For about three months, Karen Kelly would drive around Enumclaw, Wash., after midnight looking for her 13-year-old daughter, Hollie. She carried Hollie’s photo with her, pulling over to show it to everyone she saw. Sometimes she got lucky. She learned that Hollie had talked a hotel manager into giving her a free room, or that she was camping out near the P.O. boxes in a post office, or that she’d settled into a tent in the bushes behind an industrial park. Hollie remained in Enumclaw, a town of less than 12,000 40 miles southeast of Seattle.
Hollie has several mental health diagnoses, including PTSD and Reactive Attachment Disorder. Karen and her husband, Sean, adopted her in December 2012, when she was almost 12, but had parented her on and off from the time she was a toddler at the request of her biological mother, an acquaintance.
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The transition after the adoption was rough. Before coming to the Kellys a few months before the adoption, she hadn’t lived with them for three years. As a teenager, she found their rules too strict and refused to live by them. She acted out at school and began cutting herself and running away. A man she knew on the street introduced her to meth. It made her feel in control, on top of the world, like she could do 10 things at once, she’d later say.
At first when Hollie began disappearing, Karen would file a runaway report. When police brought Hollie home or the Kellys picked her up, Karen said, “She might come in and stay a while or she might get onto our property and then be like, ‘Good-bye.’”
State law’s high bar
Karen stopped filing the reports, investing instead in cultivating eyes on the ground. She’d take drug dealers and homeless people who recognized Hollie’s photo to McDonald’s and appeal to their humanity. “Unless you’re just not a good person,” she said, “you don’t want to see a little kid on the streets using meth.” Soon she was getting texts, “Hey, Hollie’s passed out at the library right now” or “Hollie was just picked up at Safeway stealing.”
But as Karen would soon learn, knowing her daughter’s whereabouts was one thing; being able to help her was something else entirely.
State law rendered Karen powerless to initiate substance abuse or mental health treatment for Hollie against her will unless it was deemed medically necessary. The bar for involuntary treatment was high: Children had to be an immediate danger to themselves or others.
When the Kellys tried to get Hollie to agree to treatment, she refused. “Everything with me at that time was about power,” said Hollie, now 19. “If I had control, I would take it and do the opposite of what everybody wanted me to do. I was rebelling, and I didn’t see what I needed for myself.”
In an act of optimism, the Kellys applied for Hollie to be admitted into the Children’s Long Term In-Patient Program (CLIP), the most intensive inpatient treatment option for youth in Washington.
In the meantime, Karen asked her connections on the street to impress upon Hollie the importance of accepting help. “Who knows how many were talking to her or what was being said,” Karen says now. “But I do know they were talking to her.”
The desire to empower youth
When the call came that a bed was open, Karen hadn’t seen Hollie in a week and didn’t know where to find her. She texted the homeless people and drug dealers she’d enlisted and then drove around looking for them. She found a dealer she called Jim in an alley. “Jim got in the car and told me where to drive,” she said. They wound up at a grassy area behind an industrial park and then walked through tall grass. When Jim called out, “Little Bird,” Hollie emerged from some bushes. “They have your bed,” he told her.
Hollie wasn’t ready for help. She ran back through the bushes and disappeared. But the absurdity of the situation wasn’t lost on Karen: “The law couldn’t help me,” she said. “The drug dealers were helping me.”
The law that prevented Karen from being able to help her daughter as she saw fit was intended to make it easier for minors to get treatment. It gave young people 13 and older the right to initiate mental health and substance use treatment without parental authorization.
Phil Talmadge, the former state senator and supreme court justice who sponsored the 1985 legislation, says schools were starting to operate mental health clinics but grappling with legal questions about whether those who staffed them could treat students without parental authorization. The stigma associated with mental health issues was even greater than it is today, he said, and the legislature saw the need for minors to be able to ask for help without fearing that their parents would find out about it.
It was motivated, in part, by the desire to empower youth who were coming out as gay and lesbian. “A provider who was in practice at that time told me that these kids were wanting support around those and other issues, but their parents wouldn’t consent to mental health options,” said.
An unintended consequence of the law quickly became clear: If minors had the right to consent to treatment, they also had the right to withhold it — and that impaired parents’ ability to intervene on behalf of children who needed treatment but didn’t realize it or want it. The law did allow parents to initiate outpatient psychiatric evaluations and, when medically necessary, inpatient treatment. Parents of at-risk youth without medical diagnoses often felt as though they had to wait for their children to deteriorate before they could help them.
Parents weren’t the only ones who didn’t like the law. Consent and access to information went hand in hand, and providers soon realized that they were unable to release important information to the people with whom their patients lived and who were responsible for their care. Providers also thought the law blocked progress. Involuntary treatment ended once a patient was stabilized. At home, their patients could refuse the recommended follow-up treatment.
Many frustrated parents in Washington have had to look for help out of state, even going so far as to hire transport companies that essentially kidnap youth in the middle of the night and whisk them off to locked treatment centers they can’t sign themselves out of. At one point, the Kellys drove Hollie to a secure residential treatment program in Oregon. “That was really good,” Hollie said, “because I couldn’t say no.”
Families have also turned to the courts out of desperation. By filing an At-Risk Youth Petition (ARY), parents can request court-ordered support and assistance for children who are beyond their control. If youth disobey a judge’s order — whether it’s to attend school, go to counseling or follow their parents’ rules — the judge can hold them in contempt of court. In 2017, judges detained 691 minors for violations related to ARY petitions. Detention triggers services.
The Kellys filed an ARY petition when Hollie was 14, but detention for noncriminal behavior varies widely among counties and Hollie was able to ignore the judge’s orders without consequence.
The adversarial process and the risk of detention make the ARY process unappealing for many families. Peggy Dolane, an advocate for children’s mental health services, steered clear of the process when it came to finding help for her own children. “I have African-American kids, and I didn’t want to use jail to enforce what they needed,” she said. (A new law phasing out detention for noncriminal behavior over the next four years will eliminate detention related to the ARY process by July 2022.)
A cultural shift
Instead, Dolane took up a fight against the age of consent law. She says mental health lobbyists, legislators and children’s rights advocates told her the problem with the law was unsolvable. There had been 11 attempts to raise the age of consent between 1989 and 2009. All had failed.
Dolane pressed on, building a movement of parents who insisted on having their voices heard. After she reached out to her state representative, Noel Frame, asking for legislative action, she wound up on the state’s Children’s Mental Health Work Group, taking up the question how to save kids whether or not they agree to treatment.
Kathy Brewer, a therapist and manager in Seattle Children’s Hospital’s department of psychiatry, who worked closely with Dolane in the work group, said they focused on increasing the opportunity for parents to consent instead of making another attempt to change the age of consent.
As a result of their efforts, the legislature passed HB 1874 in April. Since the end of July, families have been able to initiate outpatient treatment for adolescents. The law limits the treatment to 12 sessions or three months.
“Clinicians said if we can’t engage a youth to consent by then, either they don’t need the therapy or we’re not the right therapist,” Brewer said. If the latter turns out to be the case, the parent can initiate treatment again with another provider. The hope, she said, is that youth will benefit from the treatment and consent to further treatment if needed.
HB 1874 represents a cultural shift for therapists by centering families in their efforts to help young people. It also clarifies a 2013 change to the law that resulted in confusion about what exactly could be disclosed to parents. HB 1874 provides guidelines, encouraging providers to use discretion but to inform parents about things a caregiver ought to know, such as diagnoses, medications and treatment plans.
Brewer says the message HB 1874 sends to youth is: “If you need help and you’re not willing to get it, parents can now get it for you. We don’t want you to die.”
The law is an important step toward improving access to care, according to Dolane, but it’s only “a first step” and a compromise. Providers still can deny treatment if the young person is uncooperative or not compliant.
And help is possible only if treatment options exist.
Not enough services, programs
The state is “working on public and private partnerships to develop a robust and sustainable system of adolescent behavioral health care,” Dolane said in a webinar she gave with Brewer in August to explain the new law.
“We have a long way to go,” she said.
It’s too early to tell if an increase in treatment beds will be added during Washington’s current legislative session, which ends March 12.
A new bill, HB 2883, has been filed to update HB 1874 so families can admit their adolescent children specifically to residential treatment centers without the child’s consent and if it’s deemed medically necessary, an option Frame said was inadvertently left out of the original legislation.
Few early interventions and services exist to help families in crisis in the absence of abuse and neglect, according to an April 2019 joint report to the legislature by the Department of Children, Youth, and Families (DCYF) and the Office of Homeless Youth (OHY). State-funded crisis residential centers offer young people refuge along with evaluations and referrals for services, but they’re in only nine of Washington’s 39 counties and have a total of 106 beds. CLIP has only 84 beds across the state through five programs and requires a psychiatric diagnosis, among other eligibility criteria.
There are no secure long-term residential centers for youth with intense behavioral health care needs. Brewer suspects the lack of a robust infrastructure of treatment options may be tied to the old age of consent law. Why build it, if they won’t come?
The day after Hollie ran from Jim and Karen, police found her at a library and brought her home, where the Kellys were waiting to drive her to the CLIP program in Lakewood, Wash., about 30 miles westward. At that point, Hollie gave in. “I felt out of options,” she said.
She now thinks of her 15 months there as “the happiest and healthiest” she’s ever been. But while she thrived in the restrictive setting, she struggled again after discharge. When she has the freedom to make her own decisions, she said, “I just make the wrong decision all the time.”
After returning home, Hollie received six months of probation for being drunk at school and was detained 14 times for violating its terms, she said. She was also arrested on trespassing and felony drug charges, she said, and spent nine months detained at Echo Glen in Snoqualmie, Wash., about 30 miles northeast of Enemclaw. Back in a restrictive setting, she again did well, earning her GED, undergoing intensive counseling and even gaining work experience.
In the midst of Hollie’s struggles, Karen left her job with a food bank emergency services organization and now works as the project director for Washington State Community Connectors, an organization that focuses on children’s behavioral health. She believes that if Hollie had been compelled to receive trauma-informed treatment early on and in the community, she might have gained the tools necessary to help her self-regulate in a real-world setting. “I don’t think she would have chosen to be homeless,” Karen said.
It’s also possible, she said, that given Hollie’s intense therapeutic needs, she still might have required inpatient treatment. But at least she wouldn’t have started it from scratch. If she’d come to inpatient treatment with a foundation for the work she needed to do, “I believe her stay would have been shorter, and her discharge would have looked different.”
Hollie then, Hollie now
Hollie agreed that the new law is a good one. “Back in my 13-year-old head, I was like, ‘I want to be able to have my own say.’ But giving a kid that say? Whether they get to choose treatment or not? Obviously, if that’s the only power they have, they’re going to choose not to go if that’s what everyone wants them to do.”
Six years ago, Hollie didn’t realize she was harming herself. “I was 13. I weighed 98 pounds. I had sores all over my face. I thought I was fine smoking meth. I thought I was totally OK. I was in danger, but I didn’t see it because I was so young. Now I see that I was so close to death — so many times.”
In 2018, after an abusive boyfriend beat Hollie so badly she wound up in the hospital, she decided she’d had enough of life on the streets. She’s still struggling to get well, she says, but she’s made progress. In the fall of 2019, she was working in Jack in the Box and rented a room with a new boyfriend in a house in Renton, Wash.
She has since relapsed again. She and her boyfriend were most recently sleeping at a young adult shelter in Seattle, preparing to go into detox and then rehab but Kelly hasn’t heard from Hollie in recent days. She suspects she’s on another binge.
If HB 1874 had been in effect when she was 13, Hollie said, “maybe things would have turned out differently.” But she also pointed out that the law required her to be in school and she defied it. “How can they make you go to treatment if you don’t want to go?” she asked.
But when Hollie didn’t have the right to refuse treatment in Oregon, she just went with it. Karen said if providers aren’t handing youth consent forms and informing them that they can walk away, and if all the adults around them — providers, parents, school officials, police — send the message that they must get help, it could make a big difference in a youth’s attitude and compliance. “This new law is going to be a lifesaver,” she said.