A Chance to Improve Mental Health Services for Virginians By Michael Shank and Sandra Cheldelin Richmond Times-Dispatch[WEBSITE VERSION] August 14, 2007
Virginia Tech's tragedy remains a stark reminder for those working in emergency medical services -- particularly in mental health -- that existing detection and response systems are dysfunctional. As exemplified all too painfully in the case of Tech's Seung-Hui Cho, the state's capacity to detect and respond to mental illness is deficient, misdirected, or both.
Mental health professionals, long aware of problems in handling individuals with mental illness, are now speaking out --and this time officials are listening. Virginia, one of many states now examining inpatient and outpatient services for persons with mental illness, is learning fast what needs to be fixed.
In a recent public dialogue sponsored by Northern Virginia's Community Services Board (CSB), participants verified that involuntary commitment, as it's currently structured, is not working (report available on the Institute For Conflict Analysis and Resolution Web site: http://icar.gmu.edu.)
Involuntary commitment is what Cho was ordered to receive by a judge 16 months prior to the shootings. In theory, after a person is committed, he is held, examined, and either released or hospitalized. What Virginia officials are figuring out, however, is that this process is ineffective.
Besides seemingly fixable problems like insufficient pay for caregivers, bed shortages, and inadequate mechanisms for ensuring hospital reimbursements -- as outlined in a report recently released by the state Supreme Court's Commission on Mental Health Law Reform -- bigger problems are emerging having to do with process, participation, and priorities.
On process: individuals with mental illness are avoiding the commitment process at all costs, as Cho did. Why? Because it's traumatic, and the specter of hospitalization keeps many at bay. Furthermore, families, while recognizing signs of deterioration, cannot commit their children unless a significant and obvious crisis emerges. By then it may be too late.
Hospital providers also report that the forceful nature of temporary detention undermines patient trust and willingness to accept treatment. In sum, say professionals, options beyond extremecase scenarios must be made available; what exists is too limited.
On participation: The perspectives of individuals with mental illness and their families are consistently absent. Beyond finding it hard to interpret current law, family knowledge of a loved one is neither wanted nor valued in the commitment process. Other participants in the process, such as law-enforcement officials who transport and accompany patients, feel ill-equipped to properly handle the situation.
Yet others -- e.g., community services board professionals -- see a need for stakeholder education and training and for the inclusion of legal representation during hearings. Consensus: Too many key stakeholders remain uninformed and uninvolved.
On priorities: The focus is wrong. The involuntary commitment process reacts to a worse-case scenario, while prevention-oriented processes are ignored. Currently, there is no space for an early-warning system that helps detect mental illness and prevent deterioration. Priority is given to emergency response, not emergency prevention.
Cho's treatment, or lack thereof, is an excellent example of a poor prioritization. There was no space in the system for Cho because until the shootings, there was no crisis point. Yet clearly, the crisis was burgeoning within. Thus, priority must be given to early detection and treatment, lest another Cho go undetected.
So what now? Thankfully, there are solutions relatively simple to find. Ask the stakeholders; they'll tell you what needs fixing. From the dialogues -- which involved more than 70 mental health service consumers, family members, law-enforcement officials, hospital providers, magistrates, justices, and CSB members, from five Virginia counties -- the following emerged:
First, revise the definition, criteria, and scope of law governing the involuntary admissions process so that it addresses all stakeholder concerns. State and federal legislators should begin a dialogue on this promptly.
Second, provide a continuum of intervention strategies, offer them earlier, and include a variety of outpatient treatment options. As part of this approach, establish more comprehensive psychiatric evaluation procedures and increase the compensation for independent evaluators needed for analysis. While CSB professionals and hospital providers stand ready to offer more comprehensives services, funding remains an obstacle.
Third, offer adequate and affordable legal support for family members to ensure the overall welfare of the individual. Equipped with legal advocacy, the individual may be more inclined to enter the commitment process. Without it, youth like Cho will stay far away.
Fourth, create alternatives for transporting and holding individuals to reduce patient fear and distrust. To help with this, make available input from family members during the holding process.
And fifth, establish education and training programs for all participants on the involuntary commitment process. Though too little knowledge exists among stakeholders, this is easy to fix with some simple training.
Guaranteeing public safety and preventing, detecting, and responding to mental illness are no easy tasks. Yet the current system is deeply flawed and needs fixing. Now is the time to do something. The political will is there. All that's needed is the commitment and the resources. It's worth it. In Virginia we know this all too well.
Sandra Cheldelin is a professor at George Mason University's Institute for Conflict Analysis and Resolution. Michael Shank is a doctoral student at the institute.