1.Write an essay discussing the various causes and solutions for a
Pinkerton Citizenship Theory Paper 12.5.2014
1. Citizenship Theory and Psychiatric Boarding
Jacquelyn Pinkerton
University of Washington, Tacoma
Professor Ronald San Nicolas, MSW, PhD
TSOCW 531(A): Advanced Integrative Policy and Advocacy
July 26, 2015
2. Jacquelyn Pinkerton
December 2014
Citizenship Theory Paper
On August 7, 2014 the Washington State Supreme Court ruled that “the Involuntary
Treatment Act (ITA) does not authorize psychiatric boarding as a method to avoid overcrowding
certified evaluation and treatment facilities” (In Re Det. of D.W., 2014). The current state of our
mental health system is overburdened by rising demand for services and decreased funding for
these services. This inverse relationship of funding supply and service demand has led to a state
wide crisis wherein the patients who are in the most need for treatment and evaluation are
subjected to a sub-standard level of care that, in this Supreme Court decision, is no longer
permissible. Lister (2007) discusses the importance of incorporating marginalized groups into the
policy-making process and the injustice that ensues when their voices are not heard and their
experiences not validated alongside the “knowledge and expertise [of those who] have
traditionally been privileged” (p. 53). The practice of psychiatric boarding is a violation of the
ITA and the rights of the individuals affected by it.
The ITA is a culmination of RCW and WAC codes that guide the practice of detaining
and treating individuals who are determined to be a risk of harm to themselves or others and/or
gravely disabled. RCW 71.05 addresses the involuntary treatment of adults while RCW 71.34
addresses the involuntary treatment of minors; WAC 388-865 outlines regulations for
community mental health and involuntary treatment programs. In 2012, policy changes allowed
for Designated Mental Health Professionals (DMHP) to incorporate historical record and witness
testimony when evaluating a patient to be detained; these changes had an anticipated impact of
an additional 2,716 new patients per year (Burley, 2011). The Washington State Institute for
Public Policy submitted a needs assessment and recommendations to address the decrease in ITA
evaluation and treatment capacity in Washington State and the anticipated increase in ITA
patient admissions following the 2012 policy changes. As of August 2014 the Washington State
Legislature and state RSNs had yet to address the problem of an increasing ITA population and
decrease in evaluation and treatment capacity. This inaction led to a lawsuit that was eventually
brought to the Washington State Supreme Court wherein they ruled that this deficit of adequate
treatment could no longer continue. Psychiatric boarding evolved from a need that went
unaddressed by policy makers and subsequently failed to acknowledge that ITA patients deserve
to be treated with respect, to have their dignity maintained, and are deserving of adequate and
just care (Reitz-Pustejovsky, 2002).
The population of patients who have been involuntarily detained and denied adequate
treatment highlights discrepancies in the rights of those with power and privilege relative to
those who are marginalized and at the mercy of the dominant systems. The patients subjected to
the ITA have been treated as less than full citizens and while their mental illness may prevent
them from fully participating as citizens this does not mean that they should be treated as less of
a citizen (Lister, 1998). It will be important moving forward to incorporate the opinions and
perspectives of the individuals who have been impacted by the ITA in addition to the agencies
and professionals responsible for implementing the ITA (Rowe, Kloos, Chinman, Davidson, &
Cross, 2001).
Reitz-Pustejovsky (2002) poses a question related to the treatment of homeless people
where they ask if the care afforded to this population is both ethical and just. This is a question
we should ask of any service imposed upon or offered to a marginalized population. The
chronically mentally ill are a marginalized population and until psychiatric boarding was
determined to be unlawful, the treatment they received was in some cases neither ethical nor just.
As a collective society we neglected to act to meet the needs of those on the margins and our
3. Jacquelyn Pinkerton
December 2014
Citizenship Theory Paper
mental health system and our policy makers are now forced to address this disparity. Since the
Supreme Court’s decision, Washington State’s Governor Inslee has allocated funds to increase
the number of ITA evaluation and treatment beds available in the state but this alone will not be
enough to fully meet the needs of this population on an ongoing basis. Shafir and Brysk (2006)
discuss the value of social citizenship rights as these rights frame a perspective that all citizens
deserve certain benefits and this in turn reduces the stigmatization of the vulnerable individuals
who exercise these rights. For those patients who are involuntarily detained, they deserve to
receive adequate treatment and it should be unacceptable for them to receive anything less.
Washington Supreme Court’s decision regarding psychiatric boarding supports the agency of
detained patients and mandates a better standard for treatment that should improve treatment
outcomes and participation in the greater community.
Opposition to the Supreme Court’s ruling is rooted in concern for the unaddressed ‘how’
of this decision rather than the decision itself. General opinion is that psychiatric boarding is an
unacceptable practice but the Court’s ruling fails to provide alternatives to the status quo or
expectations for long-term outcomes. Initial steps have been taken to mitigate the impact of the
Court’s decision but unless legislators understand that this is a problem that needs long-term
solutions we will not make forward progress to address the needs of the chronically mentally ill
who must be involuntarily detained (Hanson, 2014). Immediately following the Supreme Court’s
decision there was confusion and concern of how the ruling would be implemented as emergency
room providers are required to provide safe discharge plans thus creating a conflict of ‘we can’t
keep them but we can’t let them go’ (Mannix & Thompson, 2014). The Supreme Court
subsequently delayed the ruling implementation until December 2014 but inpatient psychiatric
facilities, community hospitals, legislators, and state officials still had to take immediate action
to address this need. This court decision is a mandate for what is considered socially acceptable
and should perpetuate norms that improve treatment and long-term outcomes.
Social work practice implications from this ruling will be felt throughout all levels of this
system from micro to macro. At the micro level this decision may impact the outcome of first
contact with a crisis worker and the subsequent discretion of the DMHPs who are responsible for
determining whether or not someone should be detained. Evaluation and treatment facilities that
screen initial intake and ongoing care at the mezzo level will need to evaluate their current
policies and available resources to increase capacity and meet the needs of incoming patients.
Community hospitals, short term treatment facilities and long term treatment facilities will als
need to work collaboratively to address this need. Our state legislature will need to revise
funding/reimbursement policies as well as standards for treatment moving forward. Possible
unintended consequences may be stricter guideline for detainment which may result in some
patients not receiving needed care. Although the Governor did allocate funds to address some of
the immediate need this may distract legislators from sufficient action if they feel the need is
now met. Social work values never supported the practice of psychiatric boarding, now it is
imperative that as a discipline we increase advocacy and facilitate change at all levels of this
problem.
4. Jacquelyn Pinkerton
December 2014
Citizenship Theory Paper
Bibliography
Burley, M. (2011, October). Inpatient psychiatric capacity in Washington state: Assessing future
needs and impacts (part two). Olympia, Washington: Washington State Institute for
Public Policy. Retrieved from http://www.wsipp.wa.gov/reportfile/1093/wsipp_inpatient-
psychiatric-capacity-in-washington-state-assessing-future-needs-and-impacts-part-
two_full-report.pdf
Hanson, K. (2014, September 4). ER crisis created by Supreme Court's ruling on psuchiatric
boarding. Seattle Times. Retrieved from
http://seattletimes.com/html/opinion/2024465302_kevinhansonopedpsychiatricboarding0
5xml.html
In Re Det. of D.W., 90110-4 (Supreme Court of the State of Washington August 7, 2014).
Retrieved from https://www.courts.wa.gov/opinions/pdf/901104.pdf
Lister, R. (1998). Citizenship on the margins: Citizenship, social work and social action.
European Journal of Social Work, 1(1), 5-18.
Lister, R. (2007). Inclusive citizenship: Realizing the potential. Citizenship Studies, 11(1), 49-61.
doi:10.1080/13621020601099856
Mannix, A., & Thompson, L. (2014, August 7). Ruling that bans psychiatric boarding' has health
officials scrambling. Seattle Times. Retrieved from
http://seattletimes.com/html/localnews/2024266358_psychiatricboarding1xml.html
Reitz-Pustejovsky, M. (2002). Is the care we provide homeless people, just? The ethic of justice
informing the ethic of care. Journal of Social Distress and the Homeless, 11(3), 233-247.
Rowe, M., Kloos, B., Chinman, M., Davidson, L., & Cross, A. B. (2001). Homelessness, mental
illness and citizenship. Social Policy and Administration, 35(1), 14-28.
Shafir, G., & Brysk, A. (2006). The globalization of rights: From citizenship to human rights.
Citizenship Studies, 10(3), 275-287. doi:10.1080/13621020600772073
![Jacquelyn Pinkerton
December 2014
Citizenship Theory Paper
On August 7, 2014 the Washington State Supreme Court ruled that “the Involuntary
Treatment Act (ITA) does not authorize psychiatric boarding as a method to avoid overcrowding
certified evaluation and treatment facilities” (In Re Det. of D.W., 2014). The current state of our
mental health system is overburdened by rising demand for services and decreased funding for
these services. This inverse relationship of funding supply and service demand has led to a state
wide crisis wherein the patients who are in the most need for treatment and evaluation are
subjected to a sub-standard level of care that, in this Supreme Court decision, is no longer
permissible. Lister (2007) discusses the importance of incorporating marginalized groups into the
policy-making process and the injustice that ensues when their voices are not heard and their
experiences not validated alongside the “knowledge and expertise [of those who] have
traditionally been privileged” (p. 53). The practice of psychiatric boarding is a violation of the
ITA and the rights of the individuals affected by it.
The ITA is a culmination of RCW and WAC codes that guide the practice of detaining
and treating individuals who are determined to be a risk of harm to themselves or others and/or
gravely disabled. RCW 71.05 addresses the involuntary treatment of adults while RCW 71.34
addresses the involuntary treatment of minors; WAC 388-865 outlines regulations for
community mental health and involuntary treatment programs. In 2012, policy changes allowed
for Designated Mental Health Professionals (DMHP) to incorporate historical record and witness
testimony when evaluating a patient to be detained; these changes had an anticipated impact of
an additional 2,716 new patients per year (Burley, 2011). The Washington State Institute for
Public Policy submitted a needs assessment and recommendations to address the decrease in ITA
evaluation and treatment capacity in Washington State and the anticipated increase in ITA
patient admissions following the 2012 policy changes. As of August 2014 the Washington State
Legislature and state RSNs had yet to address the problem of an increasing ITA population and
decrease in evaluation and treatment capacity. This inaction led to a lawsuit that was eventually
brought to the Washington State Supreme Court wherein they ruled that this deficit of adequate
treatment could no longer continue. Psychiatric boarding evolved from a need that went
unaddressed by policy makers and subsequently failed to acknowledge that ITA patients deserve
to be treated with respect, to have their dignity maintained, and are deserving of adequate and
just care (Reitz-Pustejovsky, 2002).
The population of patients who have been involuntarily detained and denied adequate
treatment highlights discrepancies in the rights of those with power and privilege relative to
those who are marginalized and at the mercy of the dominant systems. The patients subjected to
the ITA have been treated as less than full citizens and while their mental illness may prevent
them from fully participating as citizens this does not mean that they should be treated as less of
a citizen (Lister, 1998). It will be important moving forward to incorporate the opinions and
perspectives of the individuals who have been impacted by the ITA in addition to the agencies
and professionals responsible for implementing the ITA (Rowe, Kloos, Chinman, Davidson, &
Cross, 2001).
Reitz-Pustejovsky (2002) poses a question related to the treatment of homeless people
where they ask if the care afforded to this population is both ethical and just. This is a question
we should ask of any service imposed upon or offered to a marginalized population. The
chronically mentally ill are a marginalized population and until psychiatric boarding was
determined to be unlawful, the treatment they received was in some cases neither ethical nor just.
As a collective society we neglected to act to meet the needs of those on the margins and our](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)