Ricky’s Law

• Nathan Hinrichs, Multicare, Pierce County Designated Crisis Responder (DCR) – formerly called Designated Mental Health Professionals (DMHP). 
• Ricky’s law filled a gap – we could detain folks with mental health, but we ran into issues where folks were dangerous because of chemical dependency.  Ricky’s law plugs that gap by allowing us to detain individuals for chemical dependency. 
• Years ago, Pierce County did have involuntary commitment for chemical dependency.  The new Ricky’s Law is more restrictive than the past law. 
• Criteria used when determining if someone can be involuntarily committed because of chemical dependency. 
  • Have a substance use disorder based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)  (funny how the chemical dependency definition is in a manual on mental disorders, but that Ricky’s law was needed to authorized detention for chemical dependency because the mental health detention rules didn’t cover chemical dependency –ed.)
  • Can detain Because of chemical use disorder only when there is imminent risk, such as:
    • someone is an IV drug user that is constantly getting abscesses and not seeking treatment
    • Someone not eating and drinking and losing significant weight
    • Someone who is suicidal when they use, but not suicidal when sober
• As with any new regulation, implementation will probably change as needs are better understood and process mature.
• Only two facilities allow can be used to detain individuals –one in Spokane and one in Vancouver, Washington.  If no beds are available, the individual cannot be detained and must be released.  With mental health, we can do single bed certifications (temporary detention in a facility not certified for detention – boring details at http://app.leg.wa.gov/wac/default.aspx?cite=388-865-0526 –ed.)
• The State is looking to open more detention centers over the years.
• When an attempt is made to send someone to a detention center and there is no space available, a report is sent to the state.  This information will be used to (along with other data) to add detention space.
• Depending on where they are with substance use withdrawals (for instance, if they need medical detox), people may not be detainable under Ricky’s law.  Benzos and alcohol withdrawal can be troublesome.  Meth and heroin withdrawals are not so lethal. 
• Under Ricky’s law, we have detained a couple folks – and there have been beds available so far. 
• If a person is referred for a Ricky’s law evaluation, we do also evaluate for mental health issues.
• with folks that have chemical use disorder, often there is a mood disorder driving the use.
• If no substance use beds are available, we do try for a mental health detention.  Conversely, we will also look at criteria for Ricky’s law when doing Mental Health evaluations.
• Prior to Ricky’s law, we couldn’t evaluate when intoxicated (I’m assuming he meant when the client was intoxicated… –ed).  Under Ricky’s law, we can now see folks when they are intoxicated.
• Brian Wilson – how long is the involuntary commitment?  Nathan - 72 hours initially, and then up to 14 days.  It may be able to extend to 90 days, but that is still not clear.  We aren’t involved in the subsequent filings for detention because there is no facility in our County where we would get involved with this work.
• Brian Wilson – is there talk of requiring a payee or navigator to prevent future detainments? Nathan - I’m not sure.  The goal is to go from detention into inpatient substance use program.
• Maureen – is the treatment plan in Spokane or Vancouver?  Nathan –  after detention, the plan is for folks to get treatment back in their home county.
• Question - how many beds?  Nathan – 16 in Spokane and 16 in Vancouver - that is for the whole state. (wow 32 beds, that seems like a lot – are there even 32 people in the state with a substance use disorder… -ed.)
• Question - what do we do to get referral?  Nathan – call Pierce County Crisis Line (800-576-7764) and ask for a DCR.  Should get a call back from one of us and we’ll screen the case.  Always prior to jumping into detention we make sure the client is offered voluntary services.  An emergency room worker may offer treatment to a patient, and only if they refuse can detention be considered.
• Brian Wilson – Are these purpose built facilities?  Nathan-  Department of Social and Health Services (DSHS) (I’m not positive he said DSHS –ed.) contracted with someone to run the centers.  Brian -What would it take to get a facility in Pierce County?  Nathan – when we can’t detain someone, we try our hardest to make it a mental health determination.  Sometimes folks don’t have a mental health issue, and they get stuck where you can’t detain them.  Detention center locations are up to DSHS. 
• Brian – any pending funding to increase the Ricky’s law funding for facilities.  Nathan – these statutes evolve over time – we see the pitfalls, what works, what doesn’t.  Brian – are there any bills to add funding?  Nathan – No, but the state is tracking the number of referrals returned because of full beds, as well as other indicators to determine if additional beds will be necessary.  Brian – I could fill those beds all up in a day. (or something like that exchange took place, I momentarily got caught up in the excitement and forgot to take notes –ed.)
• Maureen – how do you physically transport someone from Pierce County to the detention facility?  Nathan – we send folks restrained in an ambulance to the facility.  We use the same process with mental health patients transported out of county.  (this was a hard image to get out of my head. –ed.)
• Question – does the substance use detention use the same mental health court?  Nathan - same involuntary commitment court as used for mental health.  The existing RCW 71.05 (http://apps.leg.wa.gov/rcw/default.aspx?cite=71.05 ) was added to by Ricky’s law.  Added to an existing statute allowed the the same mental health court rules to apply to the substance use laws.
• Let me review the mental health Involuntary commitment criteria:
  • Criteria
    • imminently dangerous
      • Danger to self – suicidal = we believe they are going to try to commit suicide or do harm in 72 hours or less. 
      • Danger to others – paranoid – concerns people will hurt them and will injure others so they directly threatening people around them.
      • Grave Disability – do a large volume of detentions under this criteria, which includes:
        • Inability to meet health and safety needs
          • For instance, client has delusions that say food is radioactive so they stop eating.  If we have physical evidence of not eating – can get from lab test in ER – we use that physical evidence and witnesses to document the need for detention.
        • Escalating loss of cognitive and emotional control –
          • For example, voices inside their head are preventing them from functioning – but we do still have to prove imminent risk.  Detaining folks for being out in the weather and getting frostbite is another example. 
          • Can be in an extremely manic state – where they convince themselves they can safely do very dangerous things (like walking on a deck railing on a 7 story building).
          • Must have evidence = often talk to family and friends to get better picture – can rely on witnesses – professionals or neighbors.  Can still detain if someone does still present well
• Brian – client in winter wearing sandals in winter getting frostbite but not willing to get services. How to help?  Nathan – when
• Maureen – how do you work with law enforcement and jails.  Nathan – we do evaluations anywhere in Pierce County – including jails (I’m sure this makes perfect sense, but I can’t help wonder why we are evaluating someone to determine if we should detain them if they are already being detained. –ed).  If feel folks are unsafe, we come where they are to do evaluations.  Criminal court, under RCW 10.77 (http://app.leg.wa.gov/rcw/default.aspx?cite=10.77 ), can refer to involuntary – often they contact Designated Crisis Responder (DCR). 
• Maureen – has law enforcement received training in Ricky’s law?  Nathan - We are looking to educate the police. We have Designated Crisis Responders (DCRs) working for the Tacoma Police Department – currently they have 4 positions.  They are dedicated only to calls from the Tacoma Police Department.  Those 4 DCRs provide training to the officers.  Recently we started hiring 4 co-responders who are DCRs who will work with the Pierce County Sheriff’s office focusing on East Pierce County.  Law enforcement and DCRs cross paths a lot (well maybe the DCRs should obey the speed limit better or whatever it is that draws police attention…-ed.) Law enforcement gets a lot of crisis calls that should be handled by DCRs.  Many families are unaware that crisis line can be contacted instead of calling the police.  Lakewood Police have their own co-responders – although they not DCRs.  Puyallup is looking to have a co-responder as well.  (with everyone getting them, you’re going to feel silly not having your own co-responder pretty soon. –ed)
• Question - how do you get clients from detainment to treatment?  Nathan – I don’t know – my work is on the front-end – getting folks into involuntary treatment.  If someone is detained for mental health, we can’t convert it to chemical dependency. 
• Question - lots of folks get stable on mental health issues in detainment but when they exit the program, they use again and end up detained again.  Nathan – After 14 day commitment, court can dictate meds to take and such.
• Paul – Talking about locking folks up involuntarily is concerning – many people don’t like to take medical advice that would increase their lifespan (case in point, I’m drinking bourbon and eating cookie dough right now. –ed.) What are the safeguards of the rights of individuals?  We see folk with abscesses - there are reasons folks don’t go to the doctor.  Nathan – I’ve had people refuse kidney dialysis – they don’t want to deal with the pain and are choosing not to do the dialysis.  That sort of a thought out decision is different from someone hearing voices that are telling them unhealthy things.  We approach those two situations differently.  We detain less than 50% of folks we see.  The hard part of the job is to ferret out the reasons people are behaving in a certain way (I sort of think there are probably not any easy parts to the DCR job – just sayin’ -ed).  We work hard to protect rights.  After 72 hours, need to show evidence to a judge to show danger in order to keep people detained.  People often show distinctive patterns over time.  The imminent risk standard is high – if they simply refuse psychiatric meds – we can’t detain.  But, if in the past, they did something dangerous when not taking meds, it might be a different story on whether we detain or not.   Paul – I understand the reasons – but want a thoughtful process before someone is detained.  James – we must show significant evidence.  It is a tough threshold and we are often frustrated that someone is not quite meeting the criteria for detention. 
• Brian – in California, it is much easier to detain.  Later on, people are often thankful for this type of forced intervention – it can help them get out of a life where they are dying.  Nathan – yes, it is much easier in California. 
• During the investigation – we look at 10 year of history – including acts of violence and mental health history.  We look at Western State forensic reports and review them prior to detaining an individual.  We also reach out to available witnesses.  Often neighbors swarm to tell you things.  In addition to the investigation, we do offer them voluntary options and do a face-to-face medical analysis.
• Al – if you encounter a person who is already enrolled in a treatment program of some kind, does the law permit you to consult that program before making a decision?  Nathan – Designated Crisis Responders (DCRs) are able to get information without consent of the client.  DCRs can talk to anyone who has credible information.  Whenever I find a crisis plan, I call the case manager to find out how they have been  doing on it.  We reach out to treatment providers all the time.  Crisis plans are very helpful – because they often document how folks behave normally so we can compare that to their behavior during their crisis.
• Janet – on the referral side, librarians, community center mangers - when they are not sure about behavior going on, I recommend 211 to connect them to a mental health professional.  Does that them to the Crisis Line?  Nathan – I’m not sure – we get our referrals from the crisis line.  Out crisis team does outreach – accessed through the crisis line.  Hopefully 211 would connect the call to the crisis line.  DCRs will do regular crisis calls when the crisis team is backed up.
• Patricia – some of your consultations are with folks who are homeless on the streets?  Nathan – yes, in cars, camped out, etc.  Patricia – what happens to their stuff and their pets?  Nathan -we have to protect their belongings.  If a case manager or family member is around, we’ll have them take those possessions.  Pets are tough.  We’ll work with the person to find a family member or a neighbor.  Will work hard to find solutions.  When taking someone to detention, we make sure the home they are leaving is safe – things are turned off, windows are shut – and make sure the keys go with the clients – that is our responsibility.
• David – what is this going to do for folks on the street who are non-US citizens? Nathan – that is a touch question.  I have detained non-US citizens – the court system doesn’t treat them any differently?  David – does ICE get involved?  Nathan – we’ve detained folks from the ICE facility, although the state now forbids that.  The only process that is different for immigrants that we’d get involved in is that certain countries require a call to their consulate to let them know one of their citizens is detained and why.  Otherwise, for undocumented folks, we don’t really have a different process.  We don’t call ICE on anyone. 
• (Lots of clapping. –ed) 
• James – Again, the Pierce County crisis number is 1-800-576-7764 – a person will ask you  a variety of questions.  Depending on your answers, you can get a different responder.  Voluntary center in Fife allows you to do all the work to get a client to a facility.  There is little housing available – once folks are restored with treatment – most clients exit to homelessness because there are not adequate resources in the community to house them.
• Maureen – you are a great presenter – you might consider a video or webinar for librarians or community members – this is valuable information.  Nathan – if you want training – I’ll give you my supervisor name.  We’d love to educate you all on the process.  That helps us serve folks better.  Ian Callahan (253.301-5203 or callaia@multicare.org ) is my supervisor.   We are happy to have someone come out and meet with any group.