Mason Burley - October 2011

In 2012, recent amendments to Washington State’s Involuntary Treatment Act (ITA) will take effect. New legal guidelines will allow a designated investigator to more fully consider information from both credible witnesses and historical records when making commitment decisions. The 2010 Legislature directed the Washington State Institute for Public Policy (Institute) to estimate the number of additional psychiatric admissions that may occur as a result of this law and examine how many inpatient psychiatric beds may be necessary to accommodate this increase. These estimates were presented in a companion to this report (completed in July 2011).

This report outlines various approaches for addressing the projected increase in psychiatric admissions. First, we discuss options for developing additional capacity within the state’s inpatient psychiatric system. Next, we highlight both programmatic and statutory alternatives that may help prevent (or divert) future psychiatric admissions. This section also summarizes laws from four different states that provide for alternatives to involuntary inpatient admissions. Finally, this report examines the relationship between ITA-related psychiatric admissions and utilization of both county jails and hospital emergency departments.

Steve Aos, Stephanie Lee, Elizabeth Drake, Annie Pennucci, Tali Klima, Marna Miller, Laurie Anderson, Jim Mayfield, Mason Burley - July 2011

The 2009 Washington Legislature directed the Institute to “calculate the return on investment to taxpayers from evidence-based prevention and intervention programs and policies.” The Legislature instructed the Institute to produce “a comprehensive list of programs and policies that improve . . . outcomes for children and adults in Washington and result in more cost-efficient use of public resources.” The Legislature authorized the Institute to receive outside funding for this project; the MacArthur Foundation supported 80 percent of the work and the Legislature funded the other 20 percent. This main report summarizes our findings. Readers can download the two detailed technical appendices for in depth results and statistical methods.

Mason Burley - July 2011

In 2010, the Washington State Legislature amended the legal guidelines for Involuntary Treatment Act (ITA) commitments to allow a Designated Mental Health Professional (DMHP) to more fully consider reasonably available information about individuals from credible witnesses and historical records (RCW 71.05.212). These statutory changes will take effect in 2012. The Legislature directed the Institute to assess the potential impact of these changes.

This paper discusses trends in both the utilization of inpatient psychiatric treatment beds and changes in the capacity of these facilities to admit patients. To assess potential increases in psychiatric admissions as a result of this law, we conducted a survey that asked DMHPs to review ITA cases during a one-week period in 2010. Based on this survey, we estimate that the commitment rate could increase from 40 percent to between 45 and 55 percent of all investigations as a result of the statutory changes. Between 42 and 168 additional psychiatric beds (above current capacity) would be necessary to accommodate this growth in admissions.

Roxanne Lieb, Hazel Kemshall, Terry Thomas - June 2011

Published as:

Lieb, R., Kemshall, H., & Thomas, T. (2011). Post-release controls for sex offenders in the U.S. and UK. International Journal of Law and Psychiatry, 34, 226-232. doi: 10.1016/j.ijlp.2011.04.006

In recent years, both the United States and United Kingdom have developed numerous innovations in legal efforts to protect society from sex offenders. Each country has adopted special provisions for sex offenders. In particular, governments have focused on forms of social control after release from incarceration and probation. These policy innovations for this category of offenders have been more far reaching than those for any other offender population. The two jurisdictions have adopted policies with similar goals, but the selected strategies have important differences. Generally speaking, the U.S. has favored an ever-expanding set of policies that place sex offenders into broad categories, with few opportunities that distinguish the appropriate responses for individual offenders. The UK government observed the proliferation of Megan’s Laws in the U.S., and deliberately chose to establish carefully controlled releases of information, primarily relying on governmental agencies to work in multi-disciplinary groups and make case-specific decisions about individual offenders. Although the UK policy leaders expressed significant concern that the public’s response to knowing about identified sex offenders living in the community would result in vigilantism, to date the results have not born out this fear. Both governments have turned to other crime control measures such as polygraphy testing, electronic monitoring, and civil protection orders as a means to prevent further sexual violence.

Roxanne Lieb, Mason Burley - May 2011

In response to a 2010 legislative direction, the Institute and DSHS are investigating options regarding the use of mental health assessment tools for two DSHS reports to the courts:

- Competency to stand trial assessments of criminal defendants whose competency is in question, and

- The Secretary’s recommendations to the courts concerning the potential conditional release of criminally insane patients from inpatient treatment.

This document summarizes results of an October 2010 survey of state forensic evaluators concerning their use of assessment instruments. Thirty-one (of the 35) mental health experts who conduct forensic evaluations for the three state psychiatric hospitals (Western State, Eastern State, and Child Study and Treatment Center) responded to the online survey; this represents an 89 percent response rate.

We present three options for assessment strategies and instruments, with advantages and disadvantages of each option. A detailed comparison of instruments is included.

Marna Miller - May 2011

In 2008, an Institute study found that American Indian, Black, and Latino children were more likely to have referrals to Washington’s Child Protective Services (CPS) than White children. Following referrals to CPS, American Indian and Black children (but not Asian or Latino children) were more likely to be placed and remain in foster care significantly longer than White children. In 2009, the Washington State Legislature directed the Institute to examine whether DSHS’s recent adoption of the Structured Decision Making (SDM) risk assessment tool affected racial disproportionality in the foster care system. SDM is used as part of CPS investigations to classify families on their risk of further child maltreatment.

Our analysis took advantage of the fact that DSHS began using SDM statewide in October 2007. We compare rates of placement and re-referral to CPS for children with referrals in 2008 to children with referrals before SDM was implemented.

Disproportionality after CPS referral varied markedly from year to year for Black children. Some of the variation can be explained by annual differences in rates of referral. However, analyses that controlled for referral rates still revealed year-to-year differences in rates of out-of-home placement for Black children. We are unable to explain these yearly fluctuations.

When our analysis combined children of all races, we observed no effect of SDM on out-of-home placements or new referrals to CPS. We also analyzed outcomes for each race separately. For White, American Indian, Asian, and Latino children, we found no effect of SDM on placements or new CPS referrals. For Black children—but not for any other race/ethnicity—we observed a significant increase in the rate of out-of-home placements in 2008. We cannot be certain that the SDM risk assessment was the cause of the differences in 2008; differences may also be the product of the largely unexplained year-to-year fluctuations in disproportionality for Black children.

As implemented in Washington State, the SDM risk assessment did not reduce disproportionality after CPS referral for either Black or American Indian children.

Jim Mayfield - May 2011

In 2006, the Washington State Department of Social and Health Services established two pilot sites for the Integrated Crisis Response Program. At these sites, Designated Crisis Responders (DCR) investigate and have authority to detain individuals with serious mental illness or substance abuse problems. Elsewhere in the state, this function is conducted separately by mental health professionals and chemical dependency specialists. The pilots also created secure detox facilities to hold involuntarily detained individuals. This report describes the 18-mounth outcomes of nearly 1,000 individuals admitted to these secure detox facilities from May 2006 through October 2007. Outcomes examined include psychiatric hospitalization, substance abuse treatment, emergency department utilization, employment, arrests, and mortality.

Annie Pennucci - April 2011

The research literature reveals a relatively small, positive impact on student outcomes resulting from a longer school year. When benefits are measured in terms of the labor market earnings gained from improved test scores, we find that increases to instructional time outweigh the cost of providing that instruction.

Brian Bruen, Richard Jensen, Patricia Riley, Anthony Lara, Xiaoxiao Lu - April 2011

The 2010 Washington State Legislature funded a study to examine options to contain costs in the state Medicaid program. Following a competitive bid, George Washington University was selected as the contractor. They found that small numbers of users account for most fee-for-service spending for inpatient and outpatient services. Options to reduce short-term costs include reducing reimbursement, placing restrictions on benefits, and instituting cost-sharing for beneficiaries. Long-term solutions require concentrated, coordinated care management for high-use, high-cost Medicaid beneficiaries and strategic approaches to reform the service delivery system, with accompanying payment reform to incentivize change.

Jim Mayfield - April 2011

In 2007, the Washington State Department of Social and Health Services established the Thurston-Mason Children’s Mental Health Evidence-Based Practice Pilot Project (Pilot) to provide mental health services to children. The first evidence-based practice selected by the Pilot was Multisystemic Therapy (MST), an intensive family- and community-based treatment program for youth. Over a one-year follow-up period, the Institute examined criminal convictions of youth enrolled in the Pilot’s MST program. Compared to youth with similar criminal histories and demographic characteristics, MST youth were convicted of fewer crimes on average. Due to sample size, statistical significance was not attained in this evaluation of MST outcomes. The effect sizes observed, however, are within the expected range for MST according to other rigorous studies of that intervention and would likely return a net economic benefit to tax payers and crime victims.