Paved With Good Intentions?
Source: National Journal
When he entered Norris Hall on the morning of April 16, the Virginia Tech gunman had already slipped through a deeply fractured mental health system split by technological, economic, and political changes that began some 40 years ago. State officials across the country have known about the cracks -- and in some cases have struggled to fill them -- since the 1970s. In recent years, those officials have begun to address their most severe difficulty: forcing the seriously mentally ill into treatment.
A key flash point, say advocates on various sides of the debate, is the multistate effort to pass laws making it easier to medicate seriously mentally ill individuals, even when they oppose the treatment. In 2005, a Virginia court declared Seung-Hui Cho to be "an imminent danger to himself as a result of mental illness" but only directed him to enroll in an outpatient treatment facility.
This debate is clouded by medical ambiguities, is often swayed by financial interests, and is highly emotional for those with mental illness and their families. "We deserve more than a gavel and a bag of pills," says David Oaks, director of MindFreedom International, an association of former psychiatric patients, whose members fear being forced into institutional treatment.
Oaks and his allies "have dominated the debate for a long time," counters Mary Zdanowicz, executive director of the Treatment Advocacy Center in Arlington, Va., which lobbies state legislators to enact enforced-treatment laws. "They intimidate people and use a victim-culture approach."
The road to hell is paved with good intentions, and the campaign to close the country's mental institutions surfaced a good deal of it. The first calls for change came in the late 1950s, and by the 1960s the institutional asylums -- portrayed poignantly in the book and movie One Flew Over the Cuckoo's Nest -- were being shuttered.
The closures, prompted by the deplorable conditions endured by long-term mental patients in many state hospitals, came just as psychiatrists found themselves equipped with a new generation of "miracle" drugs promising cures for mental illness. The reform movement hailed a 1961 report from the National Joint Commission on Mental Illness and Health, which called for creation of community mental health clinics "operated as outpatient departments of general or mental hospitals ... or as independent agencies" that would be part of state or regional systems for patient care. The goal was that the clinics would curtail "the need of many persons with major mental illness for prolonged or repeated hospitalization."
In 1963 Congress passed the Mental Retardation Facilities and Community Mental Health Centers Construction Act; two years later it added funding to build the centers. As state budget planners began closing the expensive asylums, thousands of former mental patients found themselves on the streets. In 1955, public mental health hospitals housed about 559,000 patients, according to psychiatric researcher and activist Fuller Torrey. In 2007, the remaining state institutions care for fewer than 50,000.
The anti-establishment trends of the 1960s accelerated the dismantling of the old system. "Those were the counterculture years, and it was much more fashionable to be different," says Zdanowicz. Civil libertarians pushed to restrict state laws allowing involuntary commitment in mental institutions. Most states adopted codes requiring proof that a mentally distressed person was an imminent danger to him- or herself or others before a judge would agree to a civil commitment. "It all contributed to making it very difficult to get someone hospitalized," Zdanowicz says.
The changeover failed almost immediately: Community health centers found themselves overwhelmed, many neighborhoods rejected proposed clinics, and local funding began drying up as state budgets shrank. The medications that had promised a miracle were often discarded by patients once they experienced the hazardous and unpleasant side effects. A 1999 surgeon general's report on mental illness offered this blunt assessment: "The dual policies of community care and deinstitutionalization ... were implemented without evidence of effectiveness of treatments and without a social-welfare system" to provide housing, job opportunities, and other support for people who needed help reintegrating into communities.
The system cracked and has never recovered, mental health experts say. Thousands of mentally ill Americans continue to slip through the gaps and wind up either on the street or in jails and state prisons. "We've ended up with several hundred thousand people with mental health problems living in the community," says Torrey, who is also president of the Treatment Advocacy Center.
His group has had some success in persuading states to adopt new forced-treatment laws. In 2005, for example, New York state reported that a new treatment statute had put 3,908 individuals with severe mental illnesses under court orders to cooperate with mental health professionals. Because of the law, fewer mental patients have been arrested or are homeless, the number of hospital stays has been sharply reduced, and many fewer patients have tried to commit suicide, attacked other people, or stopped taking their drugs. Similar laws have been passed in Florida and Wisconsin, and are being considered in Illinois and New Mexico.
Ron Honberg, the legal director for the National Alliance on Mental Illness, supports streamlined civil-commitment laws. "It's not only in the interest of society, it's in the best interest of the individuals themselves," says Honberg, whose organization is supported in large part by the pharmaceutical industry. "Whose rights are we really protecting when we allow people to freeze to death under bridges?"
Unsurprisingly, these laws are opposed by a loose coalition of former patients and civil libertarians. "The voice on mental health that's missing is the one on the sharp end of the needle," says MindFreedom's Oaks. The drugs that patients take are debilitating and have harmful side effects, he says, and people can often recover without them.
Torrey and others disagree, citing a new generation of antipsychotic drugs that have fewer side effects. But they concede that Oaks and his allies have been effective at blocking efforts around the country to make civil commitments easier. Competition for state budget dollars has also drained support from programs that compel mental health treatment.
Among the more prominent advocates for the mentally ill is the state-based network of federally mandated Protection & Advocacy Systems. These so-called P&A agencies believe that "autonomy trumps needed treatment," says John Stanley of the Treatment Advocacy Center, noting that advocates helped to defeat forced-treatment bills in the New Mexico Legislature in 2006 and 2007. He calls the agencies "the federally funded mental health branch of the ACLU."
Jim Jackson, the executive director of New Mexico's Protection & Advocacy System, says the bills "would have authorized forced treatment on adults who are competent to make their own decisions." He contends that state law already allows for a legal representative to grant approval for treatment on behalf of an incompetent patient.
Some of the $1.2 million a year in federal funding that Jackson's P&A receives helps to pay for legal challenges on behalf of the mentally disabled as well as lobbying in Santa Fe. Jackson notes that he is a registered lobbyist in New Mexico.
Barry Bitzer, chief of staff to Albuquerque Mayor Martin Chavez, contends that Jackson's agency "should be working for the truly vulnerable, but they end up advocating on behalf of the 'high-functioning' folks well in recovery" who needlessly worry about being forced back into treatment. The city passed its own forced-treatment law after an Albuquerque police officer in 2003 was shot in the head by a man who had been in and out of the state mental health system numerous times. The officer survived.
Protection & Advocacy sued the city over the law, and a judge ruled that officials did not have the authority to pass the measure. The city is appealing the decision.
Lobbyists for the mental health sector say they cannot predict how the Virginia Tech massacre might reshape the debate in Washington. President Bush has directed Health and Human Services Secretary Mike Leavitt to study how such murders can be avoided. "We're going to wait and see what Secretary Leavitt finds, before rushing to judgment about what kind of legislation" is needed, says Andrew Sperling, director of legislative affairs for the National Alliance on Mental Illness.
For many years, mental health providers have pushed Congress to require that health insurers cover mental ailments on par with physical illnesses. The campaign has failed so far, in part because advocates want equal coverage for all mental health diagnoses, from such severe conditions as schizophrenia to the milder determination of "worried well." This broad goal is opposed by employers who say their costs would rise if insurance companies had to provide reimbursement across the board.
Congress may do nothing in response to the rampage, Zdanowicz says. In 1998, Russell Weston, a schizophrenic, shot and killed two U.S. Capitol Police officers, but Congress's only reaction was to protect itself by building a new visitors center, she says. One reason for congressional inaction, she contends, is that major mental health lobbying groups are "afraid that talking about mental health and violence portrays all people with mental health problems as violent. The American people know better."
Meanwhile, colleges and universities say they are reacting to the Virginia Tech shootings by offering expanded mental health services to troubled students and by beefing up campus security communications systems.
In Senate testimony on April 23, higher-education officials said the hiring of additional campus police and mental health professionals, and the construction of campus-wide warning systems were among their efforts to improve the situation. Russ Federman, director of counseling and psychological services at the University of Virginia, cited a recent survey in which 22 percent of students said that on at least three occasions during the last school year, they "felt so depressed [that it was] difficult to function." Although the suicide rate at his university is considered low -- three students have killed themselves in the past six years -- "we're not getting ahead of the curve," Federman said. "We are beginning to slide behind."
But, says Gary Pavela, the director of judicial programs at the University of Maryland (College Park), federal laws "are geared to prevent taking action against anyone" diagnosed with a mental health problem. When administrators are faced with student behavior that is disturbing (such as eating disorders or self-cutting) but that does not violate discipline codes, they can ask the student to leave the campus for treatment. A student cannot be removed from the campus unless a mental health expert determines that the person is a "direct threat" to him- or herself or others, Pavela says.
A focus on behavior rather than on mental health, he says, "is fundamentally fairer" because it allows students to appeal their cases through the university governance systems, which include a significant number of fellow students.
The state of the science on issues of mental health is inadequate, he says, noting that studies have concluded that rampage-killers can't be reliably detected among the enormous variety of both ordinary and troubled students at colleges and universities. "We are not able to weed out in advance who is likely to be violent, unless we have a pattern of recent violence in the past or we have an immediate threat -- someone saying they're likely to be violent," Pavela says.
In Virginia, universities are also caught between legal precedents that create liability if university officials reach out to disturbed students and a 2007 law that requires them to help those students, says Greg Nayor, president of the Virginia Association of College and University Housing Officers, whose group includes administrators that deal with students and resident assistants in dormitories. "We're in the middle between a rock and a hard place," he says.
Universities continue to be affected by changes that were spurred by the anti-establishment culture of the 1960s and early 1970s. Back then, for example, mental health care consisted of visits to chaplains and friends, and young men were met by concierges when they arrived at women's dorms. These days, few colleges act in loco parentis -- in place of a parent. Moreover, college students older than 18 are adults, with the attendant legal rights.
Still, the pendulum has been swinging back over the past 15 years. Pavela describes it "as dramatically moving toward more control." He ascribes one of the causes of this reversal to parents worried about their sons and daughters, and university managers worried about expensive lawsuits. The new oversight includes a variety of elements, among them increased numbers of campus police and psychiatrists, and campus policies that ban smoking, guns, and "hate speech."
Not surprisingly, these moves have sparked controversy. Some critics say that universities are pressuring students to follow "politically correct" behavior, some want parents to have easier access to their own child's college records, and some insist that students would be ready to protect themselves and others if they could carry guns on campus. But students' academic records are not readily available to parents without the student's permission, and few university administrators would welcome students carrying weapons around campus in their backpacks, Pavela says.
"We would regard it as a stupid idea," because beer-drinking students, at the very least, can't be trusted to handle guns, Pavela says. "I would not want to go near any academic building where the typical professor has an automatic weapon in their desk."
Moreover, many administrators and professors see a danger in this accelerating oversight of students. They believe that as young adults, students must learn to govern themselves. "There will be mistakes and even tragedies," Pavela concludes. "But it is in the overall public interest to allow students a degree of autonomy, so they learn how to be adults."