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This story is part of an ongoing series looking at problems facing Hawaii’s mental health system and possible solutions.��

On a cloudy Saturday in April, a 33-year-old Honolulu man checked into a Waikiki hotel room and neatly unpacked an arsenal of loaded guns and knives.

Hatchet on the bamboo dresser. Shotgun and rifle on the four-poster bed. In the closet, he hung up army fatigues and a ballistic vest. Before long, a menacing display of 22 weapons and more than 800 firearm ammunition rounds were tidily arranged around the suite.��

Over the course of a two-week hotel stay, the man would occasionally loiter in the lobby, warmly telling the receptionist about his work as a kind of 007 agent. One night, the man logged onto Facebook and typed a message so disturbing that it compelled one of his friends to call the FBI tip line.

A Honolulu police officer escorted the man out of his hotel room, put him in handcuffs and drove him to The Queen’s Medical Center for an emergency psychiatric evaluation.

Three weeks later, it happened again: the man barricaded himself in a hotel room with an alarming collection of weapons, prompting a police officer to send him back to the hospital for a forced psychiatric intervention.

When it comes to obtaining emergency treatment for some people with severe mental illnesses, Hawaii’s system is often a revolving door.

When police bring in people in crisis who pose a danger to themselves or others, but have not committed a crime, those people can’t be held against their will by doctors for more than 48 hours.

Often those interventions are inadequate.

New Honolulu Police Department data shows hundreds of patients go on to repeated hospitalizations and brushes with law enforcement, sometimes just days or weeks after their release back into the public.

It’s a knotty problem that’s overwhelming emergency rooms and raising questions about the state’s lack of mental health resources and the merits of protecting a person’s civil liberty to refuse psychiatric treatment — even when they’re too sick to recognize they are suffering from mental illness.

On Oahu, there are a growing number of emergencies in which police officers send a person with mental illness to a local hospital for psychiatric treatment, according to the report published this year by a collaboration of police and health care agencies.

These hospitalizations occur after a police officer consults with an on-call police psychologist. Often they happen against the patient’s will.

The report revealed that one-fifth of citizens who come into contact with a Honolulu police officer consulting with a psychologist go on to become involved in at least two, and as many as 20, additional police encounters.

More than 200 people who were assisted by a police officer working with a psychologist in the first half of 2017 were taken to the hospital against their will two or more times.

The report’s conclusion: people with the most severe cases of mental illness aren’t getting the help they need.

People who are hospitalized under an emergency psychiatric intervention commonly refuse further services when they are released.�� Many are adamant in their refusal to accept help.

Each time a mental health intervention falls short, research shows the person becomes sicker, more difficult to treat and more likely to engage in serious criminal behavior.

The enduring challenge, according to Institute for Human Services Executive Director Connie Mitchell, is that it’s unlawful to treat someone with mental illness against their will for more than 48 hours. But in many cases, she said, it’s inhumane to allow someone to go without help when they aren’t well enough to know they need it.

“We can’t just say, ‘Well, they don’t want treatment, so that’s that,’” said Mitchell, who is also a psychiatric nurse. “But that’s what we’re saying and people are dying from it.”

In one dramatic example, a woman was struck and killed by a pickup truck in June while walking in the middle of the fast lane on Interstate H-2. Her death occurred less than two weeks after police hospitalized her against her will for wandering around naked and shouting about demons in the middle of a road racing with traffic.

Cases that end in death are rare. But many situations risk the safety of the public or the person who’s sick.

No one was harmed by the young man whose mental illness caused him to believe he was a federal agent on the two occasions when he secluded himself in a hotel room filled with weapons. But it would be difficult to overstate the calamitous potential of those scenarios.

“People are dying from it.” — IHS Executive Director Connie Mitchell

While research indicates that people with mental illness are no more inclined to commit violence than the general public, some forms of mental illness reduce a person’s risk of violence and others, like psychosis, increase it.

“From a human compassion perspective, these people obviously need help,” said Louis Erteschik, executive director of the Hawaii Disability Rights Center. “And sure, they can kind of patch you up at the ER and stabilize you, but then they just throw you back out there with nothing.”

The accounts of two failed emergency mental health interventions included in this story are based on public records. Civil Beat is withholding names and identifying details to protect the privacy of the subjects, who have or had a mental illness and were not arrested in connection to these crises.

Their stories are remarkable, but not uncommon, examples of a systemic failure to provide those who are sickest with adequate help.

Armed And Loaded In Waikiki

The Facebook post attracted so much concern that the man would eventually delete it.

“To everyone who made my life awesome it’s been a great adventure,” he typed from a hotel room full of weapons. “I can’t name all the people who were such a huge part of some of my best adventures. You know who you are and we went all out. So now looks like my time has run out. It’s ok.”

None of this jibed with the content the man typically shared on Facebook — photos of himself swimming in waterfalls, hiking mountains or enjoying the beach with his arms slung around the shoulders of a couple of pretty, bikini-clad women.

A friend who read the post sent the man a private message asking if he was okay.

“I’m a federal agent,” the man replied, explaining that he was preparing for��an overseas mission to take out terrorist cells for the U.S. government.

The next morning, a pair of Honolulu police officers arrived at the hotel to check on the man’s well-being. What they found was a mild, well-mannered person battling paranoia and delusions.

The man told one of the officers he wasn’t thinking of hurting himself or others, but that he wanted to be prepared to defend himself and others in the event of a terrorist attack.����

After a consultation with the police psychologist, a police officer��collected the man’s four firearms, each properly registered in his name, and drove the man to The Queen’s Medical Center, where he agreed to undergo a psychiatric evaluation.

Three weeks later, police hospitalized the man a second time after he��barricaded himself inside another hotel room with a large collection of swords, machetes and daggers.

Civil Liberties On Hold

The goal of an emergency psychiatric evaluation is to stabilize a person enough so that they are no longer an imminent danger to themselves or others.

With six psychiatric beds in its emergency department, The Queen’s Medical Center treats more of these patients than anywhere else in the state.

The first step is a mental, physical and social evaluation by an ER doctor, who will often try to get patients who have awareness of their illness to check into the hospital voluntarily. But for those patients who don’t, the doctor must make a judgement call: Is this person an imminent threat of danger to themselves or others?

When a person is making verbal threats to inflict self-harm, the answer is obvious. Other situations are much more unclear.

“They are brought in by police against their will, so you’re taking away their civil liberties by doing this,” said Dr. Howie Klemmer, chief of emergency medicine at Queen’s.

“And these are people that were walking into traffic or yelling at people walking by or laying in their own filth or whatever they were doing that triggered the police to say, ‘This person’s mind isn’t right.’”

If a person is deemed to be an imminent danger, the hospital has the right to administer psychiatric treatment against their will for up to 48 hours. Otherwise, they are released.��

A psychiatrist can petition for a court order to hold a patient longer. That rarely happens.

“If we feel they have insight and awareness to make decisions, then we can’t forcefully hold them against their will — even if they have chronic mental illness and they’re always delusional,” Klemmer said. “It’s a free country, you’re allowed to think what you want to think and you’re allowed to do what you want to do, as long as you don’t break laws.” ��

The doctor’s job in these situations is to yank the patient out of the throes of crisis. But for people with persistent mental illness, it can be all too easy to slide back into crisis again.

“You’re taking away their civil liberties by doing this.” — Howie Klemmer, Queen’s emergency medicine chief.

The hospital tracks thousands of what it dubs “super-utilizers” — patients who come to the emergency department repetitively for reasons including mental illness.

Last year, Queen’s spent more than $80 million on these super-utilizers. About half of the hospital’s resources are consumed by less than 5 percent of the patients, according to Klemmer.

All told, 65 percent of Queen’s super-utilizers are homeless, a number of whom have mental illnesses,�� Klemmer said.

“Some of them are there because of mental illness, but most of them come because it’s a safe place and it’s an easy place because they can call 911 and get a free ride,” Klemmer said.

“So we’re trying to help that group of people understand that the ER is not necessarily the best place for them and that they would be better served by going to their primary care physician, an outside community clinic or another place for help with meals, shelter, clothing or companionship.”

Arising from this crisis, the hospital has partnered with social outreach groups to establish Queen’s Care Coalition, which assigns super-utilizers to a healthcare navigator. The navigator can help them find shelter, stay connected with their primary care physician and stay on their medications.��

Limited resources contribute to the difficulty of treating emergency psychiatric patients.

Queen’s inpatient unit is under renovation, the result of which is a temporary reduction from 40 to 25 inpatient psychiatric beds. For now, some psychiatric patients are being held in the ER instead.

Klemmer described this temporary arrangement as “very difficult.”

“When it comes specifically to mental health, the system has been pretty stressed for the last three months,” he said.

Although the patient load is shared with Castle Medical Center and, to a lesser extent, small community clinics, the loss of beds at Queens has been taxing. Full capacity is expected to be restored by the end of the year.

‘Don’t Even Know They’re Sick’

In Hawaii, are rare, reserved only for individuals found by the court to be perpetually dangerous to themselves or others — or so gravely disabled that there is no less restrictive treatment alternative than hospitalization.

It is difficult to prove plainly in court that a person poses an immediate and persistent threat to themselves or the public. A series of 1970s protects the rights of people with mental illness to turn down treatment.

“When there’s a lost dog we treat them better than we treat people like this.” — Marya Grambs

Marya Grambs, former executive director of Mental Health America of Hawaii, contends that patient rights should not be upheld at the expense of resigning someone to a life of neglect and poor health.

“What kind of civil liberties do you think these people are enjoying right now?” Grambs said. “They’re defecating outside, they may or may not have clothes on, they look beaten up because they have been beaten up, they’re hallucinating, they’re delusional — and they don’t even know they’re sick.”

“That’s something people don’t understand: They truly, actually do not know. So why would they want to take any medication if they aren’t sick? When there’s a lost dog we treat them better than we treat people like this.”

Last year eight people were civilly committed to the Hawaii State Hospital. Seven of them had been found by the court to be imminently dangerous to themselves or others or otherwise in need of hospital care. The eighth person was admitted to the hospital in error and discharged the next day.

The hospital’s 578 other patients that year had at least one criminal charge racked against them. The most common offense was property crime, such as burglary, trespassing or property damage.

In Hawaii, court-ordered inpatient treatment is almost exclusively available to criminal offenders.�� In 2016, the state had just one civil commitment.

The Legislature moved last year to allocate $160 million for to address concerns for the safety of patients and staff, as well as a shortage of beds. But the new facility is expected to continue to primarily hold patients who have committed a crime.����

There are other inpatient psychiatric treatment facilities on Oahu, but only for patients willing to be treated.

“We’re going to get back to the point where they are institutionalized at some point,” said Honolulu Deputy Police Chief John McCarthy. “We almost have no choice because these people cannot function in the so-called free world — it’s just a matter of when and at what cost.”

Apart from expanding Hawaii State Hospital’s scope and capacity to take on more civil commitments, mental health policy advocates say a relatively new law that’s difficult to implement could become a solution for people with serious mental illness.

New Alternatives

Under Hawaii’s fledgling Assisted Community Treatment Act, a judge can order a person to undergo intensive outpatient mental health treatment while remaining in the community. Usually this treatment comes in the form of intensive case management coupled with a long-acting injection that combats the symptoms of psychosis.

The recently revised law targets people with serious mental illness who may be homeless or cycling through the emergency medicine or criminal justice systems.

Less than 10 people have received outpatient treatment through the program since the law passed in 2013. Most of the have been for patients on the verge of release from Hawaii State Hospital.

This summer the Institute for Human Services successfully petitioned to get a person into the program who has been arrested more than 30 times. The nonprofit is now fighting for outpatient treatment for someone who has been arrested on more than 80 occasions.

“The effort to use this law to get them into treatment has been met with a lot of barriers, and most of them have to do with protecting a person’s right to live in inhumane conditions,” Grambs said.

“But if they were well, they would not want to be living like this.”

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