable utilization rate for the state hospitals,” the department stated in a report earlier this year to the General Assembly

Hospitals are considered safest for patients and staff when operating at no more than 85 percent capacity, according to the department. Virginia’s hospitals, though, are often operating at 95 percent capacity, if not 100 percent.

“By consistently operating well above 85 percent, the pressures of the state hospital census are placing both staff and patients alike in potentially unsafe conditions, compromising the quality of care provided, and leading to unprecedented increase in turnover in critical staff,” the report says.

The increase is driven by the fact that private hospitals, citing a rise in voluntary admissions to their psychiatric departments, are taking a smaller percentage of TDO patients than they did in years past.

And the “bed of last resort” law championed by Sen. Creigh Deeds, D-Bath — whose son attacked him before taking his own life after a psychiatric hospital bed couldn’t be found — means all patients must go somewhere.

The state’s private psychiatric hospitals still take the bulk of TDOs, and they’ve admitted more of those patients over the past several years.

But the percentage of TDO patients they admit has fallen from 91.2 percent in 2015 to an estimated 79 percent for the 2018 fiscal year, according to the state.

The problem seems to be that there are more people in general requiring psychiatric beds. The private hospitals, which are under no obligation to accept any TDO patients, have seen an increase in voluntary admissions, which takes beds away from TDO patients.

Julian Walker, a spokesman for the Virginia Hospital & Healthcare Association, said that since fiscal year 2015, the number of voluntary inpatient psychiatric admissions to private hospitals has increased by 3,752, while the number of TDO patients has increased by 3,164.

“Public and private hospitals each have a role to play in serving patient needs,” Walker said in an emailed statement. “Accomplishing this means evaluating both treatment capability and capacity at admitting facilities, among other factors, including patient disposition, age and other diagnoses that are important considerations in patient placement decisions.”

According to the National Institute of Mental Health, more than 18 percent of adults in the U.S. have a mental illness.

“As the population goes up, there’s going to be a natural increase in people experiencing mental health conditions,” said Rhonda Thissen, executive director of the National Alliance on Mental Illness of Virginia. “And many people across our state don’t have access to consistent treatment. The better access they have, then the less need for crisis care.”

During a November meeting of the Joint Subcommittee Studying Mental Health Services in the Commonwealth in the 21st Century, Sen. George Barker, D-Fairfax, said that lawmakers, when working on the “last resort” law in 2014, knew there was a risk.

“But I, at least, did not expect we were going to see such a radical shift,” he said. “It was not our intent in 2014, when we were working on the legislation, to say we want the state hospital to be where every TDO goes.”

During another subcommittee meeting later that day, Department of Behavioral Health and Development Services Commissioner Hughes Melton said the department is still in conversations with Gov. Ralph Northam’s office about potential legislative recommendations that may mitigate the hospital crisis, but said it was too early to provide details.

Safety at risk

Jones says her dissociative disorder made her “switch.”

“I compartmentalized,” she added. “So something would come up and I would deal with it in that emotional state, but I wouldn’t remember it in another emotional state. That’s the easiest way to explain it.”

Jones thinks she got caught in a cycle in which her history was a more likely indicator of whether or not she got a new TDO than her state of mind. But for those in serious need of the orders, she said, finding a bed as quickly as possible is the only option to stop a crisis from escalating.

“We’re coming in and we’re seeing this person at a point where they’re having their rights taken away, they’re being told they don’t have a choice in the matter,” said Toni Nutter, emergency services coordinator with Northwestern Community Services Board in Front Royal. “That can heighten the level of resistance for the client.”

Community services board workers across the state report that private hospitals are less likely to accept patients who may be aggressive or violent. So typically state hospitals end up with those patients.

While mental health workers and advocates agree it is better that patients are at least guaranteed a bed, the increase in those types of patients poses safety risks.

Staff injuries due to aggression and workplace compensation costs both grew by 17.2 percent over the past three years, according to the Department of Behavioral Health and Developmental Services.

That problem is compounded by high vacancy rates, causing existing staff to frequently work 50 to 60 hours a week.

“The acuity has increased,” said Alexis Mapes, the 24/7 emergency services program supervisor for the Arlington County Community Services Board. “They present particularly aggressive behaviors or they lack responsiveness to medications.”

For the 2017 fiscal year, the state reported a 26 percent vacancy rate in direct care nursing positions and 17 percent vacancy rate for psychiatrists. Those positions also had a turnover rate of 38 percent and 33 percent, respectively.

The 2017 fiscal year turnover rate was the highest it had been in 10 years.

Where do they go afterward?

George Dupuy, crisis services program manager at Northwestern Community Services Board, said his team sometimes encounters patients willing to be admitted to a facility locally, but not far away across the state.

“That can snowball into turning into an involuntary placement,” he said.

“It’s always our preference to keep people as close to home as possible,” Dupuy said. “That’s definitely a concern because there’s something destabilizing and it can be traumatic to take people involuntarily hours away from their home for treatment and that can set them up for even more challenges when they’re coming back.”

Overcrowding at state hospitals is worsened by housing inadequacies for patients when they’re ready to be discharged.

Community services boards often struggle to find a suitable place — and when there are no options, the patients often end up lingering in state hospitals.

In October, there were 171 people on the state’s “extraordinary barriers to discharge” list, patients who cannot leave the hospital because there aren’t enough services or resources in the community — usually housing.

The gold standard for vulnerable individuals with housing needs is permanent supportive housing, in which individuals are able to choose their own homes but are surrounded by the supports they need to stay permanently housed, like a case manager or someone to connect them to services.

The Department of Behavioral Health and Developmental Services has been investing in more permanent supportive housing, in part to address the extraordinary barriers to discharge list.

Since 2016, it has moved 80 people directly from state hospitals into those programs.

Thissen said her organization is grateful for the increased funding the state has dedicated to permanent supportive housing.

“But, like always, it’s not enough,” she said. “It doesn’t meet the needs.”

“It’s a delicate balance,” she added. “People in crisis need to get services so their crisis is resolved. But they also need to be able to get back to the available services in the community.

“It’s like a balloon: If you squeeze it on one end, the air pops out on the other end.”

Shifting focus to community services

The answer that advocates and state officials alike point to in addressing the problem at state hospitals is that more community support would help prevent people from having crises in the first place.

It wouldn’t prevent every one, though. Often, crises are caused by external factors that sometimes even regular treatment for someone with serious mental illness won’t be able to prevent.

But ensuring that every state resident has consistent access to services means they could get treated prior to their crisis, reducing the possibility of hospitalization, the Department of Behavioral Health and Developmental Services says.

“There isn’t enough community-based intervention to deter the TDOs,” said Deidre Johnson, executive director of VOCAL, an advocacy organization for those with mental illness. “We’re certainly in a much better place than where we were years ago, however there is absolutely more that can be done.”

Virginia’s mental health system is in the midst of a transformation. STEP-VA, or System Transformation Excellence and Performance, is meant to address the underfunded and patchwork services that make up Virginia’s system.

It started in 2017 under former Gov. Terry McAuliffe’s administration with funding to cover the initial costs.

Through STEP-VA, each of the community services boards across the state will be required to offer the same services. Some, such as same-day access and primary care screening, are due to take effect by July.

Most of the others, though, including outpatient behavioral health, psychiatric rehabilitation, and peer and family supports, for example, aren’t due to be implemented until July 2021.

Finding validation

At 45 years old, Jones has been stable for about five years, or maybe a little longer, she said.

She and her daughter are very close, she’s pursuing a doctoral degree and she’s running a nonprofit, called Rise Phoenix Rise.

The organization aims to help others with mental illness through peer support and “animal-assisted wellness,” according to it website.

When she was going through the period of her life marred by the detention orders, one thing that got her through was her relationship with animals.

“I saw the inherent qualities of animals,” she said. “I just wanted to share that with others.”

There isn’t an exact cutoff date as to when she was able to break the cycle of temporary detention. It happened gradually and it was difficult.

She still gets the “vibes,” as she describes them, associated with her mental illness. It hasn’t completely gone away.

“But I’m much more stable now, than I’ve ever been before,” she said. “I’m in a relationship, and I have my daughter and my granddaughter and my son-in-law. And we are a happy family.”