Citizenship Theory and Psychiatric Boarding

Jacquelyn Pinkerton

University of Washington, Tacoma

Professor Ronald San Nicolas, MSW, PhD

TSOCW 531(A): Advanced Integrative Policy and Advocacy

July 26, 2015

Jacquelyn Pinkerton

December 2014

Citizenship Theory Paper

On August 7, 2014 the Washington State Supreme Court ruled that “the Involuntary

Treatment Act (ITA) does not authorize psychiatric boarding as a method to avoid overcrowding

certified evaluation and treatment facilities” (In Re Det. of D.W., 2014). The current state of our

mental health system is overburdened by rising demand for services and decreased funding for

these services. This inverse relationship of funding supply and service demand has led to a state

wide crisis wherein the patients who are in the most need for treatment and evaluation are

subjected to a sub-standard level of care that, in this Supreme Court decision, is no longer

permissible. Lister (2007) discusses the importance of incorporating marginalized groups into the

policy-making process and the injustice that ensues when their voices are not heard and their

experiences not validated alongside the “knowledge and expertise [of those who] have

traditionally been privileged” (p. 53). The practice of psychiatric boarding is a violation of the

ITA and the rights of the individuals affected by it.

The ITA is a culmination of RCW and WAC codes that guide the practice of detaining

and treating individuals who are determined to be a risk of harm to themselves or others and/or

gravely disabled. RCW 71.05 addresses the involuntary treatment of adults while RCW 71.34

addresses the involuntary treatment of minors; WAC 388-865 outlines regulations for

community mental health and involuntary treatment programs. In 2012, policy changes allowed

for Designated Mental Health Professionals (DMHP) to incorporate historical record and witness

testimony when evaluating a patient to be detained; these changes had an anticipated impact of

an additional 2,716 new patients per year (Burley, 2011). The Washington State Institute for

Public Policy submitted a needs assessment and recommendations to address the decrease in ITA

evaluation and treatment capacity in Washington State and the anticipated increase in ITA

patient admissions following the 2012 policy changes. As of August 2014 the Washington State

Legislature and state RSNs had yet to address the problem of an increasing ITA population and

decrease in evaluation and treatment capacity. This inaction led to a lawsuit that was eventually

brought to the Washington State Supreme Court wherein they ruled that this deficit of adequate

treatment could no longer continue. Psychiatric boarding evolved from a need that went

unaddressed by policy makers and subsequently failed to acknowledge that ITA patients deserve

to be treated with respect, to have their dignity maintained, and are deserving of adequate and

just care (Reitz-Pustejovsky, 2002).

The population of patients who have been involuntarily detained and denied adequate

treatment highlights discrepancies in the rights of those with power and privilege relative to

those who are marginalized and at the mercy of the dominant systems. The patients subjected to

the ITA have been treated as less than full citizens and while their mental illness may prevent

them from fully participating as citizens this does not mean that they should be treated as less of

a citizen (Lister, 1998). It will be important moving forward to incorporate the opinions and

perspectives of the individuals who have been impacted by the ITA in addition to the agencies

and professionals responsible for implementing the ITA (Rowe, Kloos, Chinman, Davidson, &

Cross, 2001).

Reitz-Pustejovsky (2002) poses a question related to the treatment of homeless people

where they ask if the care afforded to this population is both ethical and just. This is a question

we should ask of any service imposed upon or offered to a marginalized population. The

chronically mentally ill are a marginalized population and until psychiatric boarding was

determined to be unlawful, the treatment they received was in some cases neither ethical nor just.

As a collective society we neglected to act to meet the needs of those on the margins and our

Jacquelyn Pinkerton

December 2014

Citizenship Theory Paper

mental health system and our policy makers are now forced to address this disparity. Since the

Supreme Court’s decision, Washington State’s Governor Inslee has allocated funds to increase

the number of ITA evaluation and treatment beds available in the state but this alone will not be

enough to fully meet the needs of this population on an ongoing basis. Shafir and Brysk (2006)

discuss the value of social citizenship rights as these rights frame a perspective that all citizens

deserve certain benefits and this in turn reduces the stigmatization of the vulnerable individuals

who exercise these rights. For those patients who are involuntarily detained, they deserve to

receive adequate treatment and it should be unacceptable for them to receive anything less.

Washington Supreme Court’s decision regarding psychiatric boarding supports the agency of

detained patients and mandates a better standard for treatment that should improve treatment

outcomes and participation in the greater community.

Opposition to the Supreme Court’s ruling is rooted in concern for the unaddressed ‘how’

of this decision rather than the decision itself. General opinion is that psychiatric boarding is an

unacceptable practice but the Court’s ruling fails to provide alternatives to the status quo or

expectations for long-term outcomes. Initial steps have been taken to mitigate the impact of the

Court’s decision but unless legislators understand that this is a problem that needs long-term

solutions we will not make forward progress to address the needs of the chronically mentally ill

who must be involuntarily detained (Hanson, 2014). Immediately following the Supreme Court’s

decision there was confusion and concern of how the ruling would be implemented as emergency

room providers are required to provide safe discharge plans thus creating a conflict of ‘we can’t

keep them but we can’t let them go’ (Mannix & Thompson, 2014). The Supreme Court

subsequently delayed the ruling implementation until December 2014 but inpatient psychiatric

facilities, community hospitals, legislators, and state officials still had to take immediate action

to address this need. This court decision is a mandate for what is considered socially acceptable

and should perpetuate norms that improve treatment and long-term outcomes.

Social work practice implications from this ruling will be felt throughout all levels of this

system from micro to macro. At the micro level this decision may impact the outcome of first

contact with a crisis worker and the subsequent discretion of the DMHPs who are responsible for

determining whether or not someone should be detained. Evaluation and treatment facilities that

screen initial intake and ongoing care at the mezzo level will need to evaluate their current

policies and available resources to increase capacity and meet the needs of incoming patients.

Community hospitals, short term treatment facilities and long term treatment facilities will als

need to work collaboratively to address this need. Our state legislature will need to revise

funding/reimbursement policies as well as standards for treatment moving forward. Possible

unintended consequences may be stricter guideline for detainment which may result in some

patients not receiving needed care. Although the Governor did allocate funds to address some of

the immediate need this may distract legislators from sufficient action if they feel the need is

now met. Social work values never supported the practice of psychiatric boarding, now it is

imperative that as a discipline we increase advocacy and facilitate change at all levels of this

problem.

Jacquelyn Pinkerton

December 2014

Citizenship Theory Paper

Bibliography

Burley, M. (2011, October). Inpatient psychiatric capacity in Washington state: Assessing future

needs and impacts (part two). Olympia, Washington: Washington State Institute for

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In Re Det. of D.W., 90110-4 (Supreme Court of the State of Washington August 7, 2014).

Retrieved from https://www.courts.wa.gov/opinions/pdf/901104.pdf

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Reitz-Pustejovsky, M. (2002). Is the care we provide homeless people, just? The ethic of justice

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