Wednesday, Nov. 28 at 11 a.m. ET
Virginia Grapples With Rules For Committing Mentally Ill
Wednesday, November 28, 2007; 11:00 AM
Washington Post staff writer Tom Jackman was online Wednesday, Nov. 28 at 11 a.m. ET to discuss his story about how Virginia is considering reforms to its mental health system, starting with how to decide if someone qualifies as an "imminent danger."
A transcript follows.
Tom Jackman: Good morning, and thanks to all of you for taking an interest in Virginia's mental health situation. I hope you were able to find the continuation of the story in the print edition, which started on A-1 and continued on pg A-15 in Virginia's editions.
Anonymous: How likely is it that any of these changes could have prevented what happened at Virginia Tech?
Tom Jackman: This is obviously the key question. One change that's already occurred is that, where no one followed up on Cho to see if he actually received his treatment, now local Community Service Boards realize that they must do that.
Another change that has already occurred is that fewer special justices are ordering people into "outpatient treatment," because they aren't confident that it will actually be applied and enforced. A number of counties already weren't ordering it at all, for that same reason.
But changing the standard of "imminent danger" could possibly have gotten Cho much more intensive help, back in late 2005, and changed everything. Folks in Blacksburg would have realized, as his high school in Centreville did, that he had a special condition and needed help. No one at V.Tech ever spent the time with him to analyze and diagnose his particular difficulties.
Now whether his actions in late 2005, of writing notes on women's message boards and hinting at suicide, were enough to get him committed -- under any standard -- is certainly up for debate. But if he'd been committed, and gotten weeks or months of intensive help, it's possible he may not have exploded the way he did. Possible.
Arlington, Va.: What changes do you think will actually result from the state's efforts?
Tom Jackman: It's hard to predict the future. There is some apprehension in the state mental health community that if the "imminent danger" standard is lowered, many more people will enter a system which already doesn't have enough beds and/or mental health clinicians.
Then there's the question of money. Fixing Virginia's system, as we point out in the next chapter of this series, will require money for more beds, more crisis centers, more resources period. In most years, the likelihood of all that happening would seem slim.
But this year, in the wake of Va.Tech, with all these commissions and committees getting ready to weigh in, would seem like the best opportunity for the system to get the cash infusion it needs. So chances are better now than ever.
Arlington, Va.: First of all, I have read all your stories on this compelling subject with great interest. Keep up the good work.
My question: I know that the standards for committing a "dangerous" person vary greatly among states. Do you know if Virginia is looking for possible models to replicate here? Also, I would be interested to know where you think mental health advocates, in the main, stand on that issue. I know they think more resources should be devoted to mental health care, but are they for harsher or more lenient thresholds for forcible committal?
Tom Jackman: The models in other states don't vary too much. Most of them use words similar to "danger to self or others," without any specific criteria about how much of a danger, or in what specific time frame. It leaves the decision-maker, typically a judge or magistrate, with more latitude to examine an individual's circumstances and need for help. Virginia's commissions and committees have looked at those.
Now, judging the financial and social impact of changing the standard is something that people only now are examining. We're going to do that in a future article.
Which leads to your second question about where mental health advocates stand. Most, but not all, want a more lenient threshold. They think more people need help than have been getting it. But there are also folks who have had experience with the system, not all of it good, who think the standard is just fine where it is. They don't think the government needs to be forcibly treating people. "It's not a crime to be mentally ill," some of these folks would say. It's a valid view, and one that needs to be carefully considered before any laws are rewritten.
Alexandria, Va.: Thanks for your article. A probably unpopular comment I have is that although what these would-be criminals told professionals before they committed crimes was some crazy stuff, I do not think that locking people up against their will is the right thing to do. All of these were tragedies, but isn't this just how it is sometimes? Protecting ourselves from everything and everyone is impossible and I feel like the mental health system wants to move toward a prison system structure, which, as we know, is overburdened.
Tom Jackman: As I finished typing my last entry, this question came in. And "Alexandria" raises the point quite clearly. You can't lock up everyone. We can't protect ourselves from everything. It's a tough balance to strike, especially with an overburdened system. Well said.
Vienna, Va.: What do you think is the general opinion of law enforcement? The officer you quote in your story seems to see the possibility of looser standards for committal as a valuable tool, but I could see a downside. Namely, facing citizen complaints about making uninformed judgments about mental health.
Tom Jackman: Law enforcement seems pretty unified in the view that more people need help, and a lowered standard would get them that help. You raise a good point about citizens complaining about "street diagnoses" from officers. But the police wouldn't be making any final calls. They would simply be turning someone over to a magistrate, in Va., after they are examined by a mental health professional, and it's the magistrate who makes the initial decision on commitment. So that should insulate police from complaints or possible litigation. Should.
Herndon, Va.: Is there a "legal" definition of imminent danger?
Tom Jackman: Nope. Which is why you see such wildly different numbers from county to county on who gets committed. And while some of that is reflective of how, say, Northern Virginia looks differently at this issue than Richmond, part of it is because the state appeals courts haven't issued any rulings on it. Cases sometimes get appealed to local circuit courts, but rarely much further than that, so no legal precedent is established.
The Va. General Assembly could fix that by writing a more detailed definition of "imminent danger" into the law.
Outside the Beltway: This issue brings up the matter of privacy. All this yapping about patient privacy, signing that HIPA thing every time you get a prescription, the possibility of the Government (municipal and Federal) becoming Big Brother feed off this. There are lots of people we come in contact with every day who might be candidates for the Funny Farm. Some are squirrelly, some are very dangerous, some are psychotic, some harmless. We all can't be psychiatrists and commit every nut we meet daily. I work in an office full of legal types who scare the bejeepers out of me.
How did Cho get so far into a university setting without setting off alarm bells is beyond me. I think he should have been put away years ago.
Tom Jackman: On your first point, that's why we have standards, and magistrates and special justices, so we don't commit every, er, person we meet. But you're right, the fear of government getting bigger and more intrusive looms over all of this. And it will be a key part of the debate when the General Assembly tackles this in January.
Washington, D.C.: I have a friend who lives in Virginia, who is seriously mentally ill. She refuses to admit she is ill, so she also refuses to get treatment. Her family and friends have begged her to get help, but she won't listen and cuts off ties with those who suggest she needs psychiatric care.
She is paranoid, and believes that everyone around her is conspiring against her. What she thinks we are all trying to do to her remains unclear. Most of her friends at this point have abandoned her as they can longer handle her accusations. I'm worried she's going to hurt herself, or someone else. At one point she pushed a family member on the stairs. Later, she'll claim she didn't do it, and that we'll all making stuff about her to "get her" somehow. The family has tried desperately to get help, but have repeatedly been told that nobody can step in until she hurts someone or herself. At that point, it will be too late.
Meanwhile, she has not been able to work for several years, and her physical health is also deteriorating. I'm worried she's going to die because of her physical condition. What are we supposed to do?
Tom Jackman: These are the stories that mental health professionals in Virginia hear constantly. Many think that lowering the "imminent danger" standard would get people like this into treatment.
But people need to hear, and be reminded of, stories like this one. It's the crushing frustration that families face every day, and it doesn't go away. Not sure how to answer your question, but thanks for giving us this insight into how this affects real people in the real world.
Alexandria, Va.: Is there any empirical evidence that indicates that changing the standard has increased outcomes for people with mental illness? Do we know that people, say in other states with a different standard, actually are better off (i.e. mentally healthier)? Or is this like rearranging deck chairs on the Titanic? (in terms of an effective mental health system)
Tom Jackman: I haven't found this evidence, yet, but I'm looking for it. Maryland changed their standard several years ago, but does not have an agency which tracks the number of people who enter the system and their outcomes. Most states don't have that data. But I am trying to survey states that changed their standard, and will have that in a future story.
Manassas, Va.: A fine article. Question: Isn't the bottom line money and resources? I mean, I can't see how any of this can be changed without a serious investment of staff, willing social workers, a way to find housing for those who will really take advantage of it, etc. It seems like all this thrashing around about law and standards is pointless.
Tom Jackman: Yep, that's the bottom line. But there was one serious infusion of money, by Gov. Warner, a couple of years ago when Va. had a budget surplus. I believe it was $450 million. And now, with the momentum for change sparked by Va. Tech, it's possible that the legislature will find more money for these resources. Public pressure has to build in the next couple of months, though, or you're right, it'll be a lot of pointless thrashing around.
It's not a crime to be mentally ill: No, it's not. But I wonder how many people who say this have had to live with a parent, child, or sibling who was paranoid. It can be very scary to deal with a seriously mentally ill person on a daily basis. I have a friend who has gotten increasingly paranoid over the years, and I can no longer have contact with her because I'm afraid of her now. I say NOT treating her is cruel. One day I except her paranoia to get the better of her and she will harm someone she erroneously believes is trying to harm her. Why can't we protect ourselves, AND provide her with a better life? She cannot possibly enjoy living in her fantasy world of fear.
Tom Jackman: Well said. Thanks for weighing in.
Falls Church, Va.: Dear Tom, the Virginia code clearly states that there are two possible commitment criteria, one being "substantially unable to care for oneself." Why in the world do you state that judges and magistrates cannot order people into a treatment facility unless they meet this standard? (paragraph 4).
This looks like a serious factual error.
Tom Jackman: Thanks for reading closely. We did mention the second half of the commitment criteria in the 11th paragraph, under the "Legal Standards" sub-headline.
Arlington, Va.: Many specialists seem to trace problems involving the mentally ill back to the 1960s when the strategy of mass institutionalization was abandoned as "warehousing." Do you sense the pendulum may be shifting back that way? Whatever the answer, to that, if the state cannot come up with the resources for a popular idea like building more roads, where are they going to find the money for providing intensive care to a category of people that many would just as soon forget about?
Tom Jackman: As the pendulum swings back and forth, it would seem there would be a less severe option than the asylums of the past. Pete Earley's incredible book "Crazy" pointed out that Florida has let private companies build new modern facilities for people in need of long-term care. That raises a whole separate set of issues about profit motive impinging on need for treatment etc., but it at least establishes an alternative to state-run places.
You certainly raise a great point about where is the state going to find the money. But when we have people going out and committing murder, of police officers or college students, what's a more urgent need to be addressed than that?
Arlington, Va.: Just to clarify the previous post, there are very explicit provisions in the HIPAA regulations that allow for disclosing information to law enforcement in the interests of public safety.
Tom Jackman: This is correct.
Tom Jackman: That's all the time we've got. Thanks to all of you for your interest and your smart questions. I appreciate it. For more information on how other states approach this problem, and I meant to post this in an earlier response, the Treatment Advocacy Center in Arlington has a great website which has the laws and analysis of how all the states, and DC, handle treatment of the mentally ill. You can find it here:
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