A new ward called F-9 opened at Western State Hospital in Lakewood, Pierce County, this May. Eldorado Brown, a 40-year-old man coming from the King County Jail, can tell because it smells like fresh paint.
Brown, who is facing felony charges and has a history of mental illness, was among the first patients transferred here as 29 beds opened for people awaiting mental health services from jails.
Facing a surge in demand from local courts, Western State is expanding the amount of space it has for patients like Brown — people sent to state facilities for restoration treatment or attainment, a kind of basic mental health service that aims to make defendants competent to stand trial.
Between 2013 and 2021, competency referrals more than doubled across most counties, according to data from the Department of Social and Health Services. To keep up, the hospital is investing $612 million in the construction of a 350-bed hospital, set to open as early as 2028.
But as the state’s largest psychiatric hospital receives more and more of these patients, what does the restoration process actually look like? The treatment is extremely limited, often only providing medication and a basic education about the criminal legal system.
“Restoration is not about the human being,” said Anita Khandelwal, the director of the King County Department of Public Defense. “It is about facilitating a criminal process.”
Medication can help people with severe mental illnesses, Khandelwal said. But she points to the thorny issue of what happens afterward: People are deemed restored, get sent back to jail, and destabilize again. Or their charges are dismissed and they are discharged, potentially into homelessness, and sometimes cycle right back into jail. In the best case scenario, defendants might be diverted into an alternative program that links them to treatment or housing — but those are rare and limited spots.
For prosecutors, restoration is a step toward treatment, albeit an imperfect one. In many cases, it’s one of the few ways they can keep people out of jail and off the street, especially if the defendant is arrested repeatedly.
“We’re not looking for restoration just for the sake of holding someone accountable,” said Seattle City Prosecutor Ann Davison. “It really is to try to stem off that longer exposure … [of] decompensating.”
Davison points to times that a defendant was deemed competent but then spent years cycling through homelessness and untreated drug use or mental illness. Ultimately, they deteriorated and were no longer competent.
The process
Part of the criminal legal system hinges on the foundational idea that a person accused of a crime has an understanding of their actions — a defendant has to have mens rea, Latin for a “guilty mind,” to be charged. This comes from medieval British law where people with mental illness or an intellectual or developmental disability were charged less severely than a person who was competent and conscious of their actions.
In modern times, if a defendant is not able to cooperate with their attorney (say answer questions coherently) or doesn’t understand the criminal process (what a trial is, who the judge is), a defense lawyer can flag the case for a competency evaluation. That is called the Dusky standard and it’s what most states use to evaluate people with competency issues. Ultimately, this system is a balancing act, pivoting between the rights of victims and the constitutional rights of defendants to due process.
Once ordered by a judge, Washington law requires a competency evaluation to be done within two weeks by a mental health professional with doctorate level training, known as a forensic evaluator. That’s done through an in-person or video interview. Evaluators gather the defendant’s medical and personal history, take note of their symptoms, and file a report to court with their findings.
If an evaluator finds that person to not be competent, the defendant goes on a waitlist to get into one of the state’s psychiatric treatment facilities. There, they undergo restoration treatment: In most cases, this can take about a month for a misdemeanor charge or 90 days for a felony charge, with the possibility of extensions.
However, wait times to enter restoration are taking weeks or months past their mandated time frame — delays that have led to an ongoing court battle and millions of dollars in fines for the state. Brown, for example, spent over a year in the King County Jail before getting a bed for restoration treatment at Western State.
“The most commonly known conditions that lead to trial incompetence are those that have psychotic symptoms, or major affective mood disorder symptoms,” explains Dr. Jennifer Piel, a forensic psychiatrist and the director of the Center for Mental Health, Policy, and the Law at UW Medicine.
At Western State, one of the workbooks patients use is called “Breaking Barriers.” It teaches defendants how the court system works, educates them about their illness, and teaches them how to monitor symptoms, and prevent relapse.
Other lessons and materials teach people how to communicate with their attorney and what to expect for their trial or criminal case.
Nationally, however, there is no gold standard for restoration treatment.
“It’s not robust,” said Piel. “There have definitely been calls for more research in this area.”
That’s because the field of forensic psychiatry is still relatively young. The Dusky standard for example only came about in the 1960s through a U.S. Supreme Court case that established the basis of competency.
According to DSHS officials, restoration is also imperfect, typically bringing people back to competency about 50% of the time in all cases. On average, most defendants have three evaluations in their personal history, and around two previous restoration orders — meaning they’ve repeatedly bounced between jails and state facilities.
For his part, Brown, who is at Western, said he found restoration rewarding so far, especially in comparison to the seclusion he experienced at the jail while waiting for a bed at the hospital.
“Being a lost patient is mentally exhausting,” he said. “Going from total seclusion and isolation, to a door that doesn’t lock is a big breakthrough psychologically.”
Brown was expected to complete restoration treatment in June before being transferred back to King County for his pending charges.
Challenges to competency
Officials at DSHS acknowledge that restoration treatment is limited. When people are involuntarily committed through a separate, civil court system, and haven’t been accused of a crime, the treatment is different: It takes longer and focuses on individual and group therapy classes. In some cases, social workers or staff can help connect someone in treatment to work, school, or housing services as well.
Restoration treatment doesn’t do that.
“It’s definitely a balancing act,” said Dr. Thomas Kinlen, the director of the DSHS Office of Forensic Mental Health Services. While restoration at the state facilities does offer some social skills education and anger management, “The law sort of dictates what we’re doing,” he said.
Experts also point out restoration doesn’t always work for patients with dementia, traumatic brain injuries, or intellectual and developmental disabilities like autism.
“Research suggests that about a third to even 50% can be what we call ‘restored’ to competency, even though maybe it’s more attainment,” said Piel.
But, “there’s going to be a segment of people with intellectual disability whose condition is just severe enough that they’re not going to be able to be restored,” she said.
Likewise, addiction treatment is not addressed directly, even though research shows that co-occurring disorders — someone who has both an addiction and a mental health condition — are higher among people who are arrested in the U.S.
Coupled with the transitions to and from jail, restoration is part of a fragmented and siloed system that spans the medical and legal world. For example, hospital staff may prescribe a medication that the local jail doesn’t include in its formulary. When the person returns to jail, they can’t get that medication.
In other cases, judges need to sign off on a forced medication order to compel someone into treatment. But that often takes weeks and by that time, a person has already gone through most of their time in restoration without the necessary medication.
“It became this vicious cycle of psychosis, stabilization, then psychosis,” said Greg Jones, a nurse who worked at the Maple Lane Competency Restoration Program near Centralia. The facility has 30 beds for people coming from jails who require restoration but are typically less sick than the people who go to Western or Eastern state hospitals.
“Every time it gets harder for them to bounce back,” said Jones, who left the job after six months and now works in peer services.
Jones, like many mental health staff and researchers, advocates for early intervention and outpatient restoration services where people are out of jail custody but still receive help while waiting for their case to play out.
A bill passed this legislative session offers some relief. It prohibits jail and juvenile detention facilities from discontinuing psychiatric medication and requires courts to first consider diversion programs for people with nonfelony charges before sending them to a state hospital for inpatient services. It also creates a pilot program to study how people with cognitive and developmental disabilities are affected and if they can be better served by other programs.
For Kim Mosolf, an attorney with Disability Rights Washington, an organization that advocates for the rights of people with mental illness, restoration as it stands is failing people more than helping.
“If you are judging restoration solely by whether we are able to prosecute people repeatedly … who have serious mental illness, it’s working great,” she said.
“If the goal is to try to intervene here and pull people out of the system, it’s an abject failure.”
