Western State Hospital patients waiting to get out

Six years ago, 18-year-old Johanna Pratt was admitted to Western State Hospital, acting aggressively and hearing voices. Her combination of diagnoses made her a tough case to treat.

But by early 2007, hospital officials had deemed her "ready to discharge." To keep her any longer, doctors said, could exacerbate her mental illness and harm her physical health. In fact, there were signs she was getting worse because she was in the hospital. She had begun mimicking the troubled patients around her, who do things like swallow batteries.

Yet she's still there today.

"All the time she tells me that she wants to get out," said her father, Robert Pratt, of Washougal, Clark County. "I've screamed at those people up there. I've called senators. I've done everything I can do."

It's not as if the hospital wants to keep her.

She stays because there's no clear place for her to go.

It's now widely agreed that institutionalizing people for long, long stretches is often unnecessary and wrong. The problem is that community housing -- and related services -- for people with mental illness hasn't grown along with deinstitutionalization.

And so Pratt waits. As of October, Western State, south of Tacoma, was clogged with 150 to 170 patients who, like her, are ready to leave. That's nearly 20 percent of the hospital's 927 patients.

"It's an extraordinary amount," said Mental Health Division Director Richard Kellogg.

In July, an advocacy group filed a lawsuit on Pratt's behalf, demanding the state take steps to discharge her. In an era when the news is focused on people with mental illness who aren't locked up despite appearing to be dangerous -- such as Isaac Zamora, who is charged with killing six people in Skagit County, or James Anthony Williams, the man charged with killing Sierra Club organizer Shannon Harps on Seattle's Capitol Hill -- this might not seem like the time to talk about the people hidden away in Western State.

Yet, the troubles inside the hospital are directly related to troubles on the outside. That's because for every Western State bed taken up by someone who should be discharged, there is someone out in the community left waiting to get in.

Help she needed

When Pratt, who grew up in Clark County, first arrived at Western State, her parents were relieved. She was facing criminal charges for smashing up a caregiver's pictures and punching a nurse, according to court documents.

The hospital's assignment was to make her competent to stand trial. The fact that she has both mental illness and developmental disabilities made that impossible, and the charges were dismissed.

But she stayed at Western State under a process called civil commitment, which allows the state to involuntarily hospitalize those judged a danger to themselves or others. While civil commitment can protect both the community and the patient, it is not a step to be taken lightly. The Constitution, after all, protects citizens from being arbitrarily locked up.

Pratt's parents thought she'd get the mental-health treatment she needed, and after maybe six months she'd be back out in the community.

It was not to be. Pratt's condition has stabilized. But long stays in psychiatric hospitals can make some people worse off -- which is exactly what happened to Pratt, according to the lawsuit.

"She actually got worse at the hospital," her father said.

A hospital filled with troubled people is "particularly toxic" for someone like Pratt, according to the lawsuit.

She has been diagnosed with borderline personality disorder, a vexing mental illness that often leads people to harm themselves as an attention-getting mechanism. In addition, people with Pratt's combination of diagnoses tend to mimic the behavior of others.

While hospitalized, Pratt picked up some dangerous habits, the lawsuit said, citing several instances.

June 2006: Pratt continues to require close monitoring due to "ingestion of foreign bodies in competition with a peer who is doing the same."

December 2007: "Peer gave her a battery and they both swallowed them at the same time."

March 2008: "Copied another peer's self-harm behavior ... ingested dice bracelet."

"The longer (Pratt) remains at Western State Hospital, the more entrenched her behaviors become," according to the lawsuit.

And the longer this goes on, the "more likely it will be that (Pratt) will be unable to recover from the harm she has suffered and is currently suffering," the lawsuit said. State officials would like to release Pratt to a community care provider who can offer round-the-clock help. They say they are working hard to find such a place.

Why, then, is she still in the hospital?

Shortage of care

Kellogg, of the Mental Health Division, said the problem isn't inside Western State: It's on the outside.

"The key issue is the lack of affordable, appropriate housing," Kellogg said.

No one knows exactly how many such residential units -- which might include everything from ordinary Section 8 housing to specialized housing run by nonprofits -- are out there.

But it's not just about numbers. Mental-health workers need to find living arrangements where patients can get the help, supervision and the ongoing mental-health treatment they often need.

This type of housing was envisioned years ago by people pushing for deinstitutionalization.

Whether it's a lack of political will or the perceived expense of such housing, it hasn't materialized.

A recent study said 5,000 more units of "permanent supportive housing" are needed in Washington state.

It's estimated that 673 new units for people with mental illness will be created by 2010. But the supply hasn't caught up with the demand, said Lynn Davison, executive director of Common Ground, a nonprofit housing organization. Unless and until the numbers grow, long waiting lists will continue both inside and outside Western State.

But even if space is available, these programs don't take just anyone. Some patients, like Pratt, have a history of aggressive behavior. Others have criminal records. Still others have been addicted to alcohol or drugs.

Long-term hospitalization alone has its own consequences. At Western State, you don't have to make your breakfast or drive to the grocery store or pay your rent on time. You lose social skills. Getting a job afterward can prove difficult. It's easy to see how the hurdles are magnified over time.

"For the system to work, it has to be just like any other hospital," said Craig Awmiller, an investigator with the group Disability Rights Washington, that filed suit on Pratt's behalf. "You've got to go in, and when you're done, you come out."

In Pratt's case, the state was slow to begin planning for her discharge, even after she had been deemed ready, her lawsuit states. At one point, according to the lawsuit, hospital officials weren't even trying.

A 2007 attempt at transitioning her to specialized housing failed. Her parents say the problem was the state's lack of planning. When she arrived, the assigned caregiver was a stranger, according to her mother, Marvieen Pratt. The result was disastrous. She wound up "blowing" -- Marvieen's word for when her daughter gets out of control -- and the police were called.

Then she was right back at Western State, with scores of others awaiting discharge.

"This isn't just for Johanna," her father said. "It's for all these patients up there."

Activists have complained publicly and privately. They have gone before the Legislature.

Twenty years ago, The Seattle Times interviewed another patient in a similar situation.

"This place ... It doesn't really help after a while," he said. "You can't get out. At least in jail you get out at a certain time and that'd be it."

Back then, 140 patients were ready to leave but couldn't.

Whole system impacted

If Western State is like the back door of the mental-health system, community hospitals are the front door.

People behaving bizarrely or acting out are often taken to emergency rooms, like the one at Harborview Medical Center, for an evaluation. If mental-health workers decide someone is dangerous, they can begin the process of civil commitment.

The next step is a short-term treatment center -- and Washington state ranks last in the nation in the number of those beds, which generally are for stays of less than 14 days. For longer stays, patients go to Western State, where a recent national survey said the state has a "severe shortage" of beds.

As Pratt's case illustrates, when people aren't leaving Western State, that creates a bottleneck affecting all the other stops along the way: the short-term facilities and the emergency rooms.

The upshot is that folks in the community who need immediate mental-health treatment have trouble getting in the system's front door.

"That means there are people who are actively psychotic, who might need to get into Harborview, who can't because two steps down the road, nobody can get into Western State because people don't leave," Awmiller said.

"Sometimes people wait in the waiting room. Sometimes in emergency rooms. Sometimes local hospitals get filled, so people wind up riding in an ambulance to Spokane if there's a bed over there."

Everyone in the mental-health system seems to agree this is no way to operate.

Their sweet little girl

The Pratts remember their daughter as she was years ago, when she loved baseball and bowling and was involved with Special Olympics.

"She was a sweet little girl," Robert Pratt said.

She started becoming aggressive as an adolescent. Today her parents say they are physically unable to care for her, even though they'd like to one day. Pratt, they acknowledge, is a handful.

"But they (Western State) helped create that handful," Marvieen said.

If the state finds the right place for her, and the right people are helping her, "I think she'd start settling down in a month," Robert Pratt said.

In recent months, officials appear to have taken more active steps to find Pratt a new home.

Still, her parents understand there are major hurdles to her freedom.

"You have to be careful about who you release and how you release them," Robert Pratt said. "But they can go on and have a better life. I know my daughter can do better."

News researcher Gene Balk contributed to this report. Maureen O'Hagan: 206-464-2562 or mohagan@seattletimes.com

Information in this article, originally published December 29, 2008, was corrected December 29, 2008. A previous version of this story incorrectly stated Washington State Hospital rather than Western State Hospital.