The usual explanation for chronic overcrowding at Virginia’s state mental hospitals has missed a distinctive Hampton Roads challenge that’s been keeping Eastern State Hospital’s beds filled to capacity.
For the past three years, legislators have debated what to do about the increasing numbers hospitalized at state facilities under temporary detention orders while private hospital TDO admissions decline. But over that time, Eastern State has seen a surge in admissions from the court system and jails.
The hospital has long handled a disproportionately large share of such admissions — over the past few years, it took in between 43 and 47% of all such Virginia patients, even though its service area accounts for only 22% of the state’s population.
But a quiet tweak to state criminal procedure law, approved unanimously by the General Assembly in 2017, has sent the number of court-ordered cases soaring, a Daily Press review of admissions data shows.
Cases of defendants sent to Eastern State, in the hope they can be treated so they are competent to stand trial, have ballooned since that change.
The number jumped from 194 in fiscal year 2017 to 324 last year. The 2017 law set a 10-day deadline for placing individuals found incompetent to stand trial into a state hospital for treatment. Over the same period, the number of jail inmates sent to Eastern State under TDOs climbed from 96 to 158 — while last year’s number marks a drop from the 2019 total of 194.
Treatment for these patients is the same as for people who come involuntarily under a civil TDO or involuntary commitment. But since those civil cases generally come after a mental health crisis lands a person in a hospital emergency room, the attitude of many civil patients coming to Eastern State is quite different.
“If you end up in a hospital and transfer here, you’re likely to see that you’re here to be helped. But if you’re coming from jail and we’re trying to get you back, what you’re feeling is more that this is a struggle for you,” said Nicholas Morgan, ESH’s nurse educator.
“Imagine what it’s like, coming in here in handcuffs. Imagine what other patients think when they see you leaving in handcuffs.”
Competency restoration patients stay an average of 52 days, and the jail TDOs, 15 days before they are sent back. When their numbers are added to the 98 longer-stay individuals hospitalized after a court found them not guilty by reason of insanity, a large majority of patients at Eastern State are there because they’ve run into some kind of trouble with the law.
“The entire facility is affected,” said Brandie French, Eastern State’s chief executive officer.
“I don’t like to say harden, but we’ve had to harden facilities,” she said. The physical damage caused by patients who are often more aggressive takes a toll on the building.”
Juggling staff and sometimes moving patients, to try to keep contact between the most upset competency restoration or TDO patients and the generally much calmer longer-term patients is a challenge in a hospital that often operates at 100% of its capacity.
It’s basically up to the staff to keep the place secure, and to ensure that everyone stays safe. That, too, is a challenge for Eastern State, which like the other Virginia state hospitals, struggles to find and keep enough staff.
When, for instance, there are no beds free in the hospital’s 40-bed geriatric unit — there are currently 58 geriatric patients — and no space in the building set aside for them and for other longer-term patients, hospital administrators make a point to arrange one-to-one staff-to-patient coverage.
“At some point, our state hospitals are just going to break,” French said.
To help, Eastern State has started a pilot program for front-line staff — the orderlies and nurses in the pods — who are willing to take additional training to help them better understand patients’ challenges, treatment plan and the triggers that can lead them to act out.
The aim is make it easier for staff to help patients. Staff members who participate get a new title, acknowledging their ability to deal with emergencies, and more pay.
It’s a program that already is paying off in terms of helping patients and managing the stresses of an overcrowded facility, said Angela Harvell. the Department of Behavioral Health and Developmental Services’ deputy commissioner for facility service. She’s hoping to introduce it at the other state hospitals.
Increased demand for competency restoration, meanwhile, has led Eastern State to set up a team to focus on those patients.
“Their symptomology is the same; clinically, there isn’t a difference” from patients coming to the hospital through a TDO or civil commitment, said Kristen Hudacek, the hospital’s psychology director and forensic coordinator.
Medication regimens are the same, based on the patients’ diagnoses. The main difference is that instead of some group sessions, competency restoration patients will have weekly one-on-one sessions, and sometimes more often, with members of Eastern State’s specialist restoration team.
These focus on enhancing reasoning and the ability to understand reality — competency, under Virginia law, is not a finding of mental illness, but simply a finding that a defendant cannot participate in his or her own defense. That means Eastern State has to treat the mental illness to make sure it is not blinding a defendant to the challenges to be faced at trial.
“The only difference is, for one group, we’re working to help them to discharge them into the community, for the others, we’re helping them, to discharge them back to court for their cases to be heard,” Hudacek said.
Roughly 80 percent of patients admitted for restoration head back to court for their trials. Those who can’t be generally have other conditions, such as dementia, or an intellectual or developmental disability.
The rise in competency cases is a national trend, Hudacek said. But Eastern State may be feeling it particularly intensely because courts here have long been more inclined than others to issue restoration orders.
Part of what’s going on in recent years, said Hampton Commonwealth’s Attorney Anton Bell, is that more people with mental illness are showing up in court, a trend he fears means that earlier interventions that might have kept them out of crisis and out of trouble aren’t available.
Part is that many Hampton Roads communities, like Hampton and Newport News, have taken a lead in setting up special mental health dockets, he said.
These, like the longer-established drug courts, seek to steer offenders to get help rather than to continue on a revolving door in and out of jail. They require defendants show up and report to a judge and other defendants on their progress; this, along with regular reports from probation or mental health workers, creates a kind of mix of 12-step program and trial.
The program, along with universal “crisis intervention training” to help Hampton and Newport News police, sheriff’s deputies and first responders recognize and manage a mental health crisis has heightened awareness of mental illness across the criminal justice system, Bell said.
Bell says police officers in Hampton are making an effort to steer people to help rather than directly to jail for such common misdemeanor offenses as trespassing and disorderly conduct.
But this isn’t always an easy call, he said.
“Sometimes, with these situations, you don’t know where it will go, and I’ve seen it go south real fast,” he said.
Still, with nearly 4 out of 10 competency restoration cases coming to Eastern State involving people with misdemeanor charges, Hudacek thinks the mental health dockets in area district courts could be a tool to ease pressure on hospital beds.
Virginia law allows for competency restoration to be done outside of a hospital, with the mental health services provided by local community services boards — a model other states are looking at — and Hudacek hopes reminding courts of this option might increase use when cases involve nonviolent misdemeanor offenses.
Newport News Sheriff Gabe Morgan, whose longstanding concern over mental health challenges in the criminal justice system led him to serve on the Virginia Interagency Civil Admissions Advisory Council and the Virginia Supreme Court’s Commission on Mental Health Law Reform, says Virginia needs to do more to help.
“When you drive around Eastern State and see those abandoned buildings and overgrown lawns, that’s an issue … we have a capacity problem,” he said.
Dave Ress, 757-247-4535, dress@dailypress.com
