Task force recommends changes to state's involuntary commitment laws

Recently, people with mental illness have perpetrated several "high profile" violent crimes. On April  16th, 2007, Seung Hui Cho, a young man previously diagnosed with anxiety and major depression, killed 32 people during a shooting rampage on the campus of Virginia Technical College. On December the 8th of that same year Robert A. Hawkins, who spent his early years as a ward of the state, and had been diagnosed with major depression and attention deficit hyperactivity disorder, killed 8 people in a mall in Omaha, Nebraska. States, cities, and communities have reacted in different ways in the wake of these tragedies (see the Virginia Tech Review Panel Report as an example.)

On December 31st, 2007 in Seattle, WA, James Williams, a man who had been diagnosed with schizophrenia and had a history of violence, attacked and killed Shannon Harps. Mr. Williams was under court ordered supervision at the time but had violated the court order by stopping his psychiatric medications. After the murder, a diverse panel of community members and leaders, law enforcement professionals, and mental health professionals, met to develop recommendations for improving the mental health system and potentially preventing a similar incident in the future. Carol Smith, 10/9/08 seattlepi.com reported on the findings of the panel and its recommendations.

"A mental health system facing a critical shortage of hospital beds, riddled with breakdowns in communication and hamstrung by the state's commitment laws helped create the conditions that led to the killing of Sierra Club worker Shannon Harps outside her Capitol Hill apartment last New Year's Eve, a task force reviewing how the system operated in that case has found."

You could apply this statement to just about any community in America, urban or rural. The problem is complex. Nationally, long term psychiatric beds have been gradually cut over the last few decades to deal, usually by court order,  with the overcrowding, treatment inadequacy, and patient abuses associated with the Asylum model of psychiatric care. Corresponding development of community psychiatric care programs to replace the long term beds has lagged due to a failure by federal and state goverments to shift or even provide funding for the systemic changes. As this process has evolved, it has become apparent that some patients require more structure and support than previously anticipated by the court systems in order to acheive or maintain their recovery from their mental illness.

Communication between different community providers is often poor. Barriers to communication are numerous. The process of deinstitutionalization has occurred in a piece-meal fashion with no coherent development of services (since there has never been a coherent plan!). Within a single community, both state and private entities provide services for mentally ill patients. Internal turf battles arise between state agencies which provide duplicate care for the same population. Private and public agencies have difficulty communicating. Federal privacy laws and regulations are confusing and many providers take an attitude of "better safe than sorry" (meaning, in this case, that it is better NOT to release information on a psychiatric patient if the provider is unsure about the circumstances for which they are requested).

Other recommendations include:

"One of the biggest reforms would be to change the state's involuntary commitment laws to mandate treatment for those with a significant history of violence, the Seattle P-I has learned." Who would decide sort of history of violence mandates treatment? How long would the treatment be mandated? Who would pay for the treatment?

"Providing more tools for enforcing outpatient treatment in the community." Currently, the only tool we have for enforcing outpatient commitment in Birmingham is the threat of inpatient commitment. 

"Reducing privacy barriers so police can know the mental health histories of people they deal with in "real time." This is the recommendation that makes me uncomfortable. It's one thing to allow freer communication between caregivers, but quite another to extend that access to information to law enforcement.

"Allowing those who make involuntary treatment decisions more leeway to consider past history of violence." Numerous studies have shown that a history of violence predicts future violence. I believe that if involuntary treatment is being considered for an individual patient, a history of violence should be a consideration in whether or not that person is committed to involuntary treatment.

"Other proposals emerging from the task force include allowing juries a new option of "guilty but mentally ill" in addition to "not guilty by reason of insanity."I have been involved in several cases where patients committed crimes while mentally ill, but had made a conscious decision to be non-compliant with medications prior to the commission of the crime. Though their mental illness played a role in the commission of the crime, their decision to be non-compliant with treatment was what set the ball rolling. Should the patient be held accountable for this factor?