Wednesday, May 16, 2007
Imagine better mental health care
Elizabeth Strother
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From the RoundTable blog
Imagine if before Seung-Hui Cho got the guns, before he talked of suicide, before he scared college classmates and professors, before he even went to Virginia Tech, he had received all the mental health care he needed.
Imagine that today we weren't still mourning the people Cho killed at Tech and I wasn't writing about whether mandatory outpatient treatment makes sense because it -- or something short of it, or something more -- had prevented his spiral into violence.
As the governor's commission investigates all the various aspects of the April 16 shootings, the picture we in the public need to keep in our minds is a mental health system that works better.
The tragic drama at Tech shouldn't let any of us look away anymore.
"This is huge because of its impact showing the significant flaws of caring for people on the boundaries of risk," Jim Sikkema told me when I called the other day.
Sikkema is executive director of Blue Ridge Behavioral Healthcare, the Roanoke Valley's community services board. It is a parallel agency to the New River Valley CSB that was supposed to have monitored Cho's treatment plan -- had it known he had one.
A special justice had ordered Cho in December 2005 to get outpatient treatment. Virginia is ambiguous on who is to track a patient's compliance, and a CSB spokesman has said the agency had not even been notified that an order had been issued.
Last week, the state Department of Mental Health, Mental Retardation and Substance Abuse Services revised the form mental health special justices use, clarifying that the CSB is to notify the court if a person is noncompliant.
"That will not, in itself, solve the problem," Sikkema said. The state closed one gap in the loop of accountability. "But the form creates an expectation that doesn't exist."
I had called Sikkema to ask him to explain what seemed, to me, inexplicable: How can treatment for serious mental illness be both mandatory and outpatient?
"I'm perfectly fine with mandatory outpatient treatment," he said, "but the services really need to be in place to really make it work, rather than just a paper trail."
Consumer groups -- people who need these services and their advocates -- have concerns about mandatory treatment, given that the overwhelming number of people with mental illnesses are not dangerous. They have a reasonable desire not to lose their rights and be treated, essentially, as criminals when they have committed no crimes. They have an illness of the brain.
"Huge numbers of families [of mentally ill people] want to see mandatory outpatient treatment," though, Sikkema said. "It would put hooks in their treatment plans. It would assure their adult children receive the treatment whether they want it or not -- out of caring."
Research suggests that whether or not people get the individual community-based services they need, though, has less to do with whether a court mandates them than with their availability at the level of intensity required.
People sick enough to be ordered to get outpatient treatment need plans that are "highly individualized and extremely intense to give them what they need and to manage the risk" to public safety, Sikkema said.
Mary Ann Bergeron, head of the Virginia Association of Community Services Boards, acknowledged in a phone interview that there has been a lot of variation across the state in interpreting and applying the law covering involuntary commitments and mandatory outpatient treatment.
The revised commitment forms "have clarified a number of pieces of this process," she said, though she thinks there's still room for interpretation -- and a big need for training.
Changes in the law itself "ought not to be a knee-jerk reaction. They ought to be very considered," she said.
"There are still so many things we don't know about the incident," she warned. Cho's treatment history is not part of the public record.
"All of these sections of the code are being closely scrutinized," she pointed out, by the Supreme Court of Virginia's Commission on Mental Health Law Reform, which is expected to make recommendations next year. Bergeron is a member of one of the commission's task forces.
Should people who are not hospitalized but ordered to get outpatient treatment be coerced to take medications that are part of their treatment plans, but which they don't want to take, I asked her. Is that part of the bargain they strike to live in the community?
"I don't think you can do that, at least without court intervention," she said. "There are consumers who experience life-threatening side-effects." But, she stressed, "many consumers say the benefits overcome the side-effects.
"There are thousands of mentally ill people taking their medications, receiving supportive services and working who are under the care of community services boards -- who are complying with their regimen and living successfully in the community.
"It is also very true, it is hard for people who do not have stable homes to keep to their medication regimen. There are some survival things, if they're not present, it's harder for them to comply." The top three on her list: medications, a case manager and housing.
Virginia does have some intensive community treatment programs, but because they are expensive -- and difficult to staff -- they are reserved for the sickest people, with histories of hospitalizations and perhaps incarcerations.
"We really and truly do not have those resources for people who are not exhibiting the kind of behavior that would make people very alarmed, that would tip people off," Bergeron said.
Because community services must focus on the very sick, Bergeron and Sikkema agreed, resources aren't available to help people before they reach that stage.
"People who are less ill, in the beginning stages of their disease, we can't see anymore," Sikkema lamented.
Bergeron mentioned young children in need: "We're seeing young kids who need services now who are 4, 5, 6, 7 years old. They're not all that young, but they are seriously emotionally disturbed. It's rising to a level of great concern."
She said the state distributes about $6.4 million a year to the CSBs to provide services for children and their families, and localities contribute funds, too. "They serve a lot of children. That money has been used very, very well.
"And we need more."
Imagine all of Virginia's disturbed children having all the mental health care they need.
Strother is on the editorial board of The Roanoke Times.
