King County's Mental Health is Deteriorating

Amnon Shoenfeld

Yesterday morning on my way to the office, I bicycled past a man who was shouting to someone from the sidewalk. "MA MEENY MA MOSEY!" he yelled, repeatedly, spittle flying. His eyes were fixed somewhere in the middle distance, his face was red with rage, and the object of his anger was invisible to me.

Depending on who you are, and the time of day, this is the kind of sight--after Shannon Harps--that usually reminds you that there's a good reason to walk a block out of your way. Stretch the legs.

I have felt that I've been seeing more and more homeless, mentally ill people in the grip of visible psychosis since the recession started, and I called Amnon Shoenfeld, director of the King County Mental Health, Chemical Abuse and Dependency Services Division, to see if this was purely anecdotal or not.

Shoenfeld has been director for the past seven years, and with the County in various capacities for 30. He earned his MSW from the University of Washington, and went to work for King County as a crisis outreach and involuntary commitment specialist in 1979.

There are about 27,000 people who rely (voluntarily or not) on King County's mental health services, and another 12,000 who are involved in substance abuse services. This number hasn't varied much recently, Shoenfeld said, but recent budget cuts at the state level have reduced funding by $7 million for mental health, and $3 million for substance abuse.

Funding cuts are about to worsen: Governor Gregoire has just released a doomsday balanced budget that would eliminate the Basic Health Plan and GAU (assistance for people unemployable because of mental or physical disabilities), slash financial aid for college students, and suspend "all-day" kindergarten and support for poorer school districts.

The Seattle Times notes that, "Most of the state budget is off-limits to cuts because it's either protected by the state constitution (such as funding for basic education) or by other requirements (such as the state's share of Medicaid, a federal-state insurance program for the poor.)"

"If I could say anything right now, I'd just say: Please don't cut us any more," Shoenfeld said near the end of our conversation.

I had asked him, looking for a bright spot, if extra funding was somehow found, where he would like it to go. But Shoenfeld, beleaguered, thinking of his case managers with up to 70 clients, couldn't go there at first.

Despite the fact that much of the mental health and substance abuse "bill" is associated with Medicaid, with the federal government footing as much as 60 percent, the state is perversely focused on what it is permitted to cut, rather than the overall cost-effectiveness  of combined federal and state dollars.

"We had to cut back on outreach to kids--mainly street kids--who are abusing substances." As in so many cases, prevention is the cheapest option, Shoenfeld explained, but it seems less critical to the budget-cutting eye.

"We've had to cut back on the number of people who can get into outpatient treatment, both adults and kids. In King County, we have to use all our 'non-Medicaid dollars' to cover crisis services and involuntary commitment services, our evaluation-and-treatment programs, our residential programs," said Shoenfeld.

Now he's expecting proposed cuts of over $1 million in those core crisis services, which for the general public, is related to the sense of insecurity you feel at noticing more people ranting and raving, and behaving unpredictably.

The one bright spot in all this is what's called the MIDD (Mental Illness and Drug Dependency) Plan, King County's attempt to deal with mentally ill and drug-dependent people outside of the emergency room or jail cell. It's funded by a one-tenth of one percent sales tax through 2016 (but even so, with declining retail sales, the revenue generated is off $7 million from projections, and the County Council has reallocated another $13 million to deal with the County's overall mental health/substance abuse budget shortfalls). It is also just about the only way to receive outpatient treatment for mental illness if you aren't on Medicaid.

"If we didn't have MIDD," said Shoenfeld, "this would be absolutely the worst it's ever been."

Shoenfeld has also heard--"This is incredible"--that the state may shutter the PALS program as Western State Hospital. "PALS" is an example of governmental obfuscation; it's described as "a residential facility on the grounds of Western State Hospital for patients who do not need inpatient care but have not been successful at making the transition back into the community." That "have not been successful" is masterful bureaucratic understatement.

King County has reduced the number of people it pays for in the PALS program from 40 to eleven over the past few years. As Shoenfeld explained it, "the reason these people are there is we really can't place them in the community at large. Of those eleven people, two have committed murder--one murdered a Seattle police officer--three are sex offenders, and four have committed arson. Trying to place these people in the community? Where are we going to find a place that's going to be willing to take them?"

He also anticipates losing about $2 million for substance abuse services. "We would lose our detox facility, a lot of people would end up going to hospital ERs instead, which is of course way more expensive." Roughly 1,000 people would lose access to outpatient treatment for substance abuse issues, and again, the consequences for the public are real. People with drug habits make terrible decisions.

When Shoenfeld did return to my question about where any imaginary "extra" money should go, he suggested...housing. "We have thousands of people without homes, most of whom have problems with mental illness or substance abuse. We have been very active in working with the Committee to End Homelessness, to find new housing for people and provide [mental health and substance abuse] services attached to that housing."

He paused. "We can't simply consign people to being homeless and untreated, and to dying on the streets. It's very disturbing. When they're homeless, it's so much harder for them to stay in treatment, to stay on medications, to stay out of jail and out of the hospital. If I had new money, I'd say let's put it into housing."

Until then, his over-burdened case managers are tasked with desperately trying to keep mentally ill homeless people on Medicaid, so they can afford the medications they need. People "fall off" Medicaid all the time, let alone those without mental illness troubling their ability to deal with bureaucracy. Paperwork needs to be filed regularly, and filed by the applicant--the case manager can't do it for them. Taking a temporary job or getting a back payment could mean they end up with too much money temporarily to qualify for Medicaid.

With the end of Medicaid, comes the end of medication and a doctor's supervision. And unplanned pharmaceutical "vacations" can have serious side effects beyond the reappearance of the symptoms of mental illness. "For psychotropic medications in particular, there can be some real risks to just stopping medication without it being tapered down," said Shoenfeld. "We know what happens when people who need it are unmedicated--they're much more at risk for big problems, whether that's violence toward themselves or violence toward others."

To me, it comes down to the crazy guy on the sidewalk. Seattle can spend all the money it wants on tourism and slogans, but there is nothing like the unmitigated wretchedness of a homeless person wandering in freezing weather--too loud and frightening for a shelter--to suggest who we are for visitors.