Kyle Green | The Roanoke Times

An empty gurney on the seventh floor of Catawba Hospital.

Stephanie Klein-Davi | The Roanoke Times

The front doors of St. Albans Behavioral Health Care Center in Radford.

Commitment process

A process of evaluation Virginia sets a higher threshold than most states for ordering someone into mental health treatment. Committing someone to in- or outpatient treatment can only happen after multiple evaluations and a special justice’s decision that a person presents an imminent danger.

• A magistrate may issue an emergency custody order if someone is believed to be having a mental health problem. The custody order allows authorities to hold the person for four hours while an initial evaluation is conducted by the local community services agency.
• If the initial evaluation finds the person is an imminent danger to herself or others, a temporary detention order may be issued. This allows the person to be held for 48 hours or until the next day that is not a weekend or holiday. During that time, an independent evaluation is conducted and a commitment hearing is held.
• At a commitment hearing, a special justice or judge reviews the initial evaluation, the independent evaluation and whatever other information may be available, then decides if the person should be committed to an institution for up to 180 days, ordered to undergo outpatient treatment or released.

Recommendations scheduled

• On Aug. 30, the Virginia Tech Incident Review Panel is scheduled to issue its report, including recommendations for the state’s mental health system.
• The Commission on Mental Health Law Reform is scrambling to get a preliminary report and interim recommendations out before January, said the group’s chairman, Richard Bonnie. The commission’s full report won’t be written until next year, with public hearings by summer and a final version prepared later in 2008.

If there's one thing that's certain at the odd nexus that is Virginia's civil commitment system, it is that change is on the way.

This is the intersection of the legal and medical systems, where a person with mental illness can be forced into treatment.

It is where Seung-Hui Cho, some 16 months before the campus killings that made him infamous, had his tantalizing, frustrating brush with mental health care.

Next week, the first of what promises to be multiple recommendations for reforms is expected as the state panel reviewing the Virginia Tech shootings presents its report.

And the Commission on Mental Health Law Reform, a state body that has been working for a year, is hustling to put out its own suggestions before the General Assembly -- spurred by the April 16 shootings -- delves into mental health law.

Even before Cho turned from disturbed Tech student to mass killer, a state study found that no one, not patients, doctors or judges, was happy with Virginia's civil commitment process.

But whatever changes come, the process will remain a mechanism for answering a basic question: When are people with mental illness a danger to themselves or others?

Recent visits to commitment hearings at Carilion Saint Albans Behavioral Health, the mental health wing of Carilion New River Valley Medical Center, found mental health workers, patients and patients' families struggling through the complexities of determining danger.

Saint Albans is where Cho was held overnight in December 2005 after he instant-messaged a Tech roommate about suicide. The room where Barnett and Teel each month swap roles as advocate and justice is where Cho was the subject of a commitment hearing, and where Barnett decided to release him with an order to get outpatient care.

In Virginia, as in just a handful of other states around the country, the legal threshold for forcing someone to undergo mental health treatment is imminent danger. A special justice who decides someone is about to harm him- or herself, or others, or is so ill that they cannot care for themselves, can commit the person to an institution for up to 180 days.

The special justice also can order someone to accept treatment on an outpatient basis.

Barnett has declined to discuss his decision not to send Cho into inpatient care.

Lynn Chenault, who had been executive director of New River Valley Community Services for two decades when he retired last year, said that while he knew nothing about Cho at the time, what he has heard in the wake of the shootings makes Cho's case seem relatively ordinary. In late 2005, Cho was a depressed college student who had been visited by police after another student complained of harassment.

Though Cho's initial exam by community services found he was an imminent danger to himself, which is why he was taken to Saint Albans, the standard independent evaluation by a psychologist concluded he was not a danger and did not require hospitalization.

It was the midst of exams at Tech, and the semester would soon end. Chenault speculated that a special justice might not want to disrupt a student's schedule too much.

Deciding what danger a person may pose -- or what danger they may pose in the future -- is "not an exact science," Chenault said.

Forty-five states set the trigger for compelling mental health care at something short of imminent danger, according to the Treatment Advocacy Group, a national nonprofit devoted to removing barriers to mental health treatment.

In the wake of the Tech shootings, some Virginia legislators said the imminent danger standard should be reviewed and that perhaps it should be easier to require someone to undergo treatment.

Blacksburg resident Edgar Howard said he thinks it's already too easy for authorities to take a mentally ill person into custody.

A 57-year-old former electrician who said he has a long history of depression and anxiety, Howard went to the community services office in Blacksburg on July 23.

Howard said he wanted to make a counseling appointment for later in the week, but, "The next thing I knew, the deputies come, handcuffed me and took me to Saint Albans."

Howard's account of how that occurred and the record kept by New River Valley Community Services are in basic agreement: A counselor quizzed him about guns and suicide, and he said that while he was depressed and angry, he had no desire to hurt himself or anyone else. He said he did not want to go to a hospital for further evaluation.

Community services thought that was advisable, however, and Howard was held in Saint Albans for two nights under a temporary detention order. Then a commitment hearing was held and Howard was released on July 25.

Howard, who has been writing to legislators and local governments to ask that the community service agency's funding be cut, said he thinks his hospital stay was the result of a new wariness on the part of authorities.

"I think they have just way overreacted to the Cho shooting," he said.

Special justices are basically specialized general district court judges, but with powers sharply limited by their courts' location at the junction of medical and legal realms.

The Tech shootings brought a spotlight to this limitation, highlighting Barnett's inability to ensure that Cho attended outpatient treatment. Privacy laws have so far cloaked whether Cho kept the appointment made for him at Tech's Cook Counseling Center or whether he received any care in the more than a year between his appearance before Barnett and April 16.

It is impossible to know, of course, if any treatment would have prevented the deaths of 33 people, including Cho, and the injuring of about two dozen more.

Barnett said his interpretation of state law is that he has few options when someone disregards an outpatient order.

As a judge, he could hold someone in criminal contempt and send the person to jail, which hardly seems helpful in mental health cases, Barnett said.

He also could seek to bring the person back through the process of another commitment hearing, and if the person is found to present an imminent danger, an inpatient admission order might be made. But by itself, refusing to follow an outpatient order doesn't justify a finding of imminent danger, Barnett said.

Richard Bonnie, chairman of the state Commission on Mental Health Law Reform, said his group's ongoing review of mental health practices has found significant variations in how outpatient commitments are handled across Virginia, and that it's a rarely used option, chosen in about 8 percent of commitments, according to the most recent figures.

As his commission prepares recommendations, it will look at what would be needed to allow outpatient orders "to be used more effectively," Bonnie said.

Sam Mela hopes the various recommendations heading toward the legislature won't just be suggestions to make it easier to send people into hospitals.

A longtime mental health advocate and former community services board member in Lynchburg, Mela created vatechcoverup.com, a Web site that uses the Tech shootings to draw attention to what Mela calls a lack of openness and accountability in Virginia's mental health system.

His suggestion for improving care is to do away with confidentiality rules that keep the public from seeing what occurs inside mental health institutions.

"Just put a little sunlight in there," he said.

In the wake of the Tech shootings, New River Valley Community Services is finding itself stretched, co-director Harvey Barker said.

For one thing, coverage of Cho's case brought out that there was no community services representative at his hearing and that after Barnett ordered outpatient care, the agency had not carried out its state-mandated duty to recommend a treatment plan for him. Instead, a Saint Albans worker helped Cho make his appointment with Tech's counseling center, which has a policy of not accepting court referrals.

Chenault, the former director, said he did not recall a decision to stop staffing all commitment hearings. He said he assumes that when his staff learned Cho's independent evaluation had not recommended treatment, the social worker who might have attended went on to other duties.

Barker said that staffing at commitment hearings declined after special funding for that purpose ended. "We were always available by phone," he said.

Now the agency again is attending hearings at Saint Albans.

It also is dealing with a jump in requests for outpatient care such as counseling. These are up by about a third since the Tech shootings, Barker said.

There has been a similar increase in calls from schools, police and others for mental health evaluations, from about 100 calls per month to 150. When there is an emergency call related to mental health, the law gives community services four hours to conduct an initial examination and, if more review seems necessary, to find a hospital bed where the person can stay for up to 48 hours while awaiting an independent evaluation and a commitment hearing.

About half the calls that community services gets each month end up in commitment hearings, Barker said.

"It's a clinical judgment," Barker said of the decisions his agency makes every day.

A person can be dangerous at one point, then -- perhaps after a day to calm down in a hospital, or just by being removed from the stress of daily life -- may no longer be the imminent danger that the law requires to act.

A person might seek treatment himself, or refuse to be treated. Medications that worked once may become less effective. Family and work can affect someone's condition.

Each case is an individual tangle that mental health workers try to sort out using whatever information and time are at their disposal.

It's a job that gets harder as demand rises. After the shootings, New River Valley Community Services applied for $350,000 in special federal funding to hire more staff, Barker said.

But the money is tied to disasters, and has to be used within a year of the event.

Four months have passed since April 16, Barker said, and the agency has not heard if it will get the grant.