Senator Manka Dhingra: A Senator Maps The Gap Between Passing A Bill And Actually Helping People

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one story at a time. Hi, I'm Tony Mantur. Welcome
to Why Not Me? Embracing Autism and Mental Health Worldwide.
This is our special event crafting justice, empowering autism and
mental health through legislation. Joining us today is Senator Manca Dingra,
a true advocate for mental health reform. As a Washington
State Senator and passionate champion for mental health access and equity,
she has been at the forefront of groundbreaking policies that
prioritize well being for all, from tackling stigma and pushing
for systemic change. She's here to share her insights, experiences,
and vision for a healthier future. Thanks for joining us today.
Absolutely my pleasure.
I'm always happy to talk about anything to do with
mental health and accessing health care services in Washington.
Yeah, that's so good. We all have to put our
heads together to help as many as we can. What
led you on this journey to help those with mental illness?
You know, I have been a senior deputy prosecuting attorney
with King County for twenty years, and you know, when
you start off at the prosperous office, you kind of
do your rotation between District Court and Jubie Court, and
I did a lot of work on genda base violence
and hate crimes. And at that time, I actually became
a supervisor and there was this new thing that was
starting up in the United States of America called mental
health court. So the first one was created in Florida
and in King County we were the second ones to
start a mental health court. And the way it worked
in King County at that time is when you became
a supervisor, you kind of went and handled this calendar
once a week, and that was my first exposure to
really like a therapeutic court, and I remember going there
and kind of being like, what is this thing? And
the more I learned about it, the more horrified I
was to learn that the largest mental health hospitals in
this country and in the state of Washington are basically
at jails and prisons. And you know, there's something fundamentally
wrong with the society if our jails and prisons are
our number one mental health institutions. And so I really
started getting involved then on taking a look at individuals
with the diagnoses who are in the criminal justice system.
And so that is how I got started in this work,
And for the last twenty five years, I've done a
lot of work around forensic mental health, helping develop the
crisis intervention training for law enforcement, and then really trying
to work upstream in preventative and early intervention early detection issues.
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?
You know, I'll just say I have 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 bills.
The biggest problems come out in the implementation that makes sense.
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 road blocks, and the second roadblock I'll
tell you is people's definition of individual liberty.
Right. 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 nine one one, an ambulance comes, they stabilize
the person, and then they talk about after care and said,
when we see actively psychotic individuals.
What do we do? We continue walking?
And so until this parody and 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. Do you have an AOT law in
your state?
Yes, I worked on that a few years ago, and
I got to 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 a 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 the 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.
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 passed, you can start implementing it and it's going
to help people.
Thank you, You know, that is such a great question.
And I actually have a perfect example for you. Representative
or Walt now Senator or Walt and I worked on
a nine to eight bill for the state of Washington
when this number became available across the nation. We crafted
a bill that actually now is the standard for bills
across the country, and we really took that opportunity to
tell everyone who is 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.
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.
So we created a very interesting multi level committee. The
big large committee is called Chris Committee Crisis Response. You know,
I'll have to find the exact words for you, but
it is made up of caakeholders from the entire continuum
of hair, including family members and peers, impacted individuals. We
have rural representation, urban representation, Immigrant representation, LGBTQI 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 farmer subcommittee, and so you know, any
issue that we were working on, we created that subcommittee
that would then finnel its work to the Chris 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 Chris and be finally responsible for implementation.
We did that work for three years and that is
what made the biggest difference in implementation.
That sounds really good. Can you give an example of
how this helped implementation.
In real time?
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 out patient treatment.
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?
You know, I'll tell you 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. They used to be
a forensic component of it called fact the sort of
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 deed a substances disorder,
a professional, you're a mental health court professional. You want
to appear 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 twenty twenty. We passed our
budget and you know, I was like, this is my
dream budget for mental health services.
And COVID hit.
Yes, COVID hurt so many things around the world.
Was sure, all.
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 right. It's not
just the money. It's the money, the implementation, the workforce,
and making sure you have the right resources for the
right to population.
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 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 lucky to say,
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 is
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 where 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 big cosmopolitan areas,
you know, like King County where Seattle is what 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 pad Line, where any of the providers
in the state can actually call and get consultations, 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.
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 healthcare and of course hospitalization in
the country, and of course you're one hundred percent 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
with 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?
Yeah, So I mentioned me with a 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 away 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 there's a twenty three hour crisis centers and
individuals can be dropped off, so you know, it's taking
a look at the entire time when someone comes into
contact with law enforcement, and this is when nine eight
eight plugs in as well. We actually do co location
for nine eight and nine one one because so many
people call nine one one and there are times when
that nine one one call actually should be a nine
eighty eight call. So with the co location, they're able
to easily transfer calls amongst themselves, so that even that
initial response is not law enforcement, it is a behavior
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 re entry programs where we ensure that people upon
release are released with thirty 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 re entry side is actually done with Medicaid, and
so with the cuts of the federal government, we're actually
really greatly concerned about what that might look like for
our re entry programs that we have through our jails
and even through our prisons.
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.
That is absolutely too long. And I think this is
where I will tell you Unfortunately location matters, and so
in our 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 stuff. And
this is where we also do the telehealth so that
they can actually consult with the psychiatrists 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
more populated counties do have access to mental health services
and psychiatrists.
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. 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 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 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 instead of 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
is 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 that 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 you know, it comes back down to money,
but it also comes down into 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 dreaming 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.
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.
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 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. 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 in a 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 ninety eight. I mentioned the twenty three hour
crisis centers. You know, we got that idea from Arizona
and we had gone there toward 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 at work, and so if you
are in a position to go to judicial conferences or
therapy courts conferences or mental health conferences, and this is
where like the NAMIS, the National Alliance on Mental Illness
or SAMSA, 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.
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.
And 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 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
and tells us also what they think the solution should be.
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.
Absolutely, I always having to chat about these issues and
good luck to you and feel free to reach out anytime.
I will. It's been a pleasure to have you here.
Thanks again. Thanks for taking time out of your busy
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