Massacres revive debate on involuntary commitment, better treatment

By Mary Winter

Mass shootings in Colorado, Connecticut and, most recently, in Southern California, where police say an ex-cop gunned down four people, raise questions we cant begin to answer:

Did the shooters give warning signs we failed to spot? What caused them to snap? Could earlier mental health interventions or tougher gun laws have prevented the tragedies? And finally: When do we need to lock up mentally ill individuals for our own protection?

The subject of forced hospitalization of potentially dangerous mentally ill people known as involuntary commitment has gained currency in the immediate aftermath of the killings. Had a stricter involuntary commitment law been in place, some argue, suspected shooter James Holmes might have been in a psychiatric hospital rather than an Aurora movie theater on the night of July 20, 2012.

But many experts believe involuntary commitment is a specious solution to a very complex and poorly understood problem.

Involuntary commitment laws may very well need to be beefed up, say many, but such a move in itself is no guarantee we can prevent massacres like the ones in Aurora and Sandy Hook.

Whats really needed, they say, is more public education surrounding mental illness, a shift in attitudes and, most of all, more money and resources dedicated to treating mental illness before it progresses, and, in those rare cases, culminates in violence.

Mental health issues need to be viewed like other manageable illnesses, said Michael Lott-Manier, public policy and advocacy coordinator for Mental Health America of Colorado. The problem is making sure (patients with mental illness) follow up, and that they take their medications. If we have cancer or diabetes, we get care on a continuum. We dont have the same level of awareness with mental health.

Civil rights vs. safety

Colorados involuntary commitment statute allows police and courts to hold a person in an emergency room or mental health facility for 72 hours if hes deemed an imminent danger to himself or others, or is gravely disabled. The courts can order additional inpatient or outpatient therapy.

Last year, about 2,800 involuntary holds occurred in Colorado, and up to 500 of those patients were ordered into longer-term therapy. This year, in the aftermath of the Aurora shootings, state lawmakers may make it easier to put a person in an involuntary hold by changing the criteria from imminent danger to a substantial probability of danger. Rep. Beth McCann, D-Denver, has agreed to carry the bill, which would also consolidate separate statutes for alcohol, drug and mental illness holds to make them less confusing.

Scott Glaser

Scott Glaser

But opinions about the merits of the imminent vs. substantial probability language are mixed. As an organization, were divided, said Scott Glaser, executive director of the National Alliance on Mental Illness of Colorado. How do you define substantial probability? On one hand, you have consumers who are worried about violating an individuals civil rights, but on other hand, you have family members who know their loved ones are possibly dangerous, or who feel endangered themselves.

Lott-Manier agreed that crafting an involuntary commitment law thats fair to all involved is a delicate balancing act. Parents of adult children with mental health issues have a right to call police and ask for an involuntary hold if they fear they are dangerous, just as individuals have a right not to be hospitalized without consent.

But many in the field say mass shootings while horrific are only one aspect of a larger problem. Every day, the quietly depressed take their own lives or the lives of others. The really dramatic events are rare, but they call attention to the fact that there are lot of people who suffer every day, said Andrew Keller, PhD, a clinical psychologist and partner with Boulders TriWest Group. Keller and many others say the threshold for getting treatment for mental illness needs to be much lower and the level of resources much higher.

While Colorado has 17 community mental health centers, not all of them offer walk-in services for patients with urgent mental health needs. The Metro Crisis Line at 1-888-885-1222 is staffed by professional counselors 24/7, but doesnt serve the entire state.

Moe Keller

Moe Keller, a former Colorado legislator and currently vice president of public policy for Mental Health America of Colorado (no relation to Andrew Keller), said states can play with the wording of involuntary commitment statutes, but in the end, what matters is money.

States that have expanded the language to substantial probability have not seen an increase in the actual number of persons referred to be evaluated in emergency rooms because the resources arent there anyway, she said. Its not worth anyones time, particularly law enforcement, upon whom this generally falls. If indeed we want to get treatment to people, we have to have the resources. Why change the statute if youre not going to follow through on the back end?

Follow-up services inadequate

In the current system, a person on an involuntary hold is kept in a hospital emergency room and evaluated within 72 hours. Within those three days, Moe Keller said the person generally has calmed down or has been medicated, and is released back on the streets. Theres no follow-up, no family contact, no transition plan and no advice or information on where to seek treatment in the community, she said. Their obligation is over. Done. Boom.

Its a common practice to have an individual, whether involuntary or voluntary, sit in the ER for three days and then go home They sit there on a cot because no one really wants to pay for a residential placement, and we dont have enough bed capacity, said Moe Keller. No one wants to pay for having someone in a facility, whether private or public. Theyre expensive, and theyre not profitable.

The annual cost to house a prison inmate is $32,000 to $38,000, she said. A one-year stay in a psychiatric facility such as Fort Logan, on the other hand, is close to $100,000. But to have an individual successfully treated in the community is about $7,000. So why dont we do the community piece? Because we have been unwilling to put money into the community. Were going to pay its just a matter of where we pay.

Moe Keller added that the goal is certainly not to keep a person in a residential setting. But there is that safety net piece: you have to have the Fort Logans and the Pueblos and psychiatric units in other hospitals to be there for individuals who really need that support in residential settings.

Years of neglect

Since the start of the recession in 2009, mental health treatment programs have been cut by $4.6 billion nationally, escalating a years-long funding decline, she added. Weve had 20 years of real neglect in terms of dealing with this population and their families.

Like others interviewed for this article, Moe Keller pointed out that while schizophrenics can be dangerous, they are generally not homicidal, and that mentally ill individuals are more likely to be victims of violence than to be perpetrators. Ninety-five percent of violence with guns is committed by people who do not have a mental health issue, she said. Since Sandy Hook, 1,600 people have died by guns and nobody pays any attention because they re not large numbers at one time. Theyre domestic violence, gang-related, or some guy who gets mad at his employer, or the guy who stalks his girlfriend after she breaks up with him. That stuff goes on every day.

Our culture is violent, she said. Our concern at Mental Health America is that there is a perceived and somehow manipulated perception that if we do something about individuals who have mental illness issues, that everything is going to be all better, and its not, in terms of violence with guns.

Lott-Manier, Moe Kellers colleague at MHA, added that of the 31,000 deaths from guns every year, 19,000 of them, or 62 percent, are suicides, according to the Centers for Disease Control. We see guns as a public health issue, he said.

In response to the recent mass shootings, some in Colorado are pushing for policies that would notify law enforcement agencies anytime someone with a history of mental illness buys a gun.

Additionally, Gov. John Hickenlooper has called for an annual $18.5 million increase in spending for emergency mental health services, including the creation of five 24-hour walk-in centers.

Glaser, of NAMI, said he likes what Colorados elected leaders are doing to bring attention to the problem. Im happy about the $18.5 million from the governor, but its not enough. If the question is, Does this give us the ability to meet the need for ongoing care? the answer is No.

Lott-Manier pointed out that every day, 19 people are on a waiting list for a psychiatric bed in Colorado, and that in terms of beds per capita, Colorado ranks 48th of 50 states. Often, its the homeless . . . the transient male population which is at the biggest risk for suicide, domestic violence and criminal behavior.

Lack of resources and commitment is the core of the problem, Lott-Manier said. Any change must come with the commitment of funds.

Model involuntary commitment law

Two mental health professionals, Psychologist Andrew Keller, and Dr. Sara Stein, a psychiatrist, offered their views on how to improve involuntary commitment laws to enhance the safety of communities.

Psychologist Andrew Kellers opinion:

The best involuntary commitment law is one that never has to be used because the mental health, addictions, public safety and broader health and human service systems coordinate care and provide ready and proactive access to a range of assertive outreach, urgent access, crisis line, mobile crisis, crisis residential, hospital and ongoing treatment options that are research-based, trauma-informed, recovery-oriented and committed to ongoing, transparent and data-driven quality improvement.

Until we reach that state, there will never be an ideal involuntary treatment statute there will simply be a series of attempts by advocates on both sides of the question to balance civil liberties and safety. Involuntary commitment is primarily a political question, not a policy question. A listing of current involuntary treatment standards for most states suggests that Colorados employment of in need of care and gravely disabled standards already provides broader criteria for involuntary care than many other states.

People interested in increasing access to care for people at risk of harm to themselves or others are most likely to achieve their goals if they focus on moving Colorados mental health treatment systems toward the qualities noted above, which will likely require increasing Colorados investment in adequate mental health treatment further toward the top states per capita rather than its most recent ranking of 31st (in 2010). Colorado is a top tier state in so many ways why shouldnt it aspire to be among the better states in terms of its investment in quality mental health treatment? Even moving from the bottom half to the top half of states would be a marked improvement.

Dr. Sara Steins opinion:

Involuntary commitment the classic 72-hour hold is meaningless without 90-day renewable outpatient commitment after hospital discharge (when indicated), followed by intensive outpatient case management and halfway housing. Medications wear off in a few days or weeks, people stop taking them, they are lost to follow up, they relapse on drugs and alcohol. The ability to re-hospitalize someone simply because they failed to follow up is essential in the case of unstable mental illness. Unfortunately, many counties and states do not have this necessary provision.

In a phone interview with Solutions, Stein said, You can put people in the hospital, get some kind of commitment, but if you dont have follow up, including mandatory outpatient treatment with the ability to re-hospitalize simply for being noncompliant with treatment, then you have nothing.

It takes six to 11 months to stabilize psychosis or depression, Stein said. If patients are discharged after only a few days or a month, chances are they will land right back in the hospital. It becomes a costly revolving door.Civil rights concerns are not an issue because the majority of patients are not institutionalized, Stein said.

Theyre outpatients, living in an apartment, with their mother, or in group homes. No ones locked up. Were trying to keep them from being locked up.

We are saying you have to take your meds. Is that a violation of someones rights? I dont know. Is it a violation of rights to keep a schizophrenic on medication instead of having them push someone in front of a subway? You tell me.

Stein, a psychiatrist in practice for 25 years in Ohio and California, said Summitt County, Ohio has the best, most integrated mental health system shes seen. In addition to mental health courts, Summitt County has crisis-intervention-trained police, excellent outpatient case management, ample clinics and housing, and a populace that repeatedly has voted to fund mental health care, she said. Also key to the countys success is its power to re-hospitalize a patient for failing to show up at follow-up appointments.