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. Additional support is provided by City University of Seattle. The Seattle Times maintains editorial control over work produced by this team.
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Kevin Page’s flashbacks come at night: Being strapped to a hospital bed, with a nurse’s hands wrapped around his chin to keep his head from flailing. Feeling like he was suffocating and not knowing where he was, or why.
“There were so many hands on me, I just wanted them to let me go,” he said of the night in 2020 when he landed in a Seattle-area emergency room for a mental health evaluation. Nurses called for security after he grew upset, swore and threatened staff, and tried to leave, according to hospital records. “I felt like I was going to die,” he said.
Engulfed in panic and immobilized, Page spat — landing saliva in the eyes and on the mask of one nurse, and on the sleeve of another.
Just hours earlier, police had sent Page to the ER believing he was having a psychiatric crisis and was a danger to himself or others. After he spat, officers from the same department returned to pull him out of treatment and take him to jail instead. King County prosecutors then charged Page with felony assault.
Under Washington state law, any assault on a health care worker can be a felony — including spitting, slapping or other actions that might otherwise be treated as minor offenses with fewer consequences for the accused. The decades-old statute was meant to protect providers, who are increasingly harmed in violent attacks.
But an investigation by The Seattle Times and The Marshall Project found the majority of the people charged by King County prosecutors under that law showed signs of serious mental illness, with dozens of patients in severe crisis punished for behavior that landed them in the hospital in the first place.
From 2018 through 2022, county prosecutors filed 151 cases for felony assault on a health care worker. Court records show that 76% of these cases were filed against people with signs of serious mental illness. That included people who were involuntarily committed to a psychiatric facility, were in an emergency room for a mental health evaluation or had EMTs respond to their mental health crisis.
But increased penalties for people in crisis do little to deter violence, experts say. And reporters’ findings reveal an unintended consequence: More people with serious mental illness are funneled into the legal system, even as cities across the country search for ways to keep them out.
Some were arrested out of a health care facility, only to wait weeks or months in jail to get into a state psychiatric hospital, growing even sicker behind bars. A man who said he was off his medication for schizophrenia when he grabbed a nurse’s groin and spat on him in 2020 spent nearly eight months in county jail, according to court records, much of it waiting for a hospital bed.
These prosecutions often stall because the person is too ill to understand the charges against them. While the county decides whether to charge these patients, it’s up to the state Department of Social and Health Services to stabilize and prepare them to stand trial. The state has struggled with long delays and a backlog of cases for years, though wait times are now decreasing.
Whether someone was mentally fit to stand trial was questioned in nearly 40% of cases filed under this assault law between 2018 and 2022, according to the news organizations’ analysis. Even if charges are ultimately dismissed, prosecutions can cost thousands in taxpayer dollars.
Since the start of the pandemic, more states have adopted similar laws as health care workers face increasing abuse. Congress is debating whether to make these assaults a federal crime.
Multiple cases analyzed by the news organizations detail serious violence and speak to the abuse and danger that health care workers face on the job. Emergency care providers bear the brunt of an overwhelmed mental health care system, when people spiraling have nowhere to go but their nearest hospital.
About this project
This article was published in partnership with The Marshall Project, a nonprofit news organization covering the U.S. criminal justice system.
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A 2022 survey published by the American College of Emergency Physicians found that over half of ER doctors queried said they had been physically assaulted. A recent poll by the Emergency Nurses Association found over half of nurses had been physically or verbally assaulted within a 30-day period.
One of the nurses Page spat on, Aviona Williams, said she’s lost track of how many times she has been assaulted. She believes the law helps protect her and other providers.
“We live in a hostile environment,” she said. “Our job is to serve you on your worst days.”
Of the decision to charge Page, the King County Prosecuting Attorney’s Office said his behavior caused “serious concerns for the risk of violence against multiple people” because of failures to appear in court, felony trespass and misdemeanor domestic violence convictions over a decade old, and a 911 call Page made before he was taken to the hospital. Police said Page, then 47, threatened to shoot children he believed were throwing rocks at his house, but when officers arrived, they found no evidence of a gun or children present. Page disputes the police’s version of events.
“Having a mental illness does not prevent a person from committing an assault, does not necessarily alleviate them of legal responsibility, or provide a better option than the filing of criminal charges,” prosecutor’s office spokesperson Casey McNerthney wrote in an email, noting that violence against health care workers is often underreported. “Sometimes there are no other options to prevent the violent behavior that victimizes hospital staff.”
What is felony assault?
Any assault that causes substantial pain or “bodily harm,” or involves a weapon, can be a felony in Washington, regardless of the victim’s job. But spitting, for example, becomes felony-level violence when it targets people in specific professions. Along with health care workers, Washington’s assault law covers police officers, bus drivers, firefighters and courthouse employees — all public servants who are more likely to encounter people in crisis.
Statewide, at least 206 cases were filed in 2023 for felony assault on a health care worker, according to data provided by the state Administrative Office of the Courts. A defendant’s competency was questioned in 28% of these cases. In the past decade, the number of people waiting in Washington jails for state psychiatric evaluations and treatment has more than doubled, from under 1,000 in 2013 to more than 2,000 in 2023.
“No one should be assaulted at work,” said Kimberly Mosolf, former director of the Treatment Facilities Program at Disability Rights Washington. “But how you best address that is not arresting someone and booking them in jail. They will be back in your ER very shortly.”
Mosolf authored a 2020 report that found more than 100 arrests from Seattle-area hospitals and mental health care facilities in a year, some for as little as throwing a cup of juice. In her research, Mosolf was especially troubled by charges against people who were in the hospital on an involuntary treatment order, which meant a civil court had already concluded they were a danger to themselves or others. “The fact that they then have behaviors that could be harmful should not be a surprise,” she said. “It makes no sense to me that you would pull them out for those very behaviors and criminalize them.”
Some states, like Virginia and Missouri, explicitly exempt people who are receiving psychiatric care or are civilly committed to a hospital from being criminally charged under new laws against threatening health care workers. Washington’s statute, passed in 1997, has no such carve-out.
King County Prosecuting Attorney Leesa Manion, who took office in January 2023, said her staff may pursue charges against someone with serious mental illness in hopes of connecting them with services.
“We often file charges as a way to get people help, not because that’s something we think is the world’s greatest practice, but because of how the system is currently designed,” she said.
But these charges can do the opposite, according to court records. At least four patients charged deteriorated so much in jail that they were found with feces in their cells or smeared on the walls. Some defendants waited so long in jail for a bed at a state hospital that their defense attorneys argued that the state was violating their right to due process. In one of those cases, a judge ordered the state to pay $16,000 in sanctions for the patient’s time in jail. His case was ultimately dismissed because he was too sick to participate in a criminal trial.
Court records show this law disproportionately ensnares homeless people and people of color. More than a third of cases involved people who were homeless — a population with a higher rate of illness and who are more likely to end up in the ER.
Like Page, 40% of the people charged with this kind of felony assault were described as Black in police reports. That is an even higher racial disparity than overall felony cases in King County, where roughly a third of defendants were listed as Black, according to county prosecutors’ data in recent years. The county’s population is 7% Black.
Manion said these disparities point to a broader lack of access to services and to historical inequities in health care.
She acknowledged that filing criminal charges doesn’t necessarily deter future attacks, especially if someone is in a mental crisis. “I don’t think individuals who engage in criminal behavior are thinking, ‘I might have charges filed against me so maybe I shouldn’t do this,’ ” she said.
But sometimes, she added, the legal system is more about “how you hold someone accountable for the harm that they have done to another person.”
Violence on the job
A recent study by National Nurses United, a national union with nearly 225,000 members, found that nearly half of nurses reported an increase in violence in their workplace in the past year. Multiple factors are driving this trend, experts say, including understaffed facilities, long wait times for patients and the dual crises of mental illness and substance use disorders.
Nurse Thomas Keolker has worked in Seattle emergency rooms for nearly 20 years. He has been the victim in two felony assault cases but said that’s just a fraction of the violence he’s experienced. He has been bitten, spat on, threatened, strangled, tackled and punched, records show.
Keolker said he can tell the difference between someone who “was truly psychotic” and someone who understood what they were doing was wrong and chose to do it anyway. “I’ve never really wanted people to be locked up, but I also feel like there’s a ramp-up,” he said. “It’s frequently a series of very small incidents that build up to people really harming others.”
Nursing associations are divided in their support for these laws. Some have lobbied for their passage as part of broader efforts to curb violence. Others oppose them entirely.
“Criminalizing our patients is not the answer,” said Michelle Mahon, assistant director of nursing practice for National Nurses United. “It’s a pivot away from employer responsibility to provide a healthy and safe work environment.”
In Washington state, Service Employees International Union Healthcare 1199NW President Jane Hopkins said the felony assault law is important. But without other prevention measures, she said, it won’t protect her members.
Research shows there are multiple ways to reduce hospital violence, including de-escalation training, increasing the number of staffers and offering more preventive care for people with serious mental illness.
“We don’t want patients thinking it’s OK to assault health care workers,” Hopkins said. But, referring to the people charged, she said, “Three-quarters of them have mental health problems that maybe we could have influenced before they got to that place of assault.”
Prosecuting people in crisis
When weighing whether to charge psychiatric patients, the King County Prosecuting Attorney’s Office since at least 2019 has instructed its staff to consider someone’s mental illness as a factor. Yet a defendant’s competency — whether someone’s mental illness was too severe at the time for them to be tried — was questioned in court in nearly 40% of cases analyzed by The Seattle Times and The Marshall Project. (Not every person with a mental illness facing such charges will end up in competency proceedings.)
In 2022, I.M., a college student diagnosed with schizophrenia, was arrested after he allegedly threatened to kill a nurse and others, punched a nurse in the hand and spat on two other workers at a Seattle-area psychiatric hospital, according to police reports. He was being held under an involuntary treatment order. (I.M. are his initials. He requested anonymity out of concern for how discussing his mental illness would affect his job prospects.)
I.M. had recently tried going off his medication because the antipsychotics caused him to gain significant weight, making him dizzy and short of breath, he said. But it didn’t take long for his delusions to return, setting off a cycle of being arrested, hospitalized, then arrested again. After three weeks in jail, he was “severely decompensated,” and was found naked and spreading food around his cell, according to a jail progress note. I.M. was found incompetent to stand trial and ordered to a state hospital. But the wait time was 6½ months.
If someone’s mental illness is deemed too severe to proceed with their case, they may be referred to a state hospital to subdue their symptoms enough so they understand the charges against them. But the wait times for admission in Washington have been so long that a federal court found them unconstitutional, fining the state over $100 million last year for its failure to transfer people quickly.
In 2023, Manion’s office sued the state Department of Social and Health Services over these wait times. Data provided by the department shows the backlog has improved in recent months, and the vast majority of people referred for competency restoration in April were admitted within two weeks.
After seeing cases like I.M.’s end up in competency proceedings, county prosecutors updated their guidelines in December to more explicitly caution attorneys as they consider charging people for assaults committed during a mental health crisis. The guidelines say prosecutors should also assess whether it would be appropriate to decline the case or refer someone to a diversion program to avoid a criminal conviction.
From January through March, the office charged three people under the felony assault law for allegedly attacking health care workers. Two of the defendants were receiving mental health care at the time.
In an interview, Manion, the county’s top prosecutor, stressed the importance of services people can access after they’re arrested or charged.
The county’s Legal Intervention and Network of Care program provides short-term housing, psychiatric services and other support for people with behavioral and mental health problems who are facing misdemeanor or low-level felony charges. Those referred to LINC can have criminal charges dismissed or not even filed in the first place. The King County Regional Mental Health Court can also connect defendants with services.
But only a small number of people charged under this law get such help. Of the more than 150 cases reporters analyzed, six people were accepted into the LINC program, according to available court records. Another six had their cases handled in mental health court. Both programs require a defendant to opt in and may screen out people who are accused of serious violence or who have a significant criminal history. And neither program has enough resources to serve everyone with a mental illness who is facing criminal charges in the Seattle area. The LINC program served 189 people in 2023.
Manion’s office said that in many cases, defendants are not willing to participate in these programs, and such initiatives might not be appropriate for people whose primary diagnosis is substance use disorder.
Anita Khandelwal, director of the King County Department of Public Defense, said that at the very least, anyone who is in the hospital for mental health care who assaults someone but does not cause serious injury should be spared felony charges and connected to mental health support. Her office has advocated for diverting these cases to programs like LINC and keeping people charged with these felonies out of jail.
“You’re setting someone up for failure by making it harder for them to access services that will help,” she said. “We know that processing them through the system is not going to make them any healthier and is a huge waste of resources,” she said, referring to the criminal courts. Khandelwal’s office estimates it costs taxpayers nearly $5,900 in attorneys’ time to defend each of these cases.
After 3½ months in jail, I.M. had been on his medication long enough to be released to his mother, who promised to oversee his continued treatment. Two years later, his criminal case is ongoing. The prospect of a felony record hangs over him as he returns to college and tries to put his life back together.
“I can’t make sense why someone getting mental health treatment would be charged with a felony,” he said. “I was really out of my mind; I didn’t realize what was happening.”
Caution in Seattle as laws spread across country
King County prosecutors are applying more scrutiny in these cases, but there is no legislative movement to change the law.
“I don’t think this is on the radar of most legislators,” said state Sen. Manka Dhingra, D-Redmond, a former King County prosecutor. When a patient gets to the point of lashing out, she said, “You know they should have received services way before it got this bad. We have to push the system to get people help earlier.”
Instead, legislators have faced pressure to increase criminal penalties for assault involving more classes of workers, including massage therapists and electricians.
State Rep. Lauren Davis, D-Shoreline, is critical of the law and opposed expanding it.
“Clearly there’s no data to suggest that the criminalization of this population is addressing the underlying, core issue here,” she said.
More states are passing similar laws. In 29 states, including Washington, any assault on a health care worker can be a felony offense, according to an analysis of state laws by the news organizations. And since the pandemic began, at least 20 states have increased criminal penalties for these attacks.
Efforts to increase criminal penalties in California and Oregon, however, have failed over concerns about their effectiveness and the impact on people with mental illnesses and intellectual and developmental disabilities.
“When an individual is in crisis, they’re not going to read a sign that says, ‘It’s a felony to assault a health care worker,’ and then change their behavior,” said Beth Brownhill of Disability Rights Oregon, which lobbied against the state bill.
Kevin Page was charged with the felony assault in April 2020, just weeks into a statewide stay-at-home order. At the time, the King County jail was only booking people whose charges posed “serious public safety concerns,” in order to lower its population and reduce the spread of COVID-19. His spitting on nurses qualified.
Sitting in jail, Page worried a felony charge would cost him his newfound stability. He had recently moved into supportive mental health housing after six years of homelessness. His son bailed him out quickly enough to avoid eviction, and his criminal case was dismissed due to “evidentiary issues” more than a year later.
But the impact of the night he was arrested lingers. He is wary of calling 911 if he needs help and of seeking mental health care. “I’m afraid of going to jail,” he said. “I try not to go to the doctor. Because it could happen again.”
Seattle Times news researcher Miyoko Wolf and The Marshall Project data reporters Jasmyne Ricard and Weihua Li contributed to this report.
Sydney Brownstone is an investigative reporter for The Seattle Times. She can be reached at 206-464-3225 or sbrownstone@seattletimes.com.
Esmy Jimenez reported this story as a member of The Seattle Times’ Mental Health Project; she is now a reporter for The Boston Globe.
Christie Thompson is a Seattle-based reporter for The Marshall Project.
