‘If I die and there is a hell’: Montana State Hospital patient recalls time in Warm Springs

State mental health experts call for more investment and a wider array of mental health services

By: - April 10, 2022 9:32 am

Montana State Hospital at Warm Springs (Photo via Wikimedia Commons | CC-BY-SA 3.0).

 The first time Danielle Lewis was in the Montana State Hospital, she told her mom she would rather lick the phone and get COVID-19 than continue to stay at the Warm Springs Facility.

In 2020 and 2021 during two separate stays, Lewis spent around nine days at the state psychiatric hospital for suicidal thoughts.

During her first stay, the 33-year-old brunette said other patients groped her, and staff ignored her pleas for help.

Lewis uses a wheelchair because of her cerebral palsy, and the second time, she said she was left almost entirely alone, and staff didn’t help her change or take a bath. She got sores.

“When you’re suicidal, sleep-deprived and hungry, it just really drags you down,” she said. “Every day, I just sat there and cried on the phone to my mom. And because it was my first time, I didn’t know how long I was going to be there.”

Instead of healing, Lewis said the conditions at the hospital exacerbated her depression and bipolar disorder, and she said she still feels suicidal at times.

“But I’m afraid to go to the (state) hospital,” Lewis said in an interview with the Daily Montanan. “So when anybody asks me if I’m suicidal, ‘I say no, I’m not.’”

After seeing media reports about the hospital’s struggles, Lewis said she was compelled to speak up about her experience.

The state hospital is on the ropes. In February, the hospital became at risk of losing federal funding after an impromptu visit from the Centers for Medicare and Medicaid Services found the hospital did not comply with federal standards. The findings included four deaths in five months and a complete absence of a COVID-19 infection plan.

“We should have evolved at this point away from institutionalization … because evidence shows it doesn’t work. But we continue to throw good money after a bad result.”

– Bernie Franks-Ongoy

On top of that, CMS had to return to the hospital in late March after a patient was hospitalized as the result of a patient-on-patient assault.

And recent data from the Department of Public Health and Human Services shows the hospital is $7 million over budget for the current fiscal year — stemming mainly from its increased use of traveling nurses as full-time employees leave the hospital. 

The number of full-time staff plummeted from 450 in 2019 to less than 350 by the end of 2021. And by December of 2021, contracted nurse assistants were billed for 16,000 hours in that month compared to just 2,000 in January 2021, a 700 percent increase, according to DPHHS data. As of April 4, there were 238 patients being served by the hospital. 

In response to the shortcomings, the State Department of Public Health and Human Services has agreed to do a “root-cause analysis” of the hospital’s problems in cooperation with CMS and is pursuing a  private contractor to review operations there and at other state-run health facilities. The department has also contracted with Mountain-Pacific Quality Health “to conduct analysis, make recommendations on process improvements, and support Corrective Action Plan implementation, with a focus on those issues raised by CMS,” DPHHS said in an email.

“The reality is the struggles at MSH have existed and remained unaddressed for far too long, as well as spanned multiple governors. Simply put, there are no quick fixes for what we are currently facing. As Director Meier has stated before, we must approach MSH comprehensively, strategically, and in a data-informed manner,” DPHHS spokesman Jon Ebelt said in an email.

In regards to the allegations raised by Lewis, Ebelt said: “Our commitment to both serving the patients at Montana State Hospital now and reforming the facility for future generations has never been stronger.”

The problems are severe, but longtime mental health professionals said they are also avoidable. Montana is using a model of mental health care that is old and broken, they said, but the field has evolved, and services in the Treasure State should, too. 

“Going all the way back to when it was opened, it was set up to fail from a business standpoint,” said Joel Peden, a longtime lobbyist for disability rights in Montana. “All institutions were built in remote areas because people didn’t want to see them.

“So as time moves on, what happens is people forget about the patients that are there. And this is not something that happens overnight. It builds its own momentum.”

But there are things the state can do to help in addition to investing more in mental health treatment. The state should provide a wider array of services, including bolstering care in communities across the state. 

The way the system operates right now is not working, said Bernie Fanks-Ongoy, executive director of Disability Rights Montana,  a non-profit advocacy group in the state

“It plucks the problem, out of the community but it puts the person into an unsafe and unhealthy environment,” she said.

But, she said, that does not mean completely getting rid of the hospital.

“We need a continuum of care. In terms of the state hospital, that facility is a very old facility … it is inappropriate and unrealistic to expect the Montana State Hospital to be the main solution,” she said. “We should have evolved at this point away from institutionalization … because evidence shows it doesn’t work. But we continue to throw good money after a bad result.”

Read the DPHHS report on pay rates and staffing levels at the hospital:


Danielle Lewis at Warm Springs

Lewis moved to Montana 12 years ago from Cheltenham, England, because she loved the views and wanted to attend an American university. Shortly after her relocation, she said she was sexually assaulted, a life-changing event that has left her with Post-Traumatic Stress Disorder. 

“(Warm springs) was the worst thing I’ve experienced since the incident I had almost 10 years ago,” said Lewis, who talked to the Daily Montana from her home in Bozeman.

So Lewis said she lied about the state of her mental health to avoid being committed for three months: “I lied through my teeth. I still desperately needed help. But there was no way that I was going to stay in Warm Springs.”

When COVID-19 began to creep into Montana, Lewis was staying in a Bozeman assisted-living home where she lodged with a 98-year-old woman with dementia. Her rooming situation coupled with COVID-19 restrictions strained her mental health, and she started having suicidal thoughts, she said.

She eventually ended up at the Bozeman emergency room, and because of her physical disability, she said no other facilities would take her in. So she was sent to Warm Springs.

“I was petrified because I knew what other people had said about Warm Springs,” she said.

Her concerns shortly became her reality.

From March 27, 2020, to April 1, 2020, she was placed in the hospital’s heavily scrutinized Spratt unit — the hospital wing that cares for elderly patients with dementia or severe mental illness. The hospital is meant to serve patients with severe psychiatric disorders like schizophrenia and not dementia patients, but the hospital cannot turn away those patients who come to the hospital via court order, such as Lewis.

When she first arrived, Lewis said screaming and banging led to sleepless nights. And the food that was brought in from the local state prison was inedible, so she only snacked throughout the day.

“I went on what they call the Warm Springs diet, where I couldn’t eat anything,” she said.

The PTSD from her sexual assault 10 years ago was retriggered after patients at Warm Springs groped and exposed themselves to her, she said.

“They touched my boob. And a lot of them came up and touched my crotch. I couldn’t deal with it. I just sat there, and I cried every day. And nobody would come up to me and say, ‘Are you OK? Is everything alright?’ They would just see me cry and leave me to cry.”

When she tried to tell staff about the sexual abuse, they were apathetic, she said: “They brushed it off and said, ‘Oh, I don’t think that’s happening.’”

She said staff would yell at the patients to take their medicine, eat their food and behave.

“They would just make it a very hostile environment. And all this made my PTSD worse, not better,” she said. “There were guys exposing themselves, and they would just go pee in the phone room, and it would take staff hours to clean it up. It was horrible.”

Hospital staff told her she was placed in the Spratt unit because it was the only wing of the hospital that could accommodate the physical care demands of her cerebral palsy, she said.

“And I don’t really think that’s fair, that just because I’m disabled, they put me on that unit,” she said.

Eventually, after complaints from her mom, she was put on one-to-one supervision for two days, but she said even that was a letdown. Her mom agreed.

“It was terrible, frightening, and I was horrified to hear that they basically put people in there to contain them,” said Lisa Lewis, Danielle’s mom, in a phone interview. “She was terribly unhappy, and she wasn’t getting any mental health support.

“What’s the idea of putting someone in a mental health facility if they are not going to get some support?”

After lying to get out of the Warm Springs hospital the first time, Lewis found herself at St. Patrick’s Hospital in Missoula in late February 2021 for suicidal thoughts. Because of the lack of crisis care services in Montana that can cater to Lewis’s needs, she said she received another court order to go back to Warm Springs.

This time she was assigned to the Bravo Unit.

“They didn’t really have anybody who knew what to do with me on that unit. So, they left me for at least a couple of days without getting changed or anything,” she said. “And I got really nasty sores because they weren’t helping me wash up or anything like that.”

There is no way to meet all the needs of the patients properly, so people have died as a result.

– Former MSH Nurse

Legislative Efforts

The Children, Families, Health and Human Services Interim Committee started drafting two bills in early March to address the challenges at the state hospital.

One of the bills would transfer patients with dementia assigned to the hospital by court orders out of the hospital and into community care facilities. The bill will be closely modeled after legislation passed in 2015 that gradually transferred patients out of the Montana Developmental Center. And in its own way, the bill will increase transparency over how Montana treats patients.

“The importance of family and family visitation … it’s a set of eyes that we don’t really have at the state hospital because if you’re living in Billings, getting to Warm Springs is a big deal,” Rep. Danny Tenenbaum, D-Missoula, said at the March meeting.

The other bill would give Disability Rights Montana oversight by requiring the hospital to turn over reports of significant events and deaths at the state hospital to the disability rights organization.

Having the incidents reported to a separate entity provides an extra level of oversight. If you have the fox watching the hen house, that’s not a good system,” Franks-Ongoy said.

Common state of affairs

Unfortunately, Lewis’s experience is not uncommon.

Because of the mix of patients in the Spratt unit, patients groping other patients and exposing themselves is not out of the ordinary, said a former nurse, who asked to remain anonymous because he would like to return to the hospital.

“That happened. It happened when I was there,” he said about inappropriate sexual activity in the Spratt Unit. “There were two particular gentlemen on the unit that were notorious for it … and you had to constantly redirect them because of their brain injuries, it was just a bad setup, they needed to separate the types of patients.”

Franks-Ongoy raised the same issue and said the hospital needs to do a better job of separating and protecting patients.

“Inappropriate interactions between patients is a very common thing at the hospital,” she said. “You are mixing people with different levels of behavioral challenges. We need to think about how Warm Springs can provide a purpose and put some safeguards around who goes there and who doesn’t go there.”

Another former nurse at the hospital who asked to remain anonymous because she is still looking for employment in the industry also said she was not surprised by Lewis’ experience. 

“(Spratt) is such a hard unit, it’s a terrible place to work. I hated it. So for the staff who routinely work there all the time, I think among the traveling nursing staff, they become deadened to the needs of the patients,” the nurse said. “The acuity is so high and the needs are so high on that unit that it just universally stresses all staff that are there. There is no way to meet all the needs of the patients properly, so people have died as a result.”

And the problem is only exacerbated by the use of traveling nurses, she said. “I definitely observed that among travel CNAs … there was no sense of investment in the patient population.”

But it wasn’t always like that, she said. Prior to the hospital’s new administration in 2019, she said it was a place people liked to work and that invested in care for the patients.

“Among the new administration there is no sense of pride in work, pride in place, justice for the patients, or sense of, ‘We’re doing something good here for the patients and the state,’ and it’s created a systemic problem,” she said. “I have told other behavioral health centers in the state not to send people to the Montana State Hospital.”

Broader mental health access issues

Mental health experts said access to crisis care in Montana has become scarce, leading to more people being sent to the Montana State Hospital, which is considered a last resort for patients like Lewis.

“Because it’s the last solution for someone if someone can’t get the help and they go into crisis, no one knows what to do with them except send them to Warm Springs … if someone has a bad day, it doesn’t take a lot for them to end up in Warm Springs because there is not enough quality community care,” Peden said. 

With community care, patients have more access to mental health services that are closer to home, allowing them to be near their existing support systems instead of being shuffled off to a remote part of the state.

“I think the state hospital provides an essential role in our state, but it’s always wonderful when people can be treated in their community, and we have been focused on re-building crisis services at the community level,” said Matt Kuntz, executive director of the Montana chapter of the National Alliance on Mental Illness.

Fanks-Ongoy echoed Kutnz’s message. “We have gotten here because we continue to invest money in a system that has proven not to be the best, and we need to pause and think about the best way to provide mental services in the state.”

In 2017, the state lost a significant amount of funding for public mental health services and access to community services shrunk, Kuntz said.

“Those budget cuts, which ended up having a really dramatic system-wide impact and with the challenges of COVID-19, it’s really been a difficult time for our mental health treatment system and the people that rely on it,” he said.

Before 2017, public mental health services relied heavily on case management fees to pay for a lot of other public health infrastructure like crisis services, he said.

“Crisis services are something we need to rebuild in the state of Montana. There is no question that what we had before, we don’t have now, and I think it is putting excess strain on the Montana State Hospital,” he said.

Kuntz said NAMI and other mental health advocacy groups have been able to secure funding for more public mental health services, but he said the allocation of the money has not been decided.

“We have built a funding stream for it, but now DPHHS and the interim committees need to make sure those crisis services roll back out in the state of Montana in a way that is sustainable and serves communities around the state.”

But even before the budget cuts, he said there was little funding and a little room for margin of error.

“The state hospital and the crisis facilities around the state were always kind of on the edge. I think that is why some of these disruptions have been so difficult, like inability to hire staff and manage the day-to-day operations is sort of built-in because there was never excess funding for those things,” he said. “You get two or three things going wrong, and it doesn’t take them long to snowball.”

Still, with how things are going right now, Warm Springs is an untenable situation, Peden said, and no amount of money will fix it in a vacuum.

“In the absence of community care, MSH cannot be fixed. It cannot be the main solution for severe mental health issues and right now it is,” he said.

A better way

Both times Lewis was sent to the State Hospital, she said she wished she could have been placed in a community care center, where she had spent time before. She praised her treatment at places like Billings Clinic and the Hope House in Bozeman.

“They treat you nicely there, and they don’t have prison food or screaming, banging, swearing, peeing on the floor … and they make sure nobody touches or gropes anybody,” she said.

She said she knows the government doesn’t put a lot into mental health services, but people like her merit better treatment: “I deserve to be able to go into a normal psychiatric unit like everybody else.”

Lewis said Billings Clinic no longer would accept her because they did not have the tools necessary to lift her into bed.

“They should not discriminate against you just because you have a disability, and they should offer you the same level of (mental health) care,” she said.

After reflecting on her time at the facility, Lewis has come up with suggestions for how the hospital could have better handled her care.

“I really want it to get shut down until they can kind of reboot and look at the care that they provide,” she said. “I think there needs to be a real shake-up there, and they need to watch people more efficiently, and they need to believe you when they tell you things instead of thinking that you are a liar.”

Still, despite the animosity and disbelief from staff, she sympathized with those working at the hospital.

“Most of the staff are burnt out. And they don’t really care because they are so burned out from being sworn at, people banging and screaming,” she said.

For the time being, she doesn’t believe anyone should be forced to go to Warm Springs.

“I imagine that if I die and there is a hell, that’s where I’ll be going,” Lewis said. “And I don’t think anybody should be sent there. Not the way it is at the moment. I think it’s cruel and unusual punishment.”

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Keith Schubert
Keith Schubert

Keith Schubert was born and raised in Wisconsin and graduated from the University of Minnesota in 2019. He has worked at the St.Paul Pioneer Press, Milwaukee Journal Sentinel and most recently, the Asbury Park Press, covering everything from local craft fairs to crime and courts to municipal government to the Minnesota state legislature. In his free time, he enjoys cheering on Wisconsin sports teams and exploring small businesses. Keith is no longer a reporter with the Daily Montanan.