Where did King County’s mental health beds go?

The Mental Health Project is a Seattle Times initiative focused on covering mental and behavioral…

Where did King County’s mental health beds go?
Where did King County’s mental health beds go?

The Mental Health Project is a Seattle Times initiative focused on covering mental and behavioral health issues. It is funded by Ballmer Group, a national organization focused on economic mobility for children and families. The Seattle Times maintains editorial control over work produced by this team.

Thirty-odd years ago, Time magazine hailed a new mental health facility in downtown Seattle as a place of hope.

El Rey, with its airy interior design and individualized approach to mental health care, had opened a couple of years prior. Compared to the old institutional model, it had a modern, humane appeal. Those who could live with relative independence did so. People who needed round-the-clock care received that kind of attention. “Unless a client is unmanageable, he will never be thrown back onto the street,” the article reads. Said a facility manager quoted in the article: “El Rey is a place where some people can live indefinitely if they choose to.”

There were many new or restored mental health homes in Seattle back then. 

Now, nearly all of them are gone.

On a chilly morning in early February, a Downtown Ambassador swept litter from padlocked doorways of the now-closed El Rey building on Second Avenue. “No Trespassing,” a sign on the door warned. About a mile away, Capitol Hill’s Summit Inn mental health home has been replaced by trendy studio apartments. A facility torn down near Gas Works Park is now the site of expensive town homes.

As King County’s population swelled by nearly 50% since El Rey first opened, the number of beds where people with mental illnesses can live or recover has halved. There’s no definitive source that tracks mental health beds here. But estimates compiled by The Seattle Times suggest beds were available for about 548 people countywide in the 1990s. Roughly 261 exist today. 

The decline in beds has become an urgent focal point for local policy leaders. The number of people in mental health crisis is overwhelming jails and emergency departments, and in April, a ballot measure to build mental health crisis centers will go to voters. 

But those who’ve spent decades watching the mental health crisis unfold say the arc of decline is best understood if you zoom out. Look, they say, at how people with mental illness have long been treated by society.

“Unfortunately, behavioral health has never been a priority,” at least from a funding perspective, said Kelli Nomura, former director of King County’s behavioral health division, and the new CEO of International Community Health Services.

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When Northern State Hospital closed in the mid-1970s, and the state’s other psychiatric hospitals began emptying wards in the decades that followed, community organizations and county government attempted to fill the gaps. 

Agencies repurposed old buildings — El Rey was a former hotel — or constructed new ones. Instead of shuttling people away to big psychiatric hospitals, facilities that housed anywhere from 16 to 64 people sprung up in neighborhoods and business districts. Some places were intended to serve people for months or years. Others offered a more temporary place to stabilize, or transition from intensive care to independent living.

But when the state shifted responsibility for residential mental health care from large institutions to communities, dollars of support didn’t follow, policy experts and mental health agency leaders agree. Decades of paltry reimbursement rates from the state — and low to nonexistent funds for capital maintenance or improvements — eventually made community mental health facilities a losing proposition for the nonprofit organizations trying to run them. 

First came cost-savings measures, including mergers. Then came closures. 

Sound Health, for instance, used to operate El Rey, and until recently operated many of the county’s residential mental health facilities; Sound, which is the largest provider of Medicaid-funded behavioral health services in King County, declined several requests for interviews. Over the past few years, it has divested from all but two of its long-term mental health facilities, according to King County officials. Sound Health’s revenue dropped from $99.5 million to $79.4 million from 2019 to 2020, the nonprofit’s most recently available tax documents show. Meanwhile, compensation for its executive leadership jumped from $1.4 million to $2.4 million over the same period. 

In 2014, when Tim Sipes began working as a case manager at El Rey, signs of decline had already begun. The building itself was in dire need of repair. Sipes wasn’t paid a lot — $22 or $23 an hour — but he was drawn to working with people with mental illnesses because it was rewarding in other ways. “It’s not like I could change everything,” he said. “But if they found somebody who was compassionate and willing to listen and recognize them as a human being, that kind of made a difference. … Whereas in the greater outside world, they were often dismissed.”

As the years went on, though, services began to falter. Staff schedules became consumed by administrative and safety tasks instead of therapeutic activities.

Morale tanked.

And pressures to streamline care got to him. 

That optimism — that hope — from El Rey’s early days, had faded. And in 2019, Sipes left. 

The next year, El Rey was shuttered for good.

Rearview mirror

At the lunch hour on a recent Thursday, small groups of adults ate pizza, paged through newspapers and chatted quietly in a common area at Community House Mental Health Agency. A whiteboard advertised karaoke and a newsletter club. Volunteers wiped down tables and called out, “Last call for seconds and take homes!”

“We’re what there used to be a lot of in this town,” said Chris Szala, who has been executive director of the nonprofit since 1991. “That’s disappeared.”

On the first floor of Community House’s headquarters on Jackson Street, residents and guests can wash laundry, take a shower, stock up on food or visit with a psychiatric nurse practitioner who prescribes medication. Upstairs, people with persistent mental illness live in 54 single-occupancy units. Most come to Community House by referral from a hospital or a jail.

Community House is King County’s largest licensed, 24-hour provider of residential mental health beds. It operates several 24-hour assisted living facilities, transitional homes and supportive housing units. Still, many of its facilities have closed. 

In a 2-inch-thick black binder, Szala keeps old leases from mental health boarding homes Community House used to run. The old Tudor home on 17th Avenue on Capitol Hill, once called The Inn. A large property near the old Glo’s diner. Those facilities closed in 2008, along with two others that year. By Szala’s estimates, that first wave of closures resulted in a total of 175 mental health beds lost.

Old newspaper stories offer a slew of reasons. To start: Leases were up at several of the agency’s facilities. But the state’s Department of Social and Health Services had also leveled serious sanctions against at least six of Community House’s properties. Inspectors found poor conditions, including dirty carpets and furniture, and people living in a basement bedroom with a dirt and worm-infested floor. At one Community House-operated home, a resident died by suicide.

“I have no doubt that the state had every right to sanction things at times,” Szala said. “There just wasn’t the money to take care of it.” 

Everyone interviewed for this story repeated Szala’s concern. Most mental health facilities were paid a daily rate to care for residents. But they had few options to pay for upkeep. 

When Szala took over at Community House more than 30 years ago, land was relatively inexpensive, and building or leasing large properties for mental health care was feasible. By the late 1990s, though, many mental health facilities were suddenly put under the same umbrella as assisted living facilities, a designation that came with much stricter regulations and training requirements. These extra regulatory burdens didn’t come with extra reimbursement, Szala said. And by the time the state sanctions came down, Seattle was an incredibly expensive city to do business in.

The county was ultimately faced with subsidizing buildings in need of repair — or letting them close.

“The boat was missed” to buy and make permanent the kind of residential mental health facilities that are now sorely needed, Szala said.

Mental health resources from The Seattle Times

At the time, though, closing congregate care, or boarding homes, fit with a shift away from the old, paternalistic mindset that people experiencing mental illness can’t get better, said Amnon Shoenfeld, who was director of King County’s behavioral health division during the 2008 closures. 

“It led to us looking at those facilities and saying, ‘We really need to get people to move into the community,’ ” he said. 

The county’s plan was to move people from congregate care into a different style of housing: permanent supportive housing, where they could live independently, with access to mental health and substance use support as they needed it. While boarding homes were often set up more like dorms, with roommates, provided meals and communal bathrooms and kitchens, permanent supportive housing offers more privacy and a more typical apartmentlike space, and doesn’t include round-the-clock care. It’s also not exclusively for people with a mental health diagnosis, and is geared toward low-income people who sign leases.

But looking in the rearview mirror 15 years on, Shoenfeld said, the county didn’t account for skyrocketing housing costs, or how many people would need support. “We don’t have enough permanent supportive housing,” he said.

Was it the right decision? To let so many mental health beds disappear? 

“That’s a hard one,” he said. “In hindsight, we probably should have done more to raise the alarm about the lack of affordable housing.”

“Then what?

The county is now experimenting with the opposite approach, taking on ownership of these facilities: When a 60-plus bed facility called Cascade Hall near Northgate was at risk of closing last year, King County and state officials pooled $10 million to save it.

Sound Health had acquired the facility, which provides both mental health and substance use services, when in 2019 it merged with another longstanding behavioral health agency, Community Psychiatric Clinic, where Nomura worked for 26 years.  

Sound has not responded to repeated requests for details about why it moved to sell Cascade Hall, though executive officers have cited staffing shortages as one reason for the sale. Nomura, who still worked at King County at the time, said her office encouraged providers to work with the county to problem-solve when they were facing closure — but that providers ultimately get to make their own business decisions. 

“I had conversations with Sound. And I understood some of where they were coming from,” she said. But around the time of the sale, 70 people were on Cascade Hall’s waitlist. Nomura said she had lingering questions about people who were already living there. “For me it was: ‘Then what? What are we going to do? Where are they going to go?’ ”

She and her colleagues floated the idea that the county could buy the place; Community House is now contracted to provide services there. But she’s matter-of-fact about the cost of these kinds of deals. “The county cannot do that for every facility that is starting to close,” she said. “It cannot.”

Legislative agendas published by King County suggest county officials have lobbied state lawmakers — with varying levels of success — for capital investments and policy changes since at least 2018. In 2021, for instance, the county asked lawmakers to prevent the closure of any additional Western State Hospital wards until more community mental health beds were built. In 2022, the state allocated $16 million to the county for mental health capital improvements. 

It’s still not enough, county officials say. 

But while the county acknowledges a need for more long-term beds, big policymaking efforts are largely focusing on a different kind of behavioral health care: helping people for shorter periods while they’re in the midst of crisis.

In late January, the Metropolitan King County Council unanimously signed off on a behavioral health proposal that would raise an estimated $1.25 billion in taxes over nine years. An early estimate from the county suggests about 12% of the proposed funding — $146 million — would be used to support existing longer-term residential facilities or help build new ones. 

“Hopefully, this nine-year levy can provide a stable stream of income and revenue for these buildings and for the workforce,” said King County Councilmember Girmay Zahilay. “Right now, they just don’t have that.”

But a vast majority of the dollars are pinned to crisis care. An estimated $886 million would help build five crisis care centers that include behavioral health urgent care, short-term observation units and 14-day stabilization beds — but no long-term residential care akin to the facilities that have closed over the years. The proposal heads to voters in April.

For now, it’s raising uncomfortable questions for those who’ve helped run the mental health system for years, including those who operate crisis facilities.

“I have this conversation with colleagues somewhat regularly where we worry, wring our hands, lament that there’s a risk here,” said Daniel Malone, executive director of the nonprofit Downtown Emergency Service Center, who says he supports the levy. His worry: “We’re going to divert or build up too much emphasis on crisis response, and we aren’t going to take care of the rest of the needs that, if done well and adequately, will prevent crisis in the first place.”