Severe mental illness and traveling for the holidays

For many families, the holidays frequently mean a time for travel, with loved ones flying in from around the country. Unfortunately travel, especially flying, has become more and more difficult. This is especially true for families whose loved one may be symptomatic or otherwise struggling with a severe mental illness. As always, advance preparation is essential.

Here are some questions to make sure you have answered before you travel:

Do you have your CARE kit packed? Documented medical history, treatment preferences, and lists of medications are essential information to have if you’re dealing with an emergency in a new state.

Have you spoken to your loved one’s treatment providers to get their advice? Some obvious issues to address include ensuring your loved one has enough medication for the trip and prescription refills, but it’s equally important to discuss things like going through security at an airport and the stress of numerous family commitments.

If you are traveling to another state, make sure you know as much as you can about their treatment process. For example, if a crisis was to occur, would you know what that state’s emergency treatment laws require and how the process works? Laws vary widely from state to state. Never assume that what works in one will automatically work in another.

It never hurts to call the local NAMI chapter in the area you’re traveling to. In a crisis situation, having a contact that is familiar with the process and players in a state can be very beneficial.

Never assume that judicial determinations, treatment orders, or conservatorships will automatically be enforced in different states. In fact, they normally don’t. It pays to speak to someone knowledgeable in your state before you leave; again advance preparation is essential.

Have you thought about the added complications created by air travel? We have heard from far too many families who end up with a loved one essentially “stuck” in a state, not sick enough to meet that state’s commitment criteria, but far too ill to safely navigate air travel.

Re-institutionalization?

In the waves of deinstitutionalization of the 1950s and 1960s the number of people with severe mental illnesses in public inpatient psychiatric facilities dropped dramatically.

In 1955, 558,239 patients were in public psychiatric hospitals. By the
mid-1990s, the number had dropped to fewer than 72,000. By 2002, the total had fallen below 50,000.

Where did they all go? Too many ended up on our streets, in homeless shelters, in emergency rooms, and in jails and prisons.

In Colorado, the director of the department of corrections is requesting nearly $60 million to double the size of a 250- bed correctional facility to house mentally ill inmates.

Colorado isn’t alone. In Maine, Governor John Baldacci announced a plan to have the state assume control of all 15 county jails. Some jails, according to the plan, will be turned into “specialty facilities for people with mental illness.”

Almost 50 years after the first push for deinstitutionalization it seems we’re still housing people with severe mental illnesses in institutions. Now we require them to commit crimes to get there.

Cho, Kennedy and other tragedies in Virginia

Today’s Washington Post explores Virginia’s restrictive commitment standard that requires “imminent danger” before a person can be ordered into treatment.

Any mention of “imminent danger” and Virginia’s broken mental health system conjures images of 32 students killed at Virginia Tech by Seung Hui Cho in April of 2007 and memorials for the two officers killed by Michael Kennedy in May 2006. Both Cho and Kennedy had fallen through the gaping cracks of Virginia’s archaic mental health system.

For all of the Virginia Tech and Michael Kennedy stories that grab our attention, there are hundreds more private tragedies that don’t make the news. Virginia families are left helpless as their loved one becomes homeless, threatens suicide, is violent, or victimized. Until their loved one is an “imminent danger”, there is little they can do but wait.

This morning’s Washington Post provides a glimpse into one of the many families in Virginia that was forced to wait.

The Reston man who advocates eliminating the standard called for help recently after his son obsessed that federal authorities were eavesdropping on him. He destroyed a toilet and punched holes in the wall. Fairfax's Mobile Crisis Unit came to their home and "agreed that he was very disturbed," the man said. "But in their judgment, what he was saying and doing would not pass the threshold for imminent danger. And having sat through these hearings before, I had to agree with them."

A few weeks later, with what his father described as "a crazed look in his eyes," the young man attacked his father. The father called police, and the son was arrested. He is being treated in a mental hospital while awaiting trial on an assault charge. It took the criminal charge to get the young man held.

"Ideally, when we see terrible things happening," the father said, "we should have been able, before that point was reached, to say, 'This kid is in danger and needs to be treated.' We just couldn't get past that threshold."

"Residentially challenged"

When you have a home but refuse to live in it, can you really be called "homeless"?

William Royce had a home, and a loving family. But he died in the elements after mental illness robbed him of his ability to make informed choices. A local police department spokesperson called Royce "residentially challenged,' which many, including one letter-writer, called "a new low in political correctness."

But might that actually be the most accurate way to describe someone like William Royce?

In a response via a letter to the editor in the Tallahassee Democrat, William Royce’s father Charles makes this unique argument.

I thought "residentially challenged" was a very correct way to describe the situation, and our family appreciated its use in the newspaper.

This was a young man who wasn't homeless, but he was residentially challenged, and he chose to live where he was found. He was also mentally challenged. He had been diagnosed with schizophrenia and he periodically was affected by that. Whoever coined that phrase, or opted to use that phrase, was very kind in his choice of words and the family appreciated that.

Iowa’s cold-hearted system leads to hypothermia

Photo from Gazette.com: "Personal items and trash are strewn about the homeless camp under Iowa City's Benton Street bridge Thursday. Transient Sonny Anthony Iovino, 55, was found dead from hypothermia under the bridge Wednesday."

The cause of death for Sonny Iovino is officially listed as “hypothermia.”

But it is clear he was a victim of something equally as chilling – a system that bounced him around, seemingly unable (or perhaps unwilling) to help him.

Iovino was a familiar face to Iowa City police, and was repeatedly picked up in the past 5 years on charges like disorderly conduct, public intoxication and simple assault. In fact, “In the first seven days of November, he'd had five encounters with police.”

So fittingly, it seems from news stories that it was the police who tried the hardest to get him help. Yet all the doors were closed to him because he was severely mentally ill and belligerent – a combination that too often fails to ignite compassion.

When officers took Iovino to the VA Center, he was turned away because he was uncooperative.

When the doctor asked to take his vital signs, Iovino made what reports called an inappropriate comment. "I take that as a no," UI Police Officer Alton Poole reported the doctor as saying. The doctor released Iovino back to police.

Yet, when officers then transported him to jail, he was turned away because he was too sick.

Johnson County Sheriff Lonny Pulkrabek told The Gazette the jail won't admit anyone with an immediate medical need. He said the doctor's note indicated Iovino needed hospitalization for mental illness.

He was behaving erratically, and was, in fact, nearly naked in a city where the average temperature in November hovers at 31 degrees. Yet he couldn’t get the help he clearly needed.

The spokesperson for the medical center that released him back to police said hospital officials did all they could:

"If somebody doesn't want to be treated, you can't treat them."

Whether officials are ignorant of state law or willfully ignore it, the result is the same. In reality, Iowa has the option of assisted outpatient treatment, and actually uses its law to a certain extent, but not as much as it could, mainly because of its restrictive eligibility standard.

Iowa's commitment standard basically holds that to be eligible for outpatient treatment or hospitalization, the person must lack sufficient judgment to make responsible decisions concerning treatment AND is either (1) a danger to self/others, including that of serious emotional injuries to family members and others OR (2) unable to satisfy need for nourishment, clothing, essential medical care, or shelter so that it is likely that the person will suffer physical injury, physical debilitation, or death.

From news reports, it sounds like Mr. Iovino met that criteria. Perhaps everyone was tired of trying to help him. Perhaps his attitude and belligerence made him unpleasant to interact with. Perhaps everyone was busy and didn’t want to take the time.

The end result should shame everyone involved.

Tragic endings to a bad situation

Over the weekend we were reminded again of the role law enforcement is forced to play in dealing with severe mental illness. The failure of the mental health community to properly treat those with severe illnesses so often ends in tragedy across the country.

In Florida –
A sheriff’s deputy in Indian River County shot and killed Byruss Green, a man with a mental illness who had not been taking his medication.

In Illinois –
A jury determined that officers were not to blame in the March 2000 shooting of Joseph T. Zagar that had been called a suicide-by-cop. Officers had been to the home of Zager multiple times and had taken him in for mental health treatment. This time, Zager was threatening the officers with what they thought was a gun.

In Kentucky –
Brenda Joy Woosley, a woman with a mental illness had been driving erratically and avoiding police attempts to pull her over. Two officers fatally shot her after she drove her car into them.

In New York –
A man with a mental illness in Brooklyn was fatally shot by police officers after he repeatedly charged at them with a broken bottle. Before charging the officers, Dragan Kostovski stabbed his roommate.

Finding someone to blame

Who is to blame when tragedy results from untreated severe mental illness?

At the end of October in Richmond, VA, Johnny Hughes, a man with untreated schizophrenia, fatally stabbed a woman while she was walking her dog.

The author of a new blog - “families for timely mental health treatment laws” – noticed some of the comments posted on the website of the Richmond Times Dispatch regarding this story. Many blamed the family of Johnny Hughes for not monitoring him.

Posted October 30, 2007 @ 09:55 AM by Anonymousafter reading this man's rap sheet i too am finding compassion a hard sell. i agree the family dropped the ball, this man needed to be under lock and key somewhere and his family should own up to their responcibility.

The author of the “families for treatment” blog responds to these comments with the perspective of someone who has tried to help a loved-one get treatment.

Blame and pointing a finger at families who try desperately to get help for their loved ones and who often are involved in advocating for the changes needed will not resolve the issue of ensuring that someone with a mental illness receives the treatment they need. Enacting common-sense, timely assisted outpatient treatment (AOT) laws with adequate services and programs, as well as providing sufficient support in a hospital when needed, is what should happen.

Evidence-Based Advocacy

While personal stories and anecdotes can help to inspire elected officials to make change, they also need to present evidence to their colleagues to persuade them to adopt reforms. Sadly, many state mental health services provide little information about assisted treatment – how many people need it, how many people do not receive it but are repeatedly in crisis, how many petitions are filed for involuntary psychiatric evaluations, how many orders are issued for hospitalization, how many orders are issued for outpatient treatment, how often is law enforcement on the front line instead of mental health professionals…

Florida provides a good example of data reporting. The recent Baker Act Report provides an overview of what is happening with some of the most ill patients in their mental health system. For example, the report shows that:

“Nineteen percent of all people experiencing a Baker Act examination [involuntary psychiatric evaluation] in 2006 had more than one exam in that calendar year.”

Does your state keep good records about treatment for people with severe mental illnesses who need intervention? Is it easy for the public to access?

An exercise in futility

The title of a recent editorial in the Tallahassee Democrat says it all: "Incarerating mentally ill is futile."

"The cost in human suffering by the ill person, by his or her family and any victims is no doubt equaled by the cost to the state when it uses self-defeating systems. Even on county levels, authorities such as Leon County's Sheriff Larry Campbell decry the current system as ineffective, with no end of costs in sight, but no real improvements either."

New idea: mental health courts without the crime

In San Francisco behavioral health courts have been successful in compelling treatment for people with mental illnesses who would otherwise have been in jail or prison. The court allows that when someone with a severe mental illness commits a crime, they are diverted to behavioral health court and ordered to maintain treatment. Failure to maintain treatment sends the person back to criminal court and likely to jail or prison.

The model of connecting the services to the court does work," said Kathleen Connolly Lacey, program director of Citywide. "There has to be a benefit to people to participate. They work harder than they would if they got straight probation."

Here’s the problem. Right now, in San Francisco, court-ordered treatment is only offered AFTER someone commits a crime.

Jennifer Friedenbach, director of the Coalition on Homelessness, said it's one more example of the city offering services to homeless people and the mentally ill only after they become part of the criminal justice system. She and other advocates wonder why these well-regarded services aren't as readily available to mentally ill homeless people outside the courts.

Mayor Newsom: Why are you requiring your citizens with severe mental illnesses to commit a crime before being treated?

Survey your law enforcement officers

There is no question law enforcement officers are increasingly the ones responding to people with mental illnesses in crisis.

Use this survey to learn the prevalence and extent of the problem from a law enforcement standpoint.

In one study that used a version of this survey, it was revealed that 92 percent of officers reported encountering mentally ill individuals is crises in the month prior to the survey.

Share the results with the Treatment Advocacy Center! If you’ve surveyed your officers we’d love to hear from you. Send us an email at info@treatmentadvocacycenter.org.

Gavin Newsom: Homeless need your compassion

Can Gavin Newsom make San Francisco a leader in compassion for the homeless?

"Newsom," says political strategist Mark Mosher, "has a real opportunity to throw his traditional caution to the wind. Same sex marriage was totally courageous nationally, and somewhat so in the state, but in San Francisco it was a popular and sensible idea. So what are the most difficult issues now?"

Here's a suggestion. The streets of San Francisco.

That suggestion would be a good one for the leader of virtually any American City. At any given time, there are many more people with untreated severe psychiatric illnesses living on America’s streets than are receiving care in hospitals. The uproar is growing. The San Francisco Chronicle’s C.W. Nevius sees an opportunity for Mayor Newsom to make San Francisco an example of compassion by, among other things, implementing Laura’s Law.

Civic leaders familiar with convention bookings are concerned the city is losing business because visitors are spooked by encounters with homeless people and vagrants. Incidents like the one on Oct. 25, when a mentally ill man assaulted a police officer at Justin Herman Plaza, reinforce the perception the streets are not safe.

And it isn't just a dollars and cents issue. As anyone who walks the streets of the city knows, that man is not alone. Wednesday morning, anyone who walked past Sixth and Howard could see a barefoot man with a stick, standing on the corner and screaming unintelligible threats at pedestrians. For him to be on the street, alone and delusional, doesn't serve anyone.

As Dariush Kayhan, executive director of San Francisco Connect, which works with the homeless in the community, says, "If there is any city that has a large number
of mentally disturbed people on the streets, it is San Francisco."

That's why a good first step would be to find funds to implement Laura's Law, the California initiative that empowers local authorities to require mentally disturbed people to submit to a program if they have been refusing to do so voluntarily. Not only is it is a good idea, but San Francisco is in a unique position to do it. Laura's Law must be funded by California counties; the door is open for San Francisco, which is one of the few major cities that is also its own county.

This is a humanitarian issue – getting treatment will save them from a horrific life (the majority of homeless individuals with untreated psychiatric illnesses regularly forage through garbage cans and dumpsters for their food) and repeated victimization. One report on homeless women in San Francisco noted the women were being raped and sexually assaulted at an alarming rate, with some women being raped as many as 17 times. To protect themselves from attack, homeless women were known to wear 10 pairs of panty hose at once and bundle up in layers of clothing.

Randall Hagar, director of Government Affairs for the California Psychiatric Association, put it best:

"This is a humanitarian thing," says Hagar, the Laura's Law supporter. "It can reduce suffering for a group of people who are otherwise unreachable."

Bracing for the cold - and bitter tragedy

Every winter, we read sad news stories about homeless people with severe mental illnesses who fall victim to the elements. While the weather gets blamed for the deaths, the truth is more disturbing: About 1/3 of the nation’s homeless are people with severe mental illnesses.

• Many of these individuals are homeless BECAUSE of their illnesses.
• Most are not being treated for their illness and often the lack of treatment is because they have impaired awareness of their illness.
• The headlines overlook the daily victimization and brutal realities on the streets for people with severe mental illnesses.

Next time you read one of these sad stories, consider the fact that Assisted Outpatient Treatment can prevent tragedy. In New York, 74% fewer participants experienced homelessness while in the AOT program as compared to before they entered the program.

Criminalizing mental illness

In Putnam County, Tennessee, a crisis stabilization unit (CSU) was opened on April 30. Since its opening county law enforcement officers have seen a drop in the amount of time deputies are spending transporting people with mental illnesses to facilities in other cities.

Excellent; but deputies are still spending an inordinate amount of time driving people to mental health facilities. In fact Putnam County Sheriff, David Andrews has two deputies designated for mental health transports.

So far this year, Putnam deputies have made 319 mental health transports, compared to a total of 478 last year.

If one or two deputies transports a mental health patient to Moccasin Bend Mental Health Institute in Chattanooga, those officers are off patrol in Putnam County between five and six hours, according to Sheriff Andrews.

The CSU is a great start to getting people treatment, and relieving the burden of law enforcement acting as mental health professionals. But – the new CSU only takes voluntary patients. People who won’t volunteer for treatment, who are aggressive or violent still have to be treated elsewhere, and that means law enforcement are charged with transporting them.

"I think there's got to be a better way to do this, unless they come out of the jail, a person who has some reason to be transported to a mental health hospital hasn't broken any law in many cases," Sheriff Andrews said. "It criminalizes mental illness to put a mental health patient in the back of a patrol car."

Pennsylvania's archaic law

Yesterday the Harrisburg Patriot-News published an op-ed by the Treatment Advocacy Center's E. Fuller Torrey and John Snook. The op-ed explores Pennsylvania's outdated law that prevents treatment of severe mental illnesses, and the "rights" that are protected instead. Among those are- the right to be killed in an encounter with law enforcement, the right to hurt someone you love, and the right to be homeless.

Historically, civil rights advocates passed laws protecting the absolute right to self-determination in treatment. But in their fervor to protect people's rights, they in fact trampled on them.

Pennsylvania's civil commitment law is archaic and inhumane, requiring someone to present a clear and present danger before they can be court ordered to treatment. Clearly, that is often too late.

The law ignores their right to be free from psychosis. Read on...

Reform is long overdue

Few issues have dominated a political landscape like mental health has in Virginia. With the tragedy at Virginia Tech, the death of two police officers in Fairfax County, and the recent murder of Susanne Thompson in Richmond, it is clear that reform is long overdue.

Virginia Capitol Connections Magazine recognized the unprecedented role that mental health will play in the upcoming legislative session, and made it the subject of their fall issue. Contributors include Governor Kaine, Delegate Phillip Hamilton, and TAC’s own John Snook, who calls on the legislature to recognize the reality of severe mental illness and the need for assisted outpatient treatment.

Community members call for better treatment in Virginia

The following quotes are from news coverage of the death of Susanne Thompson, who was stabbed while walking her dog Saturday morning. Johnny Hughes, the man charged with her murder, has a history of mental illness.

He's [Richmond Mayor L. Douglas Wilder] concerned that state law doesn't always allow mandatory treatment of mentally ill people with criminal histories.

“… this situation represents a much larger problem. The real question is how many others are similarly situated across the state and the region who need coordinated mental health resources in order to reduce any possibility of this situation recurring.”

Hughes' younger sister, Chesterfield County resident Jackie Lewis, said the killing could have been avoided.

"We are so deeply sorry for this innocent loss," Lewis said on behalf of her family. "I'm sure if my brother was in his right mind, he would feel the same way."

"Somebody dropped the ball in terms of his care," she said.

Richmond Sen. Henry Marsh: "The purpose . . . is to create an assisted outpatient treatment program so that those mentally ill persons who are capable of being maintained safely in the community with the help of such a program can receive those services."

"The things he [Hughes] was saying, he didn't belong here," said [Richmond Sheriff C.T.] Woody, who has complained that the jail does not have the facilities or resources to care for the hundreds of mentally ill men and women doing time there.