Q&A: Manka Dhingra makes the case for three behavioral health bills headed to executive session

Senator Manka Dhingra is the Chair of the Senate Behavioral Health Subcommittee to Health & Long Term Care.

Today, the Committee held public hearings for three bills: SB 5073 (Concerning involuntary commitment), SB 5071 (Creating transition teams to assist specified persons under civil commitment), and SB 5074 (Establishing safe station pilot programs).

All three bills were scheduled for executive session on January 22nd. Ahead of the public hearings, I spoke with Sen. Dhingra in-depth about each bill and the impending flood of services behavioral health systems are expected to weather.


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Michael Goldberg: Senate Bill 5073 would expand requirements for court-ordered involuntary outpatient behavioral health treatment and modify requirements for Less Restrictive Alternative (LRA) treatment. How did this bill come about and why is it a priority at the outset of session?

Sen. Manka Dhingra: Senate Bill 5073, concerning involuntary commitment, came out of meetings Rep. Lauren Davis and I had during the interim with stakeholders from across the state to take a look at the implementation of Ricky’s Law – the substance use disorder civil commitment component of our laws.

We took a look at how we could reduce barriers and make sure people get to the right facilities for them. Individuals with substance use disorders aren’t getting to the places they need to go because traditionally, our civil commitments have focused so heavily on mental health. After integration, there’s still been some hiccups for those individuals who have a substance use diagnosis rather than a mental health diagnosis. That’s what we’re trying to address in this bill.

In our statute, we didn’t even have a requirement for LRAs in substance use disorder evaluations; it only said mental health. The language initially just referred to an initial evaluation, yet we know that after individuals go through withdrawal, their diagnosis changes. We are cleaning that language up to say that at any point, if it’s more appropriate for them to be in one of our secure withdrawal management and stabilization facilities (SWMS), that they be able to be transferred from hospitals to one of those facilities.

The bill would also make sure that we’re asking about individuals having mental health advance directives. That is a good way for them to direct their own treatment – a process they hopefully have engaged in with their case managers or counselors. The courts also asked for permission to make sure they can have people come back for hearings so they can keep an eye on how things are going and be in a position to help before someone decompensates.

MG: As you’ve tracked this issue over the years, how have programs related to mental health and substance use disorders become less siloed and more integrated?

MD: It was so siloed earlier that you had to pick whether you were civilly detained because of mental health or because of substance use. A bill I had last year actually removed those two silos to just talk about behavioral health. This is the second step where we are making sure that that is apparent everywhere else.

A lot of this also had to do with the manner in which we are doing licensing for our facilities. We are trying to give our clinicians the ability to provide both substance use disorder treatment as well as mental health treatment. These things are not mutually exclusive. The vast majority of individuals will have both. A lot of people have moved towards this recognition, but a lot of this is about cleaning up licensing provisions for facilities and professionals doing the treatment.

The work is going to have to continue in this regard because a lot of our facilities still need to be integrated. This bill is about moving us into that spectrum of really having full integration in terms of how we need to treat the human body.

MG: Shifting to Senate Bill 5071, it would require the court to specify the name of a behavioral health agency responsible for supervising the outpatient release of a person who has been civilly committed following a finding of not guilty by reason of insanity. Was it previously the case that without naming a behavioral health agency responsible for supervising outpatient treatment, patients were falling through the cracks?

MD: Senate Bill 5071 is specifically in regard to individuals who are under civil commitment at our state hospitals after being found not guilty by reason of insanity, as well as individuals who were charged with a felony and not restored after going through the restoration process. Those individuals were then converted into civil patients because they still had an outstanding felony. So this bill is very specifically for criminal justice involved civil commitments.

What we’ve been finding over the years is that it’s actually very challenging to get these individuals out of our state hospitals and placed into community for a stepped down treatment model. There were recommendations that were made to the Public Safety Review Panel board on having a more streamlined process so that there is coordination around release, and also shifting who is responsible for the release.

Earlier it was defense attorneys who would try to develop a release plan. People would then chime in and say yes or no to it. This shifts that responsibility to DSHS to do discharge planning using a care coordinator model, and create a transition team to provide a coordinated level of care so that everyone knows what everyone is responsible for. Developing a treatment plan that everybody can sign off on ensures that you avoid unnecessary delay to someone reaching a more appropriate setting.”

MG: Moving on to Senate Bill 5074, participating fire departments would designated as “safe stations.” These safe stations would provide basic by mental health professionals, substance use disorder professionals, etc to connect patients to treatment support and services. Why are fire departments the right venue for these screening services to be provided?

MD: This is a bill that I’ve been interested in for a couple of years now. Having been a prosecutor for about 18 years, we have to make sure that the public health approach is used to treat substance use disorders, not a criminal justice response. This is a way to shift access to treatment away from law enforcement to our EMTs and firefighters, who actually provide that medical help anyway.

We already have a few safe station programs in our state. We had a work session on this last year and we heard from programs in Tacoma, Port Angeles, and Seattle about how they’re able to provide treatment. We’ve also found that ambulances are transporting patients for in-patient treatment. It’s an opportunity for us to have a ‘no wrong door’ policy where people can go to our fire stations, medic ones, and ambulances to get the help that they need.

This is also a way of understanding that there can be very different ways of providing health care in rural versus urban areas. We heard amazing testimony from a paramedic from Port Orchard. He knows a lot of these individuals receiving care, so he’s able to go make home visits and check in on them. Giving them an opportunity to take people directly to our SWMS facilities is another way for them to bypass our hospitals and emergency rooms if that’s not where they need to go. It’s just creating another avenue to access services and support.”

MG: A lot of concern has been raised about the bottleneck health systems will experience as people seek out elective surgeries, procedures, and other treatments that were postponed due to the pandemic. What have you been hearing from stakeholders about what behavioral health systems, particularly crisis oriented behavioral health systems, are expecting as they begin to re-engage with more patients following the pandemic?

MD: I think there is a crisis. People have been telling us there is going to be this floodgate of services that are needed. We’ve seen the Substance Abuse and Mental Health Services Administration (SAHMSA) graph on how people navigate through crises. There is a six month period at the end of the crisis where many people will take a breath and experience all kinds of behavioral health issues. We’ve seen use of alcohol and drugs increase over the pandemic. We’ve seen overdose deaths increase.

I also think there are people who are not seeking help because they’re afraid to go to the hospital because of covid. I’ve had parents tell me about their young adult who is in their room, in bed, but because they’re not being aggressive or loud, the parents are just letting them be and seeing what happens. So I do expect that there is going to be a huge flood of need for behavioral health services. And I think we’re going to see it all across the spectrum, from people dealing with depression and anxiety all the way to the other end with people having active psychosis.

I am also greatly worried about what this is doing to our teenagers and our children. We’re hearing about concerns from parents and teachers about how they’re handling the isolation and online learning.”

MG: Democratic leaders have said that direct pandemic relief bills will be the first to be brought to the floor for a vote. In addition to public health, leaders said that these bills will prioritize economic relief measures like food assistance, rental and utility assistance and business assistance grants. Based on what we know about the cascading behavioral challenges that people are experiencing as a result of the pandemic and its concomitant impacts, do you think that the first round of relief bills should include substantial funding for expanded behavioral health services?

MD: There is so much need. I have a whole list of things I would love to be early action items. I think we’re still trying to figure how much the federal funding we got can cover and how we can move dollars around. At the end of January, I’m hoping we’ll see more help from our federal partners.

So I think there are a lot of unknowns right now, but we just have to continue working to make sure that we are providing more access to resources and setting up a system to provide care. I’m also very concerned about providers. I think many providers are running on fumes because they’re trying to take care of their patients and take care of themselves and their families. I think progress on issues like workforce and telehealth is very helpful to get people some level of care so they don’t feel as isolated.

I spent all of last year telling all my fellow electeds that one of the areas that we can absolutely not cut is behavioral health. There is just too much need out there.”

This interview has been edited for clarity and length.