Monday, May 07, 2007

The Awful Sound of a Ball Dropping - Update!

UPDATE: Since I first wrote this piece yesterday, I saw an excellent post from Catzmaw on Raising Kaine. Catzmaw is a lawyer and she explains in great detail the differences in the legal code under which a mentally ill person can be involuntarily committed and the flaws in the system.

I'm not going to try to summarize her very fine explanation. Instead, I'm just going to urge you to click on the link and read her superb diary on this subject. Thanks Catzmaw for shedding light on a topic that we cannot let fade from the public view.


Virginia definitely dropped the ball on Seung Hui Cho. And what makes this all the more disturbing is that it is not as rare as we would like to believe. According to an article in today’s Washington Post, journalists Brigid Schulte and Chris L. Jenkins report that Cho never received treatment that a judge in Blacksburg ordered for him after he was declared a danger to himself and others.

As the article points out, it is impossible to predict whether treatment would have prevented the terrible tragedy at Virginia Tech, but it might have averted it or at least made it far more difficult for Cho to purchase a gun.

Because of loopholes in Virginia law, Cho neither received court ordered treatment nor was he placed on a list that would have alerted gun shop owners not to sell to him. Given Cho’s serious lack of interpersonal skills, I suspect it would have been difficult for him to go out and buy illegal weapons on the street. The fact that he was so uncommunicative would have posed a serious barrier to his purchasing weapons from an illegal dealer.

But perhaps, even more important than limiting Cho’s access to weapons, timely therapy might have helped Cho back to a normal productive life. The greatest part of this tragedy was that this was a smart person who had a lot to offer society. He could have built a productive life rather than been the cause of so much destruction and tragedy.

And he’s not the first young person in Virginia for whom lack of effective mental health treatment and too easy access to guns led to a lethal result for others. Last year, Fairfax teenager, Michael Kennedy, shot and killed two police officers in a Sully District police substation after he walked out of a mental health facility. There were significant differences between the cases to be sure, but one thing was the same in both situations. These were two troubled young men whose behavior set off alarm bells among those who knew them yet didn’t receive treatment that might have saved their lives and the lives of their victims.

According to the Post, about Cho:

"Cho, they said, slipped through a porous mental health system that suffers from muddled, seldom-enforced laws and inconsistent practices. Special justices who oversee hearings such as the one for Cho said they know that some people they have ordered into treatment have not gotten it. They find out when the person "does something crazy again," in the words of one justice -- when they are brought back into court because they are considered in imminent danger of harming themselves or others.

" 'The system doesn't work well,' said Tom Diggs, executive director of the Commission on Mental Health Law Reform, which has been studying the state mental health system and will report to the General Assembly next year.

"Involuntary outpatient commitments are relatively uncommon in Virginia, officials said, because those in the system know they are not enforced. They are almost an act of faith."

I think society does have to proceed carefully when declaring any person a danger to himself or herself. To be sure, forty years ago, there were terrible abuses of the mental health system.

At that time, it was far too easy for a parent to have an adult child – usually a young woman – committed to a mental hospital as a method of interfering with his offspring’s choice of lifestyle. And adult children often had an elderly parent declared mentally incompetent and sent to facilities so that they could get their hands on their parent’s money. And in general, people were simply warehoused for years in substandard back building wards rather than treated and released. And all of that lack of care often cost the state lots of money. So, the move during the 60s to de-institutionalize mental patients was viewed as humane and pragmatic. That was especially true when new generations of drugs appeared that seemed to be capable of treating serious mental disorders while allowing patients to return to normal lives.

All of that was a positive development that ended years of abuse of people’s civil liberties and returned truly mentally ill people to society as fully functioning and productive citizens. But because of past abuses, the pendulum has swung too far. In many cases, such as those in Virginia, it’s extremely difficult to impose treatment on the mentally ill against their will no matter how desperately they need it.

But mental illness, by definition, is different from diabetes or heart disease. If I want to ignore my doctor and not take insulin or a statin for cholesterol, I have the right to make an informed decision. If I want to try chanting OM instead of taking a beta-blocker to lower my blood pressure, I’m guaranteed the right to make that choice. Nobody should protect me from my choices regardless of how foolish they might be as long as I hurt nobody else in the process.

But with mental illness, the sicker you are, the less you are able to make a decision based on informed consent. Unlike a physical illness, the more serious a mental illness is, the more likely it also is that the patient is out of touch with reality. The hallmark of a serious mental illness is the fact that the patient is delusional and is incapable of choosing care for himself. Such a person does not even realize that he is sick and out of touch with reality. To be blunt, he thinks the space men really are out to kill him in a devious plot and that he is totally justified in killing all of them to save himself. It’s self-defense. And such a person may also think that you or I are those deadly space aliens posing as human beings.

That’s an extreme and very over simplified example. But the impact of some mental disorders is that they can be dangerous to others besides the individual patient. So society has an interest in and a right to restrain that patient or to compel him to get treatment.

The problem is that we have no will and little resources to do this. Some extreme libertarians will argue that it is not the government’s place to provide care to sick people. That may be a valid argument for a diabetic who isn’t a threat to others. It may even be true for somebody with a depression who poses no risk to the public. But just as nobody in their right mind would argue that we ought to let dangerous criminals out of high security prisons because it’s expensive to keep them there for their full sentences, it’s ridiculous to argue that we shouldn’t ensure treatment, whether institutionalization or outpatient, for those whose mental illness makes them dangerous to others. That’s not being punitive.

In fact, in addition to the lives of innocent victims, the dangerously mentally deranged person is also a victim whose life might be saved. But only if Virginia stops dropping the ball and instead makes treatment a priority.
But with each passing tragedy, the sound of that ball dropping is getting too deafening to ignore.


concerned heart said...

Thank you for writing on this very important matter. There is another factor which needs to be discussed in the wake of this tragedy. The kind of mental illness evidence by this deranged person very often is caused by mutations in the DNA of sperm making cells of older fathers. Psychiatrists and pharmaceutal researchers have known about this robust risk factor for many, many years. Profits from drugs and psychiatry and research have prevented any public health warnings so we are at risk of more such individuals. If the public knew the truth about non-familial, paternal age related autism and schizophrenia we would not be having epidemics of both right now.
If you are at all interested in prevention of more and more people like Seung-hui Cho whose father was 38 or 39 when he was born he are some blogs and articles to read and possibly write about. Cryobanking of sperm is a real option for some in their mid 20s to 31.

Thanks again for writing about the safety of the nation and the failure to prevent mental illness that is basically not treatable.

Alison said...

If outpatient commitment hadn't been on the books in Virginia, Cho would have been committed to a hospital for up to 180 days, in which time it is far more likley that if he could have been helped by the MH system (and we don't know that) he would have been.

We need to get rid of outpatient commmitment in Virginia.

I really don't get your argument that you are not a danger to others if you don't take your insulin or blood pressure pills, you are, you are a danger to me, because you can end up ahead of me on the kidney transplant list when you didn't have to be there at all.

If by treatment you mean counseling, well Virginia has not invested the money to pay for it in the community. If you mean drugs, they don't work for people who are autistic or have paranoid personality and they can be very dangerous medically, so giving them to more people to prevent one person who may not have been helped no matter what is going to cost a lot more than 32 lives. People with mental illness treated in the community with drugs are already dying 25 years younger, how high are you willing for the mortality rate to go?

Also, it is a myth that institutionalization is no longer abused. Look at for the case of a woman committed by her husband when she wasn't ill at all whose life was ruined. It is also a myth that state hospitals on the whole are in better shape than they were 40 years ago. The DOJ just went in in Georgia due to 120 known suspicious deaths, Brooklyn's state hospital is being sued for neglect of basic standards and Virginia had the DOJ in several hospitals just in the late '90's.

Phoenix Democrat said...

The problem in this country is that the political will to help mentally ill people and to set up a system to make sure that people who are a danger to themselves or others get help is simply not here.

Too often in this country, Americans (conservative Americans especially) would rather be more punitive than to provide actual solutions. We are a million times more likely to throw people in jail than to give them the help they need to get on their own two feet.
Even if we were to take every miscreant in our society and blast them off our planet, the conditions we have in this country will only create more miscreants.

As long as our society continues to turn a blind eye to this problem, Seung Hui Cho won't be the last.

VA Democrat said...

A wonderful diary. Thank you for taking the time to give us this sad but important story.

AnonymousIsAWoman said...

There are so many issues to even try to respond to and I am far from an expert. But let me try to address some of your comments.

First of all, Concerned Hearts, you brought up information about risk factors that I am not at all familiar with. I will certainly check out your links to educate myself.

Alison, I'm not really sure how to answer you. First of all, though, I admit there can be unintended consequences for failure to treat physical ailments, such as kidney disease, and yes that could mean I'd be ahead of you on the list for a new kidney. Or my refusal to seek treatment could even raise your insurance rates because it would skew the statistics that actuaries use.

Nevertheless, I will stand by my belief that I, or anybody else, has a right to refuse conventional treatment for physical ailments. There are people who believe in alternative and complementary therapies. While I'm not one of them, I wouldn't deny a Christian Scientist or a Unity believer his right to choose her own way of treating his/her illness.

As for your other points, I honestly don't know quite how to answer you. Are you saying that we should do nothing for seriously mentally ill people because drugs don't always work and they have side effects? Your post ended with a sense of hopelessness. You may be right about the limits of treatment, but I think we need to try and to not give up on people. If I'm misunderstanding your intentions, let me apologize. It's just not clear to me.

As for abuses where people are still committed against their will, I don't know the laws in every state, but I'm sure it could happen. However, in general, it's difficult to get involuntary commitments. In most states, you can only be held against your will for 72 hours. And in Virginia, it's extremely hard to get an involuntary commitment for anybody.

I'm also not sure I'd do away with all involuntary outpatient commitments. But I think loopholes need to be closed and when a judge orders outpatient treatment, somebody needs to be tasked with following up to make sure the patient receives the therapy. And a report on the patient's progress should be given to the court at regular intervals.

Whenever possible, outpatient treatment is the most desirable, as long as there is follow up to make sure the patient is taking his drugs and making progress.

Institutionalization should be the last resort. But it should be used when necessary.

And Phoenix Democrat, you are right. There are too many people in our prisons who need therapy not punishment. No argument there.

And VADem, thank you.

Alison said...

Unfortunately, Catzmaw gets it wrong. Cho did not volunteer for committment, this is a known fact. Catzmaw also goes so far as to assert that no one should be able to volunteer for commitment nor have a say in their treatment. She also calls her former (current?) clients nuts. She says it is hard to get someone committed in Virginia, well only if you call 81% either involuntarily or voluntarily committed at hearing "hard".

She also omits the fact that committment in this state, unlike most states, is for up to 180 days, or 6 months. She also conflates mental illness with incapacity, which as a lawyer she should know the difference in law.

It takes hundreds of committments to prevent one arrest, not even an arrest for a violent crime, how many people are you prepared to have lose their liberty and have their lives shortened to prevent one arrest?

It's easy to give up freedom for security when it isn't your freedom you are talking about it, isn't it?

If my post sounded hopeless, it is because the situation is dire. There are effective non-drug treatments and minimal drug treatments that work to help people recover, but they are not available to most people in Virginia and elsewhere because the American Psychiatric Association has basically sold out to big pharma and studies that show that non-drug appproaches such as psychotherapy in combination with minimal drugs or no drugs work better never make the news or become accepted practice.

In Virginia, if you need and want psychotherapy, you better have the money to pay for it or really good insurance because you aren't going to get it at most CSB's.

And the drugs aren't producing "side effects", they are literally shortening the lives of people who take them long term by many years and creating serious medical illnesses such as diabetes and heart disease.
I feel hopeless when I read intelligent people falling for the propaganda of the psychiatric establishment and the forced treatment lobby which is so well funded in this country. If intelligent people can't see through the propaganda and think things through for themselves, we are in big trouble.

AnonymousIsAWoman said...

Alison, I don't disagree with your concern for the civil rights for the mentally ill. But the simple truth is that there are some people, and it's a very small amount, who truly are dangerous, both to themselves and others. They should not be in the general population without treatment, effective follow up and a structured environment.

I also agree with you about the dangers of drugs. Many of those drugs have horrendous side effects. For those who can benefit from non-drug therapies, such as cognitive therapy, which has been shown in scientific studies to be as effective as the leading anti-depressants for some forms of depression, of course, that should be the first course of therapy.

But what non drug therapies work for those who have had a psychotic break or have been diagnosed as schizophrenic? Those illnesses often have a physical cause, usually chemical inbalances in the brain.

If there are effective non drug therapies for those people, I'd certainly be intereested in hearing about it.

I would even offer you a guest post on my blog to write about non drug therapies and other issues. When I get back into town, if you are interested in pursuing that, we can.

Alison said...

I would be glad to do that when you get back into town. There are 2 new research studies off the top of my head about successful treatment of psychotic disorders through long term psychotherapy.

The question remains, don't bad cases make bad law? Or if it is a very small group, as everyone seems to agree, than why are proposals coming out that target a much, much larger group?

AnonymousIsAWoman said...

Alison, if you would like to do a post, please email me at I don't know how to get in touch with you otherwise.

If you get in touch with me, we can make arrangements for you to send me something, and I will be glad to put it up. I am very interested in learning about and publicizing non-drug treatments for mental illness. Especially, if you know any non-drug alternatives for treating Schizophrenia.

I know therapists have gotten good results using cognitive therapy to treat depression but I honestly didn't know there were alternative talk therapies that worked for more serious psychosis because I thought those were mostly bio-chemically based.

Anyway, I look forward to hearing from you.

Catzmaw said...

I just found out that Alison is accusing me of getting it wrong on my RK diary. I believe she posted a comment there, and I responded in full to her assertions there. Alison claimed I confused incompetence with incapacity, which is certainly nowhere within my diary and makes me wonder how carefully she actually reads things before going on the warpath, and also appears to have judged me as a callous individual solely because I used the term "nuts" to describe the degree to which someone has to be gone before he can be involuntarily committed under Virginia's law. It's just silly to take a statement out of context like that and use it to stage an attack on the author.

Re Alison's complaints about Big Pharma, there's plenty of room for agreement about the failure of psychiatrists and others within our mental health system to use non-drug methods, but it's not just the fault of Big Pharma. The fact is that mental health insurance is almost non-existent in our system, and public funding of mental health programs and services is feeble and miserly in the extreme, geared mostly toward group therapy of substance abuse addicts and hospitalization of the most extreme cases. Until we fix the funding of services there is no way we're going to see a transition to time-intensive psychotherapy. Frankly, it's just easier to write a prescription and send the patient on his way. And, of course, the success of psychotherapy is directly related to the desire for change within the patient. Since a lot of my clients see absolutely nothing wrong with the way they view the world or behave they are very poor candidates for psychotherapeutic intervention.

AnonymousIsAWoman said...

Thank you Catzmaw for pointing out some of the problems with non-drug psychotherapies. I believe the biggest obstacle to it is the insurance companies working in tandem with Big Pharma.

Certainly, there is a place for drug therapy, especially with somebody in an acute psychotic breakdown. But drugs should be viewed as a temporary treatment to restore some balance, not as the goal of treatment.

Many of the psychotropic drugs have really, really bad side effects, which I have witnessed first hand in other people.

I suspect Alison is very angry at what she sees as an important issue that even the most educated and progressive members of our community too often misunderstand and know too little about.

Certainly, I didn't know as much as I thought I did about it. I'm giving Alison a guest column tonight to explain her thoughts more fully.

I also think if she knew you as well as the RK community and I do, she might not have taken such offense at your statement. I know that you mean well and have miles of compassion. So do your other readers.

I would like to show Alison that on the actual issue, we are willing to learn.

And thank you for coming here to post comments. You are always welcome.