Rules Separate Mentally Ill From Treatment
With 'Imminent Danger' Requirement and Scant Resources Keeping Help Out of Reach, Some Become Violent

By Tom Jackman
Washington Post Staff Writer
Monday, May 29, 2006

There are discussions about mental health, debates about dollars, demands for more beds, mostly in general terms at the top of political and policy food chains.

Then there is real life -- and real consequences. Check out the first two weeks of this month:

May 1: A mentally ill 22-year-old man is convicted of murder for beheading his aunt in Arlington.

May 8: A mentally ill 18-year-old man drives into a police parking lot in Fairfax County, fatally shoots two police officers, then is shot and killed by police.

May 12: A mentally ill 24-year-old man allegedly stabs his mother to death in Fairfax City, then uses duct tape to seal the bathroom, where her body is found.

May 14: A mentally ill 18-year-old man in Anne Arundel County stabs himself, then menaces police and demands that they shoot him, which they eventually do. He dies.

The pace of violence hardly surprises those who deal with the mentally ill every day: social workers, police, parents, lawyers. They know how hard it is to get a sick person treatment, how few resources are available, how the money for help has declined.

And when a Michael Kennedy sprays a police parking lot with bullets, or a Matthew Pahno chokes his aunt to death and decapitates her, the veterans of the system bite their tongues and hope that the money and resources will somehow materialize.

Where once getting treatment for mental illness was almost too easy, causing psychiatric centers to become dumping grounds for the healthy and the sick, some experts said the pendulum has swung too far the other way, with most states requiring proof of a person's "imminent danger" to themselves or others before giving them treatment.

"Right now, we only deal with the extreme cases," said John C. Whitbeck Jr., a Leesburg lawyer who oversees a George Mason University law school program that helps families seeking help from the courts for mentally ill relatives in civil commitment hearings. "And that's not getting anything done because so many people need to be addressed at the middle level."

Whitbeck said a busy treatment center such as Fairfax County's Woodburn center in Annandale might evaluate 25 or 30 people in a single night but recommend perhaps four for further help. "There's nothing to address all these other people," he said.

"There've been increasing pressures to reduce beds everywhere," said Robert W. Keisling, former head of emergency psychiatric services in the District. "And there's been a dumbing down of the hospital system. Some of the folks doing assessments are not psychologists or psychiatrists, and there are a lot of stupid assessments being made."

Keisling said he recently referred a man to a hospital who thought he was a secret agent. A hospital official asked the man whether he had a problem. He said no, Keisling said, and was promptly sent away.

"We have a system that is unsophisticated," said Joanmarie I. Davoli, a former Fairfax public defender and longtime advocate for the mentally ill. She said that the law does a poor job of defining who is mentally ill, that judges are poorly trained to decide how to handle such people and that a lack of public awareness results in underfunded resources.

Davoli defended Alfred L. Head, who in 1998 repeatedly threatened his parents and slashed his own throat in Reston. Six months later, he beat his mother to death with a baseball bat shortly after walking out of a string of mental health facilities.

Head was found not guilty by reason of insanity and placed in a state psychiatric hospital for seven years, where he responded extremely well to treatment. He eventually was found fit to be released by doctors and a Fairfax judge. Today he attends college, has a job and lives on his own, his lawyers said.

"The tragedy there is," Davoli said, "had the civil commitment laws not been so restrictive, his mother might be alive."

In Maryland, mental health advocates recently succeeded in getting the legal standard for treatment relaxed, according to Evelyn Burton of the Maryland chapter of the National Alliance for the Mentally Ill. "Getting rid of that 'imminent' part made a difference," she said, but Maryland also does not provide for formal outpatient treatment under the law, unlike Virginia and the District.

The National Alliance on Mental Illness estimates that the most serious mental illnesses afflict 5 million to 10 million adults and 3 million to 5 million children. Most of those people don't pose a danger to anyone. Many of those illnesses, such as schizophrenia, begin to appear in the late teenage years or early 20s, experts said.

Numerous studies show those who go without medication or treatment are more dangerous than the general population. A Justice Department study once found that people with a history of mental illness committed more than 4 percent of all homicides and 25 percent of all homicides in which a parent was killed.

The danger is particularly acute for law enforcement officers, often the first people to encounter a mentally ill person during a psychotic episode. In 1998, according to the Treatment Advocacy Center, people with mental illnesses killed law enforcement officers at a rate 5 1/2 times greater than the rest of the population. In the Washington area alone since 1998, eight officers have been killed by mentally ill people, including Fairfax Detective Vicky O. Armel and Officer Michael E. Garbarino on May 8, by Kennedy.

Kennedy's parents tried repeatedly to get treatment for him in recent months, only to be told by various mental health professionals that he didn't qualify, said Richard F. MacDowell Jr., their attorney. MacDowell said the mental health system in Virginia was "essentially broken," particularly in Northern Virginia, where population has increased as state funding decreased.

"Unless we do something about this problem now," MacDowell said, "tragedies like this are inevitable in the future."

Virginia has been trying to shift its resources away from state hospitals to local community services boards. But in 2003, for example, $12.5 million was cut from the community budgets, and the boards have about 3,000 adults waiting for services, according to the state mental health department.

In Northern Virginia, the number of private psychiatric beds available has plummeted, from 402 in 1990 to 196. There are none in Alexandria, forcing officers there to drive to Fairfax, or farther, to obtain help. The one state hospital in the region, in Fairfax, is nearly always full, experts said. Only 20 beds remain in Arlington for a population of 195,000.

James S. Reinhard, a psychiatrist who is head of Virginia's mental health department, acknowledged the diminished funding. But he pointed out that the state is about to pour $290 million into state facilities and another $170 million into community services, and that mobile community teams -- psychiatrists and social workers who make house calls -- which already are in use in Fairfax, should have an impact.

Reinhard noted that Virginia's mental health spending per capita -- it ranks 30th nationally -- doesn't compare to its income per capita (12th nationally). Cases such as the Fairfax police shooting "show how much of a need there is out there," Reinhard said. "People in our system are pedaling as fast as they can with the resources they have."

James Kelly, manager of emergency psychiatric services in Fairfax, noted that there have always been bed shortages. But he said Fairfax conducts crisis interventions around the clock, both at its mental health centers and in the community, and finds beds for those most in need. "I have no doubt that we see a lot of high-risk clients," Kelly said, "and we make a difference. But you're not going to catch every one."

Hospitalization shouldn't be the only option, said Mary Zdanowicz, executive director of the Treatment Advocacy Center. She said courts should be ordering more "outpatient commitments," in which mentally ill people are required by court order to take medication or other treatment -- and face legal sanctions if they don't.

Meanwhile, law enforcement officers continue to be the ones on the front lines. They receive training to deal with the mentally ill, and Fairfax Deputy Chief Suzanne Devlin said people should call police rather than let a loved one act out violently.

"It is frustrating," Devlin said. "But law enforcement is a funny thing; we do a lot of everything."

And so, people wind up in the jail instead of in hospitals.

"When I first started," Fairfax Sheriff Stan G. Barry said, "it was very, very rare that someone who was clearly mentally ill ended up in jail. Over the years, I've watched that change drastically. Now, people with mental illness get routed through the jail quite frequently. It's a game of hot potato. Nobody wants to deal with the problem."

State Sen. Ken Cuccinelli (R-Centreville), a friend of Garbarino's, proposed laws in the last legislative session that would have provided for more outpatient commitments and more legal help for families of the mentally ill. Both proposals failed, he said.

In New York state, a series of violent incidents caused lawmakers to institute involuntary outpatient treatment for certain people, under "Kendra's Law." The jail population in New York City dropped by half, Keisling said. "The shooting incident in Fairfax may result in some changes being made," he said. "It takes something like this to get the politicians motivated."