Smoothing the Path to Treatment
Thursday, November 30, 2006
On a Monday morning this month, 10 mentally ill people were brought to Inova Fairfax Hospital for hearings to determine if they should be hospitalized. But because Fairfax County had no independent evaluator available to assess them, eight were released without receiving treatment.
Fairfax has since lined up enough psychologists to resolve the situation. But a month-long shortage of independent psychiatrists and psychologists in Fairfax has led the Virginia Association of Community Services Boards to push for a law that would allow mental health professionals from the local boards, or CSBs, to perform the evaluations when no one else is available.
If it is passed, the law will validate a practice used in Loudoun County, and sometimes in Prince William County and Alexandria, whereby CSB staff members are used to evaluate people before their involuntary commitment hearings. Lawyers for the mentally ill in Fairfax successfully argued that because CSB staff members do the initial screening for temporary detainment, a conflict arises if a CSB employee also does that person's independent evaluation.
"We see no conflict of interest at all," said Mary Ann Bergeron, executive director of the state association of CSBs. "CSBs do not run hospitals, they're stewards of public funds. People get treatment if they need it, not because it's nice to have. No one's going to make any money out of this."
Bergeron added, "What we decided to do is to help Fairfax, and conceivably all other localities," by introducing a bill that would clarify state law. State law says an independent evaluation must be done by a qualified mental-health professional who has no financial, familial or professional interest in the person's case, but the law does not say whether a CSB staff member meets the definition of "independent."
John C. Whitbeck Jr., a lawyer who oversees a George Mason University law school clinic that represents families of the mentally ill, said, "This is not just a legal issue, but a public health and public safety issue as well." Dozens of mentally ill people in Fairfax were released between mid-October and mid-November because of Fairfax's interpretation that CSB members were not independent under the law.
"If the legislature does not act," Whitbeck said, "many mentally ill individuals will not get the treatment they need."
The commitment process in Virginia begins when a relative, residence manager or mental health professional decides that a person needs hospitalization and is too disturbed to voluntarily commit himself or herself. A member of the Community Services Board, which provides mental health services in every county or region in the state, does a pre-screening report for a magistrate. If the report convinces a magistrate that help is needed, the magistrate issues a temporary detention order to hold the person for about two days, until a commitment hearing can be conducted.
Before the commitment hearing, a lawyer is appointed to represent the individual, and an independent evaluator is assigned to interview the person and provide a report at the hearing. In Fairfax, the CSB hires private psychologists to perform this service, though it temporarily ran short beginning last month. When the CSB began using its own staff psychologists and social workers, the special justices running the hearings decided they were not independent and dismissed those cases.
But approaches differ throughout Northern Virginia. In Loudoun, the CSB uses psychiatrists who regularly work part time for the board or its own staff psychologists, said Deborah Snyder, the program manager for the CSB's emergency services.
Fairfax is able to pay private psychologists $95 to $105 an hour, but most other counties, including Loudoun, "are not in that position," Snyder said, and pay a flat fee of $75 per case. Fairfax also has its hearings at 7 a.m., to keep from interfering with the private practice of lawyers and psychologists, but Loudoun's are at 10 a.m., further reducing their appeal to private practitioners, Snyder said. So the CSB turns to its own people, and "according to our county attorney, we're within the law," Snyder said.
"I don't know what's happening in Fairfax, but I hope it's not contagious," Snyder added.
Psychiatrists at Prince William Hospital, where the mentally ill often are placed on temporary detention orders, typically serve as the evaluators, said Rita Romano, Prince William's CSB emergency services manager. But when a person is detained elsewhere and the doctors will not serve as evaluators, Romano must try to find an outside psychologist or psychiatrist.
Prince William pays $130 per case, but that often isn't enough to attract interest.
"And then it does default to the CSB," Romano said. "We've not had any problem with special justices throwing cases out." But she added: "We try not to be the evaluator, because we are the pre-screeners and sometimes we also have to serve as the petitioners. It doesn't look good, and it doesn't feel good."
Alexandria has a complement of independent psychologists "who are consistently available," CSB emergency services director Liz Wixson said. "A handful of times we use our own staff," Wixson said. "Nobody's ever objected."
Arlington will use only independent psychologists, and "we've never offered ourselves up" to serve as independent evaluators, said Leslie Weisman, the county CSB's client services supervisors. "And we wouldn't. We're just not comfortable with that, and it does feel conflictual."