Jose Campos Jr. has struggled with mental health issues for most of his adult life.

After a violent incident at age 18, he suffered post-traumatic stress disorder, then was diagnosed with bipolar disorder. His family came to anticipate semi-annual episodes where he would go off his medication and disappear for a day or more.

In June, one of those episodes hit late on a Friday night. Campos, now 25, says he was agitated, pacing, raising his voice. With a family friend, he bounced between the hospital and Comprehensive Healthcare, trying to get help.

Instead, by Saturday morning, he’d been arrested for trespassing at Yakima Regional Medical and Cardiac Center and was taken to jail, where he was held for almost three weeks.

“It’s scary when you need help and all the places that are supposed to be there to help you turn you away,” said Campos’ girlfriend, Rebecca Rutledge. “You’re lost. You feel helpless.”

For people with mental illness, navigating the complex world of health services is often an uphill battle. Campos’ story illustrates the challenges facing law enforcement, emergency room staff and mental health professionals who collaborate to reach people before they end up in crisis.

It’s scary when you need help and all the places that are supposed to be there to help you turn you away. You’re lost. You feel helpless. ”
– Rebecca Rutledge, girlfriend of Jose Campos Jr.

But while Yakima may have more resources than many counties its size — including three inpatient psychiatric facilities and Comprehensive’s crisis triage center — providers are stretched thin and can’t always catch people in time.

“If we can’t all work together, then folks with mental illness or chemical dependency can’t get services,” said Courtney Hesla, a division director at Comprehensive. “It’s kind of a fragile system.”

 

Hospitals not equipped for aggressive patients

People qualify as being in mental health crisis if they are perceived to be a threat to themselves or others, or “gravely disabled,” meaning they’re incapable of providing for their own basic needs or keeping themselves safe.

In most medical crisis situations, people head straight to the emergency room. But in cases of severe mental illness, that’s not always the best move.

While Yakima Valley Memorial Hospital has an inpatient psychiatric ward, the hospital’s ER doesn’t have specific psychiatric providers on staff. And as the busiest ER in the state, the resources required to care for an agitated or aggressive patient aren’t always there.

“We take care of a fairly large volume of these types of patients, but they’re short-staffed overall,” said ER physician and chief medical officer Dr. Marty Brueggemann.

Safety of hospital staff and other patients is top priority, he said. Providers may try to calm patients down with medication, or even physically restrain them, depending on the provider’s own comfort level. Hospital security is trained to check for weapons, but not much else.

“If you have a patient who’s being belligerent and violent, (security) are instructed to let them leave — they’re not police officers,” Brueggemann said. Trained police can then safely get patients to the jail, which he called “just a different setting they’re going to be evaluated in.”

The ER also can call for police when agitated patients walk out on their own, to ask for a follow-up visit to make sure they’re OK.

It’s tough to decide which patients the hospital can safely treat, Brueggemann said, especially when making the wrong call could result in serious injury to staff.

Drug use is often the escalating factor, he said, rather than the mental illness alone. Meth makes people act psychotic all by itself; adding that to a psychiatric condition “is just a recipe for disaster.”

Brueggemann said patients are ultimately responsible for completing their own care, though it’s difficult with psych patients.

“Your disease by its very nature makes it harder to be compliant with some of that stuff,” he said.

When patients are cooperative, the ER does a screening exam for any medical needs, then calls Comprehensive to send a designated mental health professional, or MHP, to do an evaluation. Only the MHP can decide when someone needs to be involuntarily detained, either at Memorial or at Bridges, Comprehensive’s 16-bed inpatient evaluation and treatment center, but the goal is to get people into outpatient services for help.

If a patient has been identified as in crisis, Comprehensive makes space for a counseling appointment the next day.

At Memorial, Brueggemann said, patients sometimes have to wait hours to see a mental health professional, as Comprehensive’s team covers all of Yakima County. Staff might be on a call in Sunnyside, or have multiple calls in the queue ahead of Memorial’s patient. Meanwhile, that patient is taking up a spot in the ER that could be used for emergent medical care.

Comprehensive CEO Rick Weaver said one of the reasons the organization opened Bridges a few years ago was to address the limitations of Memorial’s psychiatric services.

“There’s somewhat of a tendency to pick and choose who they deal with,” Weaver said. Depending on who’s on duty in the ER, he said, there’s a tendency to call the cops and have uncooperative patients arrested, rather than treating them.

“I’m not saying that should never happen, but more often than not, people are acting up because of their mental illness,” he said. “Sending them to jail is never the right answer.”

“I’m all for people being accountable. ... If they commit a crime, they need to do their time, but that’s not the way to get them treatment,” Weaver continued. “We have services at the jail, but I would equate that to like a MASH unit. ... We’re not dealing with the treatment people need to get stable and functional in the community there.”

I’m not saying that should never happen, but more often than not, people are acting up because of their mental illness. Sending them to jail is never the right answer.”
– Rick Weaver, CEO of Comprehensive Healthcare

Psychiatric facilities and providers are often full to capacity statewide, something lawmakers have been working to address in recent years.

A Washington State Institute for Public Policy report found that in 2013, nearly all hospitals providing adult psychiatric care had daily occupancy rates above 80 percent, compared with the U.S. average of 64 percent. Bridges opened in 2014, along with several other facilities adding mental health beds to their rosters.

 

Least-restrictive alternatives

On that night in June, Campos had one goal: to be readmitted to Bridges, where he’s stayed before. He wanted to be where he felt safe.

To enter Bridges, however, patients first need to get a medical screening, which at midnight on the weekend can only be done at an emergency room. But Campos says he was kicked out of Regional’s ER and left of his own accord a few times that night, never getting screened.

In the meantime, Comprehensive’s hotline staff told him to come to the crisis triage center.

While the 16-bed center is referred to only as “detox” among most clients, it serves as both a stabilization and detox facility, so whether someone is coming down off drugs, or is in a mental health crisis and needs to calm down, Comprehensive’s Hesla said, the center will provide a bed.

Clients can enter the center on a voluntary basis and then leave whenever they want to, she said, unless staff determines they’re posing a risk to themselves or others.

Being detained at Bridges or at Memorial’s inpatient psych unit, however, means patients can’t leave on their own. People can be detained for only 72 hours before there must be a court hearing to determine whether they merit a longer commitment.

Campos says he was worried about being detained at detox, so he didn’t go in there, instead staying outside and talking to staff.

In mental health emergencies, Comprehensive providers hope to better establish their crisis hotline as a first line of defense for patients, as well as for cops who might encounter people in crisis in the community.

Chronically mentally ill people, including many homeless individuals, often end up in jail repeatedly for offenses such as trespassing, petty theft and vagrancy, but they’re soon back on the street, Hesla said.

“What we’d like to see happen is for law enforcement to identify those folks and bring them to us,” Hesla said.

Her team of eight mental health professionals in acute care services has at least one person on call 24/7, ready to respond to calls from police or community members worried about a mentally ill person.

The MHPs must have a master’s degree in psychology or a related field, and two years of post-graduate school experience. They’re trained to identify signs of agitation or aggression, and how to de-escalate situations. If a person is already involved in services at Comprehensive, the MHP also has access to a wealth of information about the person’s history.

From August through December of 2015, Hesla said, her team responded to 1,639 requests for evaluation throughout Yakima County.

 

Teaming up with police

Part of the training that Comprehensive provides for law enforcement includes asking cops to call for an MHP prior to bringing someone to the emergency room, to see if they can respond first.

“We don’t want to flood the ER with clients that we could potentially see in the community,” Hesla said.

Law enforcement also has an in-between option available to them, both for people under the influence of drugs and alcohol and for those who appear to be severely mentally ill, Hesla said. Police can take people into “protective custody,” sometimes called “community caretaking,” while they figure out whether the person can go home or needs to be brought to a mental health facility.

Since retiring from the sheriff’s office, former Yakima County Sheriff Ken Irwin has worked at Comprehensive as a liaison between mental health providers and local law enforcement, facilitating the crisis intervention training for new recruits and keeping all parties on the same page.

For officers who respond to the scene, Irwin said, it’s “safety first.”

“You’re constantly in that mode of being cautious and yet calm as you can be, patient as you can be, and try and gain compliance,” he said. That includes body language — open palms, slower movements, and not standing too close.

“And it’s the hardest thing you can possibly do in a very stressful, dynamic situation — to be patient,” he said.

You’re constantly in that mode of being cautious and yet calm as you can be, patient as you can be, and try and gain compliance. And it’s the hardest thing you can possibly do in a very stressful, dynamic situation — to be patient.”
– Ken Irwin, former Yakima County sheriff, current liaison between Comprehensive and law enforcement agencies

Under a law passed in 2015, all full-time peace officers in Washington must receive at least eight hours of crisis intervention training. Some receive the full 40-hour course.

Comprehensive has trained 868 officers in Central Washington so far, Irwin said.

Yakima also has a Mental Health Court, which serves as a jail diversion program for mentally ill individuals who have been charged with certain felonies. If they go through the therapeutic court program, which includes mandatory counseling, staying on meds and a weekly check-in at court, they can get their charges dismissed.

The program provides a structure that helps people succeed, Commissioner Bob Inouye says.

“We also have found that if we try to use the stricter methods with this population that it’s just not effective. You need to realize that it takes a bit more time to get people turned in a different direction, to get them supported and reliably able to take care of themselves sufficiently,” he said. “We’re really trying to break a cycle of a lot of the respondents.”

 

‘The worst thing ever’

But sometimes, despite the best of intentions, people can fall through the cracks.

Lorraine Gonzalez, Campos’ mother, said the family has reached out to mental health providers and law enforcement many times over the years. Campos has a regular counselor at Comprehensive, and after multiple episodes is familiar to police.

Sometimes when he’d disappear for a few days, Gonzalez would call the cops, asking them to look for him, to bring him home. But if he wasn’t behaving in a threatening manner, there was nothing they could do.

“It’s like the worst thing ever,” she said, becoming emotional. While he was gone, she called the hospitals and the jails over and over, worried he was going to hurt himself.

It’s like the worst thing ever.”
– Lorraine Gonzalez, mother of Jose Campos Jr.

She wishes she knew the right words to say to police or hospital staff to make them understand.

“Sometimes people look at us like we’re the crazy ones,” Gonzalez said.

Campos and Rutledge have kids, too: one each from previous relationships, and one together. Campos likes to take them to the park so they can play outside.

Rutledge says she’s wondered what she would say to them if Campos never got the help he needed.

“That’s what I was so afraid of ... that his mind was just going to be completely gone forever, and that he was going to be here but not be himself, and was just going to end up like one of these other crazy homeless people on the street,” she said. “Do I tell my son, ‘That’s your dad?’”

Campos knows he hasn’t been perfect. He’s been arrested several times for offenses including disorderly conduct, DUI, even residential burglary.

But not this time, he says.

“This time I really didn’t do anything wrong,” he said. “Just trying to fix myself.”