A (3:30)

What are some of the roadblocks that you've hit along the way? Anytime that you get into legislation with a bill you want to pass, you have good intentions, you have good things in it, then you have other people that want to put their things in it, then you have to use that magic word compromise, in order to get some things done. So have you had to deal with any of those hurdles in order to get any legislation passed?

B (3:52)

You know, I'll just say I've been very fortunate that since I came into the legislature, my colleagues have really given me that respect and given me a lot of deference because I've recognized the expertise I bring to this role. So I will say I haven't had too much problems in the actual crafting of builds. The biggest problems come out in the

A (4:12)

implementation that makes sense.

B (4:14)

You know, you can write whatever you want in a bill, but if there is no appropriate funding, it just becomes a big novel, a good novel to read. And so I'll tell you, the biggest barrier is appropriate funding. We simply do not fund services at the level that is needed. And so making that shift and really telling people that you have to have money and you have to be able to compensate people for things like sitting on a park bench and giving someone a sandwich and a cup of coffee and engaging with them. And that is part of treatment. It is part of that engagement. And so that mindset on what the state's responsibility is to pay is one of the biggest roadblocks. And the second roadblock, I'll tell you, is people's definition of individual liberty. Right? And we see this over and over again where when it comes to mental health, there is this tension on how much you can do to take care of individuals. And so the analogy I always tell my colleagues is like, you know, what do we do if we see someone having a heart attack on the side of the road? We call 911, an ambulance comes, they stabilize the person, and then they talk about aftercare. I said, when we see actively psychotic individuals, what do we do? We continue walking. And so until this parody in how we treat brain disease versus physical health, I think we're always going to be running into barriers on what the appropriate treatment or access to treatment looks like makes total sense.

A (5:37)

Do you have an AOT law in your state?

B (5:40)

Yes, I worked on that a few years ago and I gotta tell you, it's not being implemented all across the state. We have a few counties that are doing it and simply not enough. So this is something I keep going back to our healthcare authority to say, why is it not being implemented? And the number one reason I get is that the amount that we're paying to run this program is not enough for the people to do the contract. Because when you have court involvement, there's a lot more work that doesn't get compensated. So we're continuing to work on it. But our AOT program, when the bill was written, it was written taking into account some of the best evidence based practices in the country. It came down to implementation and was simply not able to implement it effectively.

A (6:23)

It seems the big elephant in the room is the word implementation. So with that said, how do we get across that bridge? How do you create legislation then once you've put all the work into it, it gets passed. What's the next step that is needed so that once it's passed, you can start implementing it and it's going to help people.

B (6:46)

Thank you. You know, that is such a great question and I actually have a perfect example for you, Representative Orwell. Now, Senator Orwell and I worked on a 988bill for the state of Washington. When this number became available across the nation, we crafted a bill that actually now standard for bills across the country. And we really took that opportunity to tell everyone who's working in the entire spectrum of care to say, you know, what if your loved one was in trouble, what would you wish for them? And let's craft a bill based on what you would want your loved one to have access to. And so we created this bill which was extremely robust and then it came down to implementation because I fundamentally believe if you don't follow through with implementation, it can't work.

A (7:32)

Everything you just said makes total sense. So with that said, what was the next step to help push things along so that they could be implemented?

B (7:41)

So we created a very interesting multi level committee. The big large committee is called the CRIS Committee Crisis Response. You know, I'll have to find the exact words for you, but it is made up of stakeholders from the entire continuum of care, including family members and peers, impacted individuals. We have rural representation, urban represent, immigrant representation, LGBTQIA representation, and that group meets monthly. We then have Subcommittees that is made up of people of that group as well as others who have expertise. So we had a technology subcommittee, we had an LGBTQI subcommittee, we had a youth subcommittee, we had a farmers subcommittee. And so, you know, any issue that we were working on, we created that subcommittee that would then funnel its work to the CRIS committee. And then on top of that was an executive committee that was made up of a very small number of people, basically the legislators and some of the governor's office that would take all the recommendations that came out of the subcommittees and the CRIs and be finally responsible for implementation. We did that work for three years, and that is what made the biggest difference in implementation.

A (8:51)

That sounds really good. Can you give an example of how this helped implementation in real time?

B (8:56)

We were able to get feedback from the people and the family members who are using this resource to the agencies and the legislature and the governor's office on what was working well, what wasn't working well, and then making sure we had those recommendations that we were implementing and then that follow up. So I think that three year window was critical in making sure we had a very intensive group of individuals who were responsible for the implementation. And that's not easy to do. It takes resources. It takes people utilizing their time to do this work. But I have seen this model work really well when it comes to implementation, and I really wish we had done that for assisted outpatient treatment.

A (9:35)

Now you can have a boatload of money. You can then throw the money at it and still get nothing. Then you can have some instances where these organizations get just a little bit of money. They use it efficiently, and it goes a long ways to helping those that need it. So do you have an oversight committee that watches this? Because ultimately, when you create legislation, you have to have money to back it up. And of course, everyone is always worried about where are we going to get that money and then how are we going to budget this? So how do you handle that scenario?

B (10:11)

You know, I'll tell you, there are a lot of metrics that the state uses in terms of making sure the money is being used efficiently. One of the other big hurdles we deal with is actually workforce. So, you know, I am very fond of these intensive treatment teams like the PACT model. There used to be a forensic component of it called fact assertive community treatment models where they go in and provide services. In order to do that efficiently and effectively, you have to have a team that is consistent of everyone that is needed to provide that level of care, which means you need a Prescriber, right. You need a substance use disorder professional, you need a mental health code professional. You want a peer on there, you want a case manager on it. And so anytime you provide this kind of funding for these groups, they can only be efficient if they're able to hire the expertise on that team and keep that team stable. And one of the other things we have found, especially during COVID and afterward, is a lack of workforce. And so we have to get really creative on trying to create new credentialing, really create a pathway for more peers to get in this work. But that is what some of the problems we have in, you know, even if you provide. So I'll tell you, the best mental health budget we had was 2020. We passed our budget and, you know, I was like, this is my dream budget for mental health, mental health services. And Covid hit.

A (11:35)

Yes, Covid hurt so many things around the world, for sure.

B (11:40)

All of that great money that we had made available, our agencies were saying they can't utilize because they did not have the workforce to do that work. And people were so exhausted that they couldn't justify adding yet one more program, even though they knew that program would be helpful. So there's a lot of things that have to come together in order to make the system work. And you're right, it's not just the money. It's the money, the implementation, the workforce, and making sure you have the right resources, sources for the right population.

A (12:07)

Yes, that makes total sense. Now, I spoke with a state legislator here a few weeks ago, and I'm wondering if you have the same issues as they do. They have a difficult time getting psychologists, psychiatrists, doctors, etc. To stay on. So they're trying to implement funding so they can help these people get through college. And once they graduate, then they give so many years to the state for the funding that they put up to help them. Do you have the same issue as some of these other states do?

B (12:42)

You know, we don't have an issue in keeping people here. We are fortunate that Washington is a desirable state for people to come to, but you also have to make sure that you're attracting that original student population to come into the state. Because we know that once they graduate with a degree, they're more likely to stay in the area where they did their education. And so we had done a big investment in the University of Washington to create a teaching hospital. And this was supposed to be really the pioneer gold standard for what a teaching hospital would look like. And, you know, it's up and running. And that is what we're hoping will attract a lot of the talent. And once they're here, the hope is that they'll stay. And that's what we have found, that people do tend to stay once they get here. The issue really is where are they staying? They're staying in base, cosmopolitan areas, you know, like King county, where Seattle is, where the east side is. But we're not getting people to go to the rural parts of the state. And so, you know, we've done this public partnership where we are trying to see whether we can get some scholarship dollars or loan reimbursement programs if they go to rural areas. But that is a problem in attracting that kind of talent to go to areas where they don't want to live. So we've done a lot around telehealth as well in making sure that in areas where they might not have a psychiatrist or they don't have that expertise that we have a line. We actually have one for children with mental health issues called PAL line, where any of the providers in the state can actually call and get consultation, especially on psychiatric issues for children. And so, you know, telehealth is a huge component of it. We actually have jails in rural areas that will use it if they end up having someone in detention with mental health issues. So we have to get creative in terms of who doesn't have access to the services. But what we are finding is if you have good educational institutions, people are coming to get that education and then are staying on.

A (14:37)

I think that says a lot about your state and what you're doing as far as higher education. And then, of course, keeping people there to work and help those in need. Now, earlier on, you mentioned about prisons being the number one in health care and of course, hospitalization in the country. And of course, you're 100% correct. I recently spoke with a sheriff in Cape Cod. In her county, the sheriff takes care of the prison system. They don't patrol and only go out on forensic issues with crime scenes. It appears that it's a groundbreaking scenario where the sheriff and the deputies watch over the inmates by making sure that while they're there, they are helped, educated, treated. So when they are released, there's a very high percentage that never come back. From what I understand, it's much like the judge down in Florida that created a facility that was much the same. They treated them, gave them shelter, and by diverting them to this facility, again, they never showed back up in front of the judge. Does your state have anything like this at all.

B (15:47)

Yeah, so I mentioned we were the second mental health court to get started in King County. I then actually as a prosecutor created the first in the nation therapeutic alternative unit at the prosecutor's office. So we actually have programs all the way from initial contact with law enforcement where they can divert them to resources so they don't even have to get booked into jails. And we have crisis centers. Instead of taking them into a hospital or to a jail, you can actually go and drop them off. These are 23 hour crisis centers and individuals can be dropped off. So you know, taking a look at the entire time when someone comes into contact with law enforcement and this is when 988 plugs in as well. We actually do co location for 988 and 911 because so many people call 911 and there are times when that 911 call actually should be a 988 call. So with the cold location they're able to easily transfer calls amongst themselves so that even that initial response is not law enforcement, it is a behavioral health response. And then when it comes to our jails, we actually have a very robust program of identifying individuals in our jails who do have a mental health diagnosis, making sure that they are able to stay on their meds. And then we have reentry programs where we ensure that people upon release are released with 30 days worth of meds, that they are released to services and support. And there's follow up. A lot of the programming that we pay for on the reentry side is actually done with Medicaid. And so with the cuts of the federal government, we actually really greatly concerned about what that might look like for our reentry programs that we have through our jails and even through our prisons.

A (17:22)

What about the person that gets caught up in the legal system unfortunately winds up incarcerated, then if they have mental illness that has not been diagnosed, they can wind up in solitary, which is the worst thing that could happen. Does your state have something set in place to where they can get help right away if they need it? I've heard of some states where they have gone up to a year without getting any type of medical help. And that just seems like it's way too long.

B (17:54)

That is absolutely too long. And I think this is where I will tell you, unfortunately location matters. And so in a more populated counties we actually have a psychiatrist that's associated with the jails. So they do have a mental health team that will be assessing individuals. And in our rural areas, obviously they don't have the resources to have a mental health professional or a psychiatrist on staff. They may have nurses or peers and other staff. And this is where we also do the telehealth so that they can actually consult with the psychiatrist and get individuals the care that they need. But unfortunately, it is also very dependent on which county you get arrested in and what the resources are in each of those counties. But our more populated counties do have access to mental health services and psychiatrists.

A (18:41)

So telehealth is good. Unfortunately, it's not the optimum. How do we get to the point of where it doesn't matter what county that you're in? You're not the only one I've heard that from. I've heard other people in other states say that they were told, oh, it's too bad that you didn't live in this county. It would have happened this way, and you wouldn't have had this problem. So how do we get to that point to where it doesn't matter where you're from. If the person needs help, they just

B (19:10)

get the help, you know, and that is the vision that we have for the state of Washington. And, you know, I always talk about that. What we want to get you in the state of Washington is that no matter where you live, you get access to the same level of care all the way from the top of your head down to your toes. While that is the vision, as you mentioned, making that a reality is very challenging. And this is where, you know, everything that we talked about in terms of money, workforce implementation, all comes into play. We simply don't even have enough individuals who want to work in our jails with this current population because it's so much easier for them to actually be in private practice where we have individuals who actually don't even take insurance, but they pay cash for their services. And, you know, for a lot of individuals, it's just so much easier for them if they're dealing with youth that have depression and anxiety. And so really dealing with individuals that have active psychosis or schizophrenia. And so that is something that's really challenging to do, is to incentivize individuals to do this work. And what I've found over and over again, especially as a prosecutor who was working on these issues, you get these really great young graduates who want to do this work because they're so passionate about it, and they burn out after three to five years because they've realized that their peers are making money. They're able to afford to buy a house, to buy a car, and these individuals are working with some of the toughest clients in very tough situations and are simply not able to have the same quality of life. So attracting talent and retaining that talent in the forensic world is really hard because it's so much easier and better, frankly financially to do this work in the non forensic sector. So it comes back down to money, but it also comes down to work conditions and making sure they aren't burnt out because the stories that they hear and the people that they encounter, it is very emotionally draining as well. So there's a combination of self care that we have to do for the providers themselves in order to get them to continue to do this work.

A (21:17)

Yes, you have some very valid points there. It always amazes me how one part of the country might have something that's really, really successful. And then you look around the country to find out if there's any others and there aren't any to be found. One example is there's a judge in Las Vegas. This wasn't planned, but after everything evolved, it wound up being a court system that diverted teenagers that were autistic out of the system so that they could learn and grow and hopefully not ever return to the system. This became hugely successful. And from what I understand, there's not another one like it in the country. Another example on the mental illness side is a judge in Florida started diverting people to a facility he found by diverting them, getting them the help they needed, he wouldn't see them in front of him in his court again. I'm amazed that this type of process has not expanded across the US and other states and counties are doing the same.

B (22:24)

Yeah, you know, I'm surprised to hear that if there is an effective program, that there's only one in the country. You know, I started off talking about how mental health health courts started. And I remember I have done trainings all across the country on starting therapeutic courts. I actually was an advisor to many of the courts that started up in California and across this country. And so states normally try to learn from each other. And I think this is important that if you do have a successful program that you are showing up at conferences and talking about your work and collecting that data and showing that evidence to get it done. I mean, we went from having two mental health courts in the country to mental health courts being, you know, in so many states, in so many different areas. Same thing with, you know, community courts. I remember first time hearing about that concept and now they're all over the country. And so normally states learn from each other and they adopt each other's best practices. I mean, that's what we're seeing with 988. I mentioned the 23 hour crisis centers. You know, we got that idea from Arizona and we had gone there and toured their facilities and learned what works, what doesn't, and implemented that. So I think there's a responsibility for the people who are running these programs to make sure that they are talking about their successes, because everyone wants programs that work. And so if you are in a position to go to judicial conferences or therapeutic courts conferences or mental health conferences, and this is where, like the namis, the national alliance on Mental Illness, or samhsa, all of those organizations are really effective in making sure that message gets across. But we have to learn from each other. We don't have to reinvent the wheel every single time.

A (24:01)

Yes, exactly. What do you think is important for our listeners to hear that you are trying to do within your state and that you're trying to do for everyone that needs the help across the country?

B (24:12)

You know, I think one of the best ways we get legislation done is when the people who are doing the work, who are having the problems are the ones reaching out to the legislators and proposing those solutions. Because the people doing the work actually not know where the pitfalls are and they also have ideas on how to fix it. So, you know, our democracy is not a spectator sport. It takes each and every one of us to work on making sure that we're improving the lives of each and every one of us. And so if people have good ideas, if they know of a problem and they know of a solution, I would highly recommend they reach out to the electeds, they reach out to organizations and talk about it. And I'll tell you, some of the best legislation we have comes from community who tells us what the problem is and tells us also what they think the solution should be.

A (25:02)

Yes, that's great information. Like they say, an email, a letter, a phone call will not be returned unless you take the time to make it. Well, this has been great, great information, great conversation. I really appreciate you taking the time to join us today.

B (25:19)

Absolutely. I am always happy to chat about these issues and good luck to you and feel free to reach out anytime.

A (25:25)

I will. It's been a pleasure to have you here. Thanks again. Thanks for taking time out of your busy schedule to listen to our show today. We hope you enjoyed it as much as we enjoyed bringing it to you. If you know someone who has a story to share, tell them to contact us at. Whynotme world. One last thing. Spread the word about why not me? Our conversations are inspiring guests that show you are not alone in this world.