It took more than half a year for Brian’s daughter to get a bed at Western State Hospital after a scare in which she put a bread knife into an electrical outlet at his Tacoma apartment.

A court ruled she needed involuntary psychiatric treatment at the 857-bed facility in Lakewood, but due to a wait list that can stretch to more than 100 patients, his daughter instead bounced around Pierce County in-patient treatment centers that provide less intensive care.

“She was just kind of surviving,” Brian said of his 30-year-old daughter, who he said has a history of mental health disorders. She is also an artist and a passionate traveler who studied science at a top college.

Last month, Brian said he was notified his daughter was stable enough to leave Western State. He also was told it might take a while to find a suitable place for her to live, a situation that helps illustrate a complex bottleneck at the root of the hospital’s admission wait list for civil, or noncriminal, patients.

Most patients exiting Western State can't live independently or with family, and Washington officials are struggling to find appropriate beds in adult family homes and other types of care facilities to discharge them to. That lag time has left scores of Western State patients stuck in limbo, and it holds up beds at the facility needed by other people in crisis.

"They don't have the places, the physical places and the staff, to treat as many people as there are that need help," Brian said in an interview with The News Tribune, The Olympian and public radio’s Northwest News Network at his new home near Port Townsend. Brian asked that his last name not be published and that his daughter not be named, saying he fears employers and others may discriminate against her in the future.

Data released by the hospital shows just how big the problem is.

About 40 percent of the hospital’s approximately 580 civil patients were on the discharge list last week. The median time currently spent on the discharge list is 104 days. Some people have waited years, or even decades to be released after the hospital deemed them ready to go, according to hospital officials.

As a result, the average wait for patients to get into Western State is about 62 days for younger adults and 48 days for older adults in the hospital’s civil wards. Marylouise Jones, the interim CEO at Western State, said if the hospital could discharge everyone ready to leave, they "may not have a waiting list" for civil admissions.

Washington Gov. Jay Inslee, center, speaks Friday, May 11, 2018, in front of Western State Hospital in Lakewood. Ted S. Warren Associated Press

Civil patients at Western State have been involuntarily committed by a judge but aren’t in treatment as part of the criminal-justice system. The state-run hospital also serves roughly 270 patients in its forensic wards, which house people who have been charged with or convicted of a crime and need mental health evaluations or treatment.

Brian said his daughter was put on the wait list to get into the hospital last summer but didn't get a bed until March. Western State would not confirm that time line, citing patient privacy concerns.

Now she's having a hard time getting out.

Brian said it’s his understanding that his daughter interviewed with one possible treatment facility for her to discharge to, but that it wasn’t the right fit. Brian said he can't safely care for his daughter at home because she is, in his words, "treatment-resistant."

Her discharge efforts hit another snag this week, Brian said, when she refused to take medication and sign paperwork that would ensure she has Social Security and medical benefits in the community.

Diagnosing the backlog

When patients are discharged from Western State, about 75 percent are released to treatment facilities around Washington that contract with state government.

While patients might be stable enough to leave the hospital, they often need ongoing help managing their condition and the daily aspects of their lives, such as taking medication, eating and bathing. Many of them are older.

Most commonly, patients from Western State are discharged to adult family homes or group homes, which are typically located in residential neighborhoods and also can serve people not in the mental health system. Some discharged patients head to nursing homes or other more secure treatment centers.

There are a host of reasons why the state has trouble discharging so many Western State patients to these settings.

For one, staff at licensed care facilities need specific training to host patients with complex psychiatric disorders, which not all providers have, said Bea Rector, who runs a division at the Department of Social and Health Services that oversees the process of finding a step-down home for patients who need mental health care.

It also can be more costly and time-consuming to serve the many needs of Western State patients, said John Ficker, executive director the Adult Family Home Council, which can be a disincentive for providers on thin budgets.

There are other roadblocks, such as when a patient rejects a proper step-down facility because it's located in a city too far away from family, Rector said.

Jones, Western State’s acting CEO, said a home might not take a Western State patient because of the stigma associated with people who have received mental health treatment at the large institution.

A portion of a wooden sign that reads "Dedicated to Mental Health" above an entrance to Western State Hospital in Lakewood is shown as Washington Gov. Jay Inslee speaks Friday, May 11, 2018 during a news conference. Ted S. Warren Associated Press

Another reason treatment facilities turn away patients is because of criminal history.

While civil patients generally aren’t at Western State due to a criminal charge, some might have them in their past. Rector said they might have a history of sexually inappropriate behavior, assault or arson.

In some cases it's "really difficult to get a provider to feel like they can accept that resident and still meet the health and safety needs of the people around them," Rector said.

Jones called it a “huge issue” over the last two decades.

“We know the patient is safe, does not present a public safety risk,” Jones said. “Nevertheless it’s still, based on their history, very difficult to find places in the community that can support them.”

Recently, tensions flared over an extreme example of this debate when Western State tried to discharge Lawrence David Butterfield, a man charged with murder, to an adult family home near an elementary school in Lakewood. Local elected officials pushed back and Butterfield stayed at the hospital.

In that case, Butterfield entered Western State as a forensic patient but later flipped to the civil side of the hospital after he was found incompetent to stand trial. A small group of civil patients at the hospital follow that path.

Lakewood is now trying to restrict adult family homes and other facilities in a way that could have implications for more traditional civil patients hoping to discharge in the area.

The city is considering a moratorium on the approval of new licenses for adult family homes, group homes and other treatment centers in residential areas. It also recently passed an ordinance signifying they believe adult family homes should not house people with violent or sexually violent histories and is debating a lawsuit against the state to make that wish reality.

[Do you have a loved one at Western State? We'd like to hear from you: https://goo.gl/wxm8z2]

The state Attorney General’s office has said such a restriction might break anti-discrimination laws. The Adult Family Home Council, which lobbies on behalf of adult family home providers, opposed the idea.

State Sen. Steve O’Ban, a Tacoma Republican whose legislative district includes Western State and parts of Lakewood, said the state should work to develop more of a secure, intensive type of treatment center for patients with violent histories, known as an enhanced services facility.

The enhanced facilities have around-the-clock nursing staff, a behavior specialist on site and more, according to Rector. Washington currently has three of them — one in Vancouver, two in Spokane — holding between eight and 16 beds each. A fourth is set to open in Everett in September, Rector said.

Criminal history or not, placing a patient from Western State at a community facility requires a process of interviews, research and collaboration, said Melissa Capobianco, the hospital’s Director of Social Work. That takes time.

“We’re really trying to hand pick, matchmake if you will, placements that will be a good fit, that will create a true home where that individual can live in the community successfully,” she said.

Seeking Solutions

There is no easy answer to the bottleneck plaguing Western State’s civil discharge list.

Rector said the state is encouraging enhanced services facilities by offering construction money to those who want to build them. The state has been providing training to some community providers so they can more easily serve hard-to-discharge patients, she said.

State officials also booked money in 2017 for building up bed capacity for hard-to-place patients and have been in active talks with some providers to develop other strategies to increase beds.

Capobianco noted that many states require treatment centers such as adult family homes to take patients from state hospitals. Some states even run their own step-down facilities, she said.

Discharging patients has a financial incentive, too. The average bed rate at Western State is $790 a day, while enhanced service facilities cost $425 per day and adult family homes just $95, according to the governor's office.

Ficker, of the Adult Family Home Council, said his providers would like to see a bigger boost in state money to pay for costly hard-to-serve patients. He said they're also hoping for more government support in managing the patients to take pressure off the homes.

In the future, Washington lawmakers hope to stop treating most civil patients at Western State altogether and instead treat them at other smaller, intensive-care facilities around the state. Legislators say patients are better off treated closer to home rather than at a centralized location.

The shift also would free up bed space for the lengthy list of forensic patients waiting to get into Western State. The state has been fined millions by a federal court for its inability to provide timely services to criminal defendants who have mental illnesses.

Gov. Jay Inslee last week set a 2023 deadline for Western State and Eastern State hospitals to stop admitting new civil patients. Lawmakers from both sides of the aisle generally agree with the strategy and have been taking steps to phase out civil patients at the hospitals since 2017.

For now, the wait list remains.

In the interview at his home, Brian said his daughter first had a “break” about eight years ago. Since then, he said she has been hospitalized several times and has even been close to homeless occasionally.

Brian said he’s knows there isn’t a quick fix for his daughter’s challenges with mental health. Once she's discharged, he’s hopeful she can find a safe place to live where she can “be monitored and get treatment at the same time.”

“It’s really really sad when something like that first happens,” Brian said of his daughter’s hospitalizations. “Eventually you just have to accept it and try to do the best you can and try to be an advocate for them and maybe for other people who have these problems.”

Editor’s note: This story was reported in collaboration with Austin Jenkins at public radio’s Northwest News Network.