The how and why of an officer's death

Last Friday, Officer Jason West of Cleveland Heights, Ohio, died in the line of duty.

An article on Sunday gave details on how he lost his life.

At 9:47 p.m., police received a report of a street fight.

As Officer West approached the scene, he stopped the car of Timothy Halton, 27, as he tried to leave. As West stepped out of his cruiser, Halton shot at Officer West from inside his own car. He then exited his car and shot West at close range. West was hit in the leg and face; he later died.

An article on Thursday detailed why the officer lost his life. Its title – Suspect in officer's killing didn't take his drugs: Agency couldn't compel medication for Halton

Nineteen days before that Friday, he showed up for a psychiatry appointment. Halton, who had been skipping his monthly anti-psychotic injections, again rebuffed his psychiatrist’s pleas for treatment.

That article also describes Halton’s history of violence and run-ins with police.

The story also contains pleas for treatment law reform that are always present but typically only gain light of the media in the wake of such a tragedy.

“Psychologist Fred Frese [and TAC Board Member] of Hudson says Ohio needs a law like New York's Kendra's Law, which gives judges greater authority to force mentally ill people into treatment. The law was named for Kendra Webdale, who died after a schizophrenic man pushed her in front of a subway train in 1999.”

We can only hope that the people of Ohio take heed of Dr. Frese’s recommendation.

Dispelling myths – Strongest support for AOT comes from people who could be saved by it

A commonly propagated myth in the mental health community is that people with severe mental illnesses oppose assisted treatment. In fact, some of the most articulate advocacy on this subject comes from people who have experienced the devastating consequences of untreated mental illness. Advocates like Jonathan Stanley, Valerie Fox, Donnie Buchanan, and Austin Mardon support interventions like assisted outpatient treatment (AOT) because they want to know that if they lose insight into their illness and begin to deteriorate, their families will be able to help them.

Mr. Mardon said it so well in his op-ed in the Edmonton Journal this week:

I live in constant fear of what will happen to me if I become extremely ill again. I am comforted knowing that if I become so ill that I can no longer understand the need for treatment, my wife and family will be able to legally get me the help I need.

Those who are against enforced treatment do not seem to understand that even those who turn their backs on the beneficial and appropriate treatment they could be receiving from their health providers, will receive some type of treatment.

The tragedy is that instead of receiving appropriate treatment from their physicians, they could receive inappropriate treatment at the hands of the criminal justice system; the rough, hopeless treatment of lives lived on the streets; or the finality of treatment at the hands of a mortician.

Treatment via criminal conviction

A 34-year-old Massachusetts woman will finally be getting the treatment she needs for her schizophrenia. Unfortunately, she had to enter the forensic system to get it.

Denise Bonilla pleaded guilty to assault and battery in court on Friday. As a result, she is ordered to participate in a treatment plan devised by the state.

Doctor’s examinations of Bonilla say she’s a different person when on her medication.

It’s too bad Massachusetts doesn’t have assisted outpatient treatment, and that citizens like Bonilla have to commit a crime to get meaningful treatment.

Confidentiality's unintended consequences

Albert Gibson was worried. His son Stephen, who had been hallucinating and seeing ghosts in their home, had been issued a pistol purchase permit. Under North Carolina law, once such a permit is issued, the sheriff’s office has few options for revoking it. John Aldridge, special deputy attorney general and a leading expert on North Carolina gun laws, explained that sheriffs must either ask the person to voluntarily relinquish their permit, or seek a court order to have it revoked.

And so Albert began working with the sheriff’s office to prove that his son was ill. Sheriff Donnie Harrison wanted to help, but needed documentation. And that’s where the system broke down. When Albert Gibson sought to obtain information regarding his son’s care, he was told that because his son was an adult the information was confidential.

Stephen died after four state troopers and a sheriff's deputy opened fire on him. Authorities say he had robbed a convenience store and led officers on a more than 70-mile car chase. According to the Highway Patrol, the officers shot at Gibson when they saw him holding a handgun as he emerged from the car.

Enough excuses – it’s time to take civil commitment laws seriously

It is heartening that there is a serious investigation of the failure to follow-up on court-ordered mental health treatment for Seung-Hui Cho who was determined to be “imminently dangerous.” But, the local Community Services Board (CSB) seems to be digging itself a bigger hole all the time with excuses.

First, when told that Virginia law requires the CSB to recommend treatment and monitor care for a court-ordered outpatient, a CSB spokesman responded - that’s "news to us."

Now, the CSB’s executive director says that “his agency was never notified that Cho was a candidate for outpatient treatment and was never ordered to devise a treatment plan as required by state law” – because no CSB representatives attend commitment hearings.

But, the CSB had to know about Cho. Unlike many other states, the CSB is the sole gatekeeper in VA. Nobody even gets before a special justice for a civil commitment hearing unless the CSB approves. I doubt the Legislature intended that the CSBs only be responsible for keeping people out of civil commitment. The statute ensures the CSBs evaluate all individuals before they enter the civil commitment process - so they always have notice of which individuals are in trouble.

Leading people to the door for commitment without meeting them when they come out is not a good excuse.

Undying love and the search for treatment

Without appropriate treatment options, parents of a grown child with severe mental illness are often the ones left to provide care. As care providers, families face a very real risk of violence. In fact, the most common victims of violence and homicides are family members, especially mothers. Despite this risk, families continue providing care and fighting for treatment.

“The first thing I thought of is … I can’t help him if I’m dead.”
- One mother’s reaction to her son’s attempt to harm her.

Waiting in vain – getting tx in Pennsylvania

Liz Spikol, managing editor of Philadelphia Weekly wrote an excellent article addressing the involuntary commitment standard in Pennsylvania. In Philadelphia Weekly and on her blog she writes of the struggle to get treatment for people who lack insight into their illnesses.

"Since I started writing this column eight years ago, I’ve been flooded with requests for help from readers trying to get treatment for sick relatives or friends who are too psychotic and delusional to know they need it. These people are almost always turned away from hospitals because they don’t seem to present a clear and present danger—Pennsylvania’s current standard for involuntary treatment."

"Now when caregivers ask me for help with an urgent situation, I tell them the truth: There’s nothing you can do. You’ll have to wait until it gets so bad, it’s life or death."

Senate Bill 226 was introduces to address this problem. The bill would change the stringent dangerousness criteria currently used in Pennsylvania and allow for greater use of assisted outpatient treatment. In short, SB 226 would help Pennsylvania’s sickest citizens get needed treatment.

In her article, Spikol says it best:

"No one wants to go back to the days when involuntary hospitalization meant months or years of spurious and damaging treatment. "

"But when there are more mentally ill people in prisons than in hospitals, you know there’s a problem that calls for serious measures."

We're all paying for a "playground for anti-psychiatric activists"

Dr. Sally Satel paints a vivid picture of how some federally funded mental health “advocates” are harming the most severely mentally ill and their families.

Take the case of William Bruce:

An appalling case of federally funded patient "advocacy" run amok was exposed just this month. On May 3, Robert Bruce of Caratunk, Maine, testified before the state legislature about his 25-year-old son, William. The young man had been a patient at Riverview Psychiatric Center from February to April 2006, where he had been committed after assaulting his father. Mr. Bruce and his wife were afraid of their son and begged the hospital to medicate him with the antipsychotic that had previously quelled his paranoia and aggression.

But William wanted to leave the hospital. Advocates from the Disability Rights Center, Maine's federally funded P&A, pushed for his release despite dire warnings from psychiatrists ("I find myself extremely concerned about this young man's potential for violence," reads one of many explicit notes in the medical record).

Nonetheless, the advocates insisted that William was "competent" for discharge and openly coached him--as a lawyer would his client--on how to placate the doctors so they'd let him go. William prevailed, and Riverview discharged him on April 20. Exactly two months later he murdered his mother with a hatchet. In his wrenching testimony before Maine legislators, Robert Bruce emphasized "the role that the patient advocates played in this tragedy."

Dr. Satel’s brilliant article makes the case that the P&A system, which Jean Isaac and Virginia Armat documented in their 1990 book Madness in the Streets as a "playground for anti-psychiatric activists" – needs to be reformed!

How many tragedies will it take?

Joel Seidel’s tragic death spurred reforms in Camden County’s jails, new diversion programs by police departments, and a federal lawsuit that was recently settled for $4 million. The one area that has yet to enact reforms? New Jersey’s mental health system.

New Jersey is still one of only eight states without the ability to order AOT for individuals who are unable to maintain their treatment in the community. Individuals like Joel Seidel, who according to news reports, had repeatedly refused to take medication for schizophrenia and had failed to complete outpatient treatment programs. An attorney for Seidel’s family explained that they hadn’t posed the $150 bail that would have released him because they were hoping he would be involuntarily committed to get the help he needed. Sadly, he never got that chance. His lifeless body was found about an hour before his scheduled court hearing on his involuntary commitment.

AB 2304, a bill that would finally provide New Jersey the opportunity to help those like Joel Seidel, sits in a committee awaiting action. It should be passed before the next senseless tragedy occurs.

15 or 16, but Not 17 – the Medicaid Numbers Game

Plug “16-bed” and “psychiatric” into Google and you will get over 26,000 results.

Hit on the first one and you’ll see that a full-time LPN is needed for the inpatient unit of a 16-bed psychiatric hospital in Muncie, Indiana. Delve further to find that a new 16-bed inpatient unit specifically dedicated to women’s mental health treatment opened in Westport, Connecticut last year. Also see that among the goals of an Arkansas provider is funding for four regional 16-bed adult inpatient facilities, one for each corner of the state. There will also be a link to a recent Associated Press story detailing that emergency rooms in New Orleans are flooded with psychiatric patients. One afternoon in one hospital, “18 of the emergency room's 23 beds held patients waiting for admission to a psychiatric ward.” A hospital spokesman commented that creating “a 16-bed psychiatric ward” would take months.

Doing the same search using “15-bed” yields a similar number (more than 20,000) and mix of items, but the results for “17-bed” are startling. There are only 681 results and most of them are links like those you sifted out in the other searches, ones where the two search terms appear to have only coincidentally been on the same page. You find out information like that there is a just-opened inpatient transitional medical care unit for patients in New Jersey with 17 beds. What 17-bed mental health care units there are mostly specialize in the care of children and adolescents or geriatric patients.

There are exceptions, such as a 17-bed medical/psychiatric unit attached to the University of Kentucky Hospital, but the conclusion is undeniable – there is a scarcity of 17-bed psychiatric facilities. The reason why, not surprisingly, comes from Capitol Hill.

The large majority of inpatient psychiatric care is paid for by either Medicaid and Medicare. The federal government reimburses states for a portion – typically one half or more – of the cost of the psychiatric care provided for people covered by these programs. When these governmental insurance programs where drafted and passed in 1965, care in “institutions for mental diseases" (IMD) was specifically excluded from Medicaid reimbursements to essentially force deinstitutionalization.

There are exceptions to this repayment prohibition; reimbursement is available for inpatient care rendered for minors and those over 65, in facilities where psychiatric treatment is given to less than half the patients, and in psychiatric hospitals of 16 patients or less. After forty years of operation, these artificial policy incentives have haphazardly sculpted the framework of inpatient mental health care – hundreds of hospitals have closed, juvenile care is largely unaffected, psychiatric patients have been increasingly mixed (albeit in a proportion less than 50%) into adult-care homes, and 17-bed psychiatric facilities are distinctly not en vogue.

Using AOT in Florida

Florida has an AOT law, but it’s rarely used outside of Seminole County. As a recent Miami Herald article shows, using AOT has been a great success for this county. Perhaps it’s time for others in Florida to do the same.

Fewer than 100 orders have been issued statewide, while thousands of people have been committed to mental hospitals. 'It's been hugely successful in Seminole County,'' said Sheriff Don Eslinger, who pushed for the law after one of his deputies was killed by a mentally ill man who wasn't taking his medication. "It's dramatically decreased homelessness, hospitalizations and violence in this population.''

Forty-four people have been committed to outpatient treatment at the Seminole County Mental Health Center, according to Dr. Valerie Westhead, the clinical director. "It's something that helps clients stay in their home community, prevents them from having to go to state hospital, and helps them to live their lives more the way they would like to live their lives.''

Police not at fault – failed mental health system is

Everyone knew Mr. Pierson struggled with symptoms of mental illness. Lately his symptoms were worse. He was hearing voices and would sit in the dark alone all day. His neighbors were scared of him – even the postman knew he was “disturbed.” On Tuesday, Mr. Pierson was fatally shot by police when he refused to lower the shotgun he had been firing in the neighborhood. His family doesn’t fault police - "If I was in the same position, I would probably have done the same thing," his son said.

The fault lies with Virginia’s mental health system that makes it nearly impossible to help a man who may be hearing voices but is not yet “imminently dangerous” or “substantially unable to care” for himself. Despite the family's understanding, it is likely that the police who shot him will suffer that memory. They too should demand accountability from a failing mental health system that results in police killing people with mental illness at a rate nearly 4 times greater than the general population.

It's time for treatment before the crime

An op-ed by Jeff Gerritt at the Detroit Free Press calls for treatment rather than incarceration for those with severe mental illnesses who have committed a crime. Before suggesting a solution, Gerritt delves into the sad history of abandoning the mentally ill. As he so explains:

A solution is long overdue. When Michigan closed most of its mental hospitals in the 1990s, the mentally ill didn't just disappear. They ended up on the street, in homeless shelters, and, increasingly, in jails and prisons. One sheriff called the state's jails and prisons the new asylums. Today, nearly 25% of Michigan's 51,000 prison inmates are mentally ill.

No doubt, putting mentally ill people in a freer, less costly setting was a good idea. But as institutions closed, the state failed to invest in community mental health programs. People with severe mental and emotional problems went untreated.

The op-ed goes on to support the creation of mental-health courts to steer people with mental illnesses who have committed a crime into treatment rather than jail or prison. This is a good step for those already in the forensic system.

An even better step? Using Michigan’s assisted outpatient treatment law – known as Kevin’s law- to get treatment BEFORE a crime is committed.

Answers are long overdue

Governor Kaine’s panel investigating the Virginia Tech tragedy began their work with questions for the mental health system. Diane Strickland, a retired Roanoke judge with extensive experience in mental health issues, laid out the questions, "We need to look into what changes need to be made to our commitment process. Who gets committed? How long? What are the terms for release in the community? Who monitors them? How do we know they are taking their medications?”

As Virginia families know far too well, answers to each of these questions are long overdue.

Too Sick To Treat, Per Regulation

A surprising, if unintentional, admission that some patients incapable of helping themselves are consciously abandoned to the symptoms of serve psychiatric disorders comes from the regulations governing the care of patients in outpatient care set out by the Maine Office of Adult Mental Health.

These regulations require that treatment must be predicated on informed consent, which is when “the recipient or his or her guardian possesses capacity to make a reasoned decision regarding the treatment and/or services and the recipient or his or her guardian is provided with adequate information concerning the treatment and/or services.”

“Capacity” is defined as “sufficient understanding to comprehend the information [provided on the proposed treatment] and to make a responsible decision concerning a particular treatment and/or service.”

A large portion of those with the most acute psychiatric conditions are affected by anosognosia, a physiological symptom that can render them incapable of comprehending that they are sick. Virtually de facto, such a person would no have capacity and be incapable of informed consent absent a guardian.

The regulations require the initial determination of incapacity be by a qualified mental health professional and confirmed by a physician or clinical psychologist. Once the incapability of informed consent is established, notice must be sent to the rights protection and advocacy agency of the Maine mental health system, the head of the mental health facility and, if the patient does not object, the recipient's next of kin.

At that point the mental health professional recommending the treatment and a representative of the treatment team must meet with the recipient to essentially solicit reconsideration and explore alternatives.

And should that prove unsuccessful, the concluding line of the pertinent section of regulations is explicit: “The head of the program may conclude that the recipient's termination from services is the only available option.” No other alternatives are delineated.

Once carefully determining and documenting that the person is so sick as to be incapable of making treatment decisions, the state encourages closing off the possibility of care in the future.

Editorial boards: Fix the system

The recent Washington Post article – Cho didn’t get court-ordered treatment – exposed the failure of the mental health system in Virginia, and editorial boards have published their reactions. Their resounding response? We cannot continue to let our sickest citizens fall through the cracks.

The Journal- Times in Racine, Wisconsin:

“But the 20/20 hindsight of Cho’s case should point Virginia lawmakers, judges and mental health professionals in the right direction to change their practices and their laws so that “news to us” doesn’t become terrible news to everyone, everywhere, again."

The Roanoke Times in Virginia:

“The families of people with mental illnesses know how hard it is to get them care. Those failures, too, sometimes end in violence, in suicides or murders that don't stun the world but are no less tragic to those touched by them.

By raising awareness of Virginia's need for a better mental health care system, Cho's case raises a fourth question, the perennial question: Will Virginia provide the resources adequate to the need? Now will it?”

The Charleston Daily Mail in West Virginia:

“But while the least-restrictive environment protects the rights of the patient, it can endanger the lives of others, as the Cho case showed.

Everything is left up to the patient, who is too sick to be making those decisions.

Dr. Helen Smith, a forensic psychologist in Tennessee, mocked that, saying, "Maybe the next step should be to let criminals decide whether or not they want to go to jail or not."”

Another day of loss in Virginia

Our thoughts today are with the families and friends of Detective Vicky O. Armel and Officer Michael E. Garbarino, veterans of the police department in neighboring Fairfax County, Virginia, whose lives were tragically cut short one year ago today.

In the last year, we’ve met so many people who knew these fine officers. One person told us that Detective Armel was the officer that others sought when they encountered individuals experiencing problems with untreated mental illness. Their deaths reminded us that the police are often on the front line dealing with people experiencing psychiatric crises.

Of course, we can’t forget the family of the mentally ill man, Michael Kennedy, is grieving as well and they sought help several times to no avail. We know the police in Fairfax County and elsewhere are just as frustrated as families of the mentally ill by the inadequate response of the mental health system.

Are you kidding?

The head of the Virginia Association of Community Services Boards (VACSB), which represents the 40 community mental health agencies in Virginia told the Washington Post that these mental health agencies are only responsible for a person committed to outpatient care by a judge "if he seeks treatment. But we can't give him treatment if he refuses it."

That’s like a state psychiatric hospital deciding “we can only commit a patient to the hospital if they knock on the door and ask to be admitted.” Of course, that would never happen because the hospitals know how to help people who are too sick to seek or accept treatment voluntarily – that’s what they do.

Unfortunately, Virginia has closed 50% of its state psychiatric hospital beds over the last 20 years. In the most recent closure, as much as $22M of state hospital funds that had been used for patients needing involuntary services was “reinvested” in community service boards that want to provide only voluntary services.

That is unacceptable. Community agencies must serve the most severely ill. At a minimum, they should serve individuals found to be an imminent danger. If the CSBs refuse to establish involuntary services, give the money back to the hospitals so these patients have somewhere to go for help!

The danger of dangerousness

Regular readers of this blog already know that Australia has been publishing very interesting work on mental health and treatment. And now, a Sydney psychiatrist is making a powerful argument that dangerousness standards delay necessary treatment by as much as six months.

Dr Olav Nielssen, a psychiatrist at Sydney's St Vincent's Hospital, found that the length of untreated psychosis was 25 weeks longer on average in countries that utilize dangerousness standards rather than “need for treatment” based standards for admission to mental health care. “That is staggering,” he said, “and not surprising really because you can't get treatment until you're dangerous, which means you've hurt or killed someone or at least threaten to. This 'dangerousness' criteria means delayed treatment and that need to be changed to save lives.”

California's three strikes law: schizophrenia + 2 bottles of booze = 25 to life

The Treatment Advocacy Center receives thousands of calls and e-mails each year from people desperately striving to help loved ones at risk because of the symptoms of severe mental illnesses. Although we were not formed to be a help organization, these pleas we cannot refuse. We inquire about the person’s condition and situation, and then offer advice, information, and referrals.

If the caller is from California, we ask one more question than with most other states: “How many strikes?” That is because California has one of the toughest “three strikes” laws in the country. In that state, a person can earn their first two strikes for serious or violent felonies. A psychotic phone call deemed by a court to be a terroristic threat is sufficient. The eligibility threshold lessens even more for the third strike: any felony will do. And a third strike means 25 years to life.

Three strikes laws are designed to keep habitual criminals off the streets; they are also vastly wide and deep pitfalls for people in crisis because of acute psychiatric disorders. The results are as sad as they can be absurd.

The Ninth U.S. Circuit Court of Appeals in San Francisco recently considered the appeal of a man with schizophrenia who had stolen $68 of liquor from a market. It had gotten him a third strike and a 25-year to life sentence. One of the justices on the appellate panel called the sentence "barbarous.'' The other two disagreed and the sentence was confirmed.

If the phrase “cruel and unusual punishment” comes to mind, don’t look for help from the U.S. Supreme Court. The nation’s high court upheld two similar, excessively punitive sentences ordered pursuant to the same California law in 2003. Both third strikes were also for theft. One man stole three golf clubs and the other two videotapes.

Research update: Parasite as schizophrenia cause?

TAC relies on its supporting organization, the Stanley Medical Research Institute (SMRI), to carry out research to ascertain the causes of and develop better treatments for schizophrenia and bipolar disorder. A recent update from SMRI follows.

SMRI continues to support promising research on infectious agents as possible causes of schizophrenia and bipolar disorder. Much of this research is taking place in the Stanley Laboratory of Developmental Neurovirology at Johns Hopkins Medical Center under the direction of Dr. Robert Yolken, who is a member of the TAC Board of Directors. In a spring 2007 issue of Schizophrenia Bulletin, Drs. Yolken and Torrey coedited six papers on Toxoplasma gondii as a possible cause of schizophrenia. T. gondii is a protozoan parasite that occurs normally in cats but is transmitted to humans in a variety of ways.

More than 40 studies have found that individuals with schizophrenia have increased antibodies to T. gondii compared to unaffected controls. A paper describing these findings is featured on www.schizophreniaforum.org, a useful website for keeping up with schizophrenia research.

Media continue to explore Va. Tech tragedy

Over the past week, the media has continued to cover the Virginia Tech shootings. The reoccuring theme is that that the mental health community failed. Some, such as the Charleston Daily Mail in West Virginia have expressed thanks that their state has an assisted outpatient treatment law.

Dr. E. Fuller Torrey in the Wall Street Journal:

The tragedy of Virginia Tech is a microcosm of our failed mental health system and our confusion about civil rights. Mentally ill individuals have a civil right to receive treatment, even when their brain disease precludes awareness of their illness. And the public has a civil right to be protected from potentially dangerous individuals. We are failing both the patients and the public.

The San Antonio Express explains these tragedies happen too often:

The same week that a disturbed student exploded in a rage of killings at Virginia Tech, there were other incidents that received far less attention.Media reports about the tragic combination of mental illness and violence are all too common, with family members the most likely victims.

Ray McAllister writes in the Richmond Times-Dispatch:

With guns readily available and checks on the mentally disabled not -- we can forget wondering if there will be another killing. The only question is when and where.
And how many will die.

In the Charleston Daily Mail in West Virginia, the editorial board is thankful for Kendra's Law in their state:

In the wake of the Virginia Tech massacre, people across the nation are wondering: How can these things be short-circuited? Could it happen here? The answer is that it's less likely in West Virginia, thanks to what is called Kendra's Law.

[Kendra’s] death caused New York state lawmakers to make it possible for courts to order people with mental illnesses to take their prescribed medications and to receive treatment. This is fair to the patient and to society as well.