Virginia Tech`s implications

I've been researching and writing this column for nearly two decades, but all good things eventually come to an end. This is my final column as Washington Editor for Behavioral Healthcare. While you read these words, I am fulfilling a lifelong dream on faculty at the University of Guam, America's westernmost land-grant college.

I am a former behavioral health clinician turned political scientist, and the past 20 years of observing policy have provided reason for both optimism and frustration. The truly positive aspect of policy has been our government's contribution to the scientific basis for effective behavioral healthcare. The National Institute of Mental Health and other federal research institutions have funded a remarkable series of breakthroughs. This research has illuminated the once mysterious biological, social, and psychological interactions of behavioral health. More importantly, increased knowledge has resulted in effective therapies that make real, measurable differences in the lives of people with behavioral health problems.

In contrast, public policy on behavioral healthcare during the past quarter century has not produced similar progress. Instead, we seem locked into a cycle of dramatic policy shifts driven by reaction to current events. When the national media highlights an individual who has succeeded in achieving recovery despite encountering barriers in the behavioral healthcare system, policy makers jump on the bandwagon of patient advocacy. Behavioral healthcare providers are asked to forget profitability and regulations, and concentrate on helping consumers and family members achieve more of this type of success. A wave of legislation and rule making to protect the autonomy of patients/clients often follows, as in state implementation of the Olmstead decision as well as the recent rush to require peer counseling in public-sector programs.

Pro-consumer euphoria rarely endures. Eventually, news media report on an individual with behavioral health problems who attempts suicide or commits a heinous crime, and then the pendulum swings in the opposite direction. Policy makers confront the behavioral healthcare field with questions such as, “Why don't you protect society from such people?” and “Are you ‘coddling’ potential murderers and sexual deviants?” Again, a wave of change results—focusing on insulating communities from the consequences of untreated addictions and mental and emotional illnesses.

The United States entered into the latter phase of the policy pendulum swing in reaction to the April 16 tragedy in Blacksburg, Virginia. The mass shooting on the Virginia Tech campus provided a vivid example of the public's worst fears about mental illness. Many of the event's details appear muddied in news coverage, but it is hard to forget the chilling posthumous videos of Seung-Hui Cho rambling as he blamed fellow students and society in general for his murderous rampage.

A formal state investigation of the murders and suicide in Blacksburg concluded in August without identifying any single factor that could have either triggered or prevented the deaths.1 The report found that Cho had a decade-long history of episodes of mental health treatment, which each resulted in brief periods of more normal behavior. Because of this history, Cho's decision to attend Virginia Tech was opposed by his family, who thought that life on a large institutional campus might overwhelm his emotional progress. Their concerns proved correct in December 2005, when campus police intervened with Cho in response to complaints from another student of harassment via instant messages. After Cho indicated a potential for suicide, a magistrate committed him to an overnight stay and evaluation at Carilion St. Albans Psychiatric Hospital in nearby Radford, Virginia.

Two mental health professionals independently evaluated Cho at Carilion on the morning of December 14, 2005. Both concluded that Cho did not represent an imminent danger to himself; one reported “no indication of psychosis, delusions, suicidal or homicidal ideation,” despite the suicide threat that triggered the hospital stay. A staff psychiatrist stated that Cho's “insight and judgment are normal.” Paul Barnett, a local attorney in the small town of Radford serving as special justice for commitment proceedings, nevertheless declared Cho to be mentally ill and ordered “mandatory” outpatient treatment; it is unclear whether Barnett specified a treatment provider or an expected treatment outcome. Cho subsequently attended one session at a campus counseling service, but was rejected as a long-term patient because the Virginia Tech facility had a policy of refusing to provide court-ordered care.

After the December 2005 incidents, Cho remained at Virginia Tech. An English instructor, alarmed by the murderous imagery in Cho's assignments, had him removed from her class. In the meantime, Cho began to purchase weapons and, apparently, practice the procedures he would later follow in committing mass murder. Neither the police nor any treatment facility knew that a special justice had ordered Cho to receive outpatient care, and Barnett was not informed that his order was not being followed until after April 16.

The Commonwealth of Virginia reacted quickly to the tragedy by using regulatory authority to address some of the more obvious oversight issues. Special judges in Virginia who rule on commitment now must identify the purpose of treatment and the source of case management. Court clerks are required to notify the state police when a special justice declares an individual to be mentally ill. These regulatory changes would have removed some of the ambiguity about Cho's case and might have prevented him from locally purchasing some of the guns that he used during the massacre. (However, it should be noted that three other states with different gun laws are within a two-hour drive from Blacksburg.)

More fundamental changes in policy will require state or federal legislation, and the first session of the Virginia legislature to consider the events at Blacksburg doesn't convene until next month. Legislators have learned that Virginia community service boards (CSBs) responsible for public-sector treatment already are required to establish a care plan for patients released into the community for treatment, but this state law applies only to patients previously committed to inpatient psychiatric care. They also have learned that CSBs lack both sufficient money and staff to be routinely represented at commitment hearings. Additionally, the legislators have discovered that Virginia's Freedom of Information Act only appears to give public agencies the discretion to release medical information, such as the result of a commitment hearing. In effect, whenever state law leaves such decisions to the discretion of a state agency, federal law prohibits disclosure.

Other state policy makers could be disappointed if they hope to follow Virginia's lead in enacting changes that might prevent an incident similar to the one in Blacksburg. Members of the Virginia state legislature already have declared that they don't perceive the state's mental health system to be broken or in need of additional funding. The National Alliance on Mental Illness is urging legislators to block changes that might dilute privacy rights on the grounds that such reforms would simply feed the myth that individuals with behavioral health problems are dangers to society. Virginia legislators may decide that the already enacted regulatory reforms are sufficient.

The fact remains that “mandatory” outpatient treatment for individuals ruled mentally ill by a court order makes very little sense. Although NAMI spokespersons are correct in maintaining that most individuals with serious mental illness are not a threat to themselves or society, it also is true that suicidal ideation is the best predictor of suicide attempts, and recurrent homicidal ideation appears to be a good predictor of the rare “motive-less” attempts at homicide. People with this condition ordered into treatment by the courts rather than seeking care on their own may withdraw from therapy and medication. Just as directly observed therapy (DOT) is now used to ensure effective care for tuberculosis patients, it is essential that recipients of court-ordered mental healthcare be closely monitored on the assumption that patients may temporarily face increased risk to harm themselves or others.

We live in a time when behavioral healthcare is moving rapidly from guesswork to treatment of known effectiveness. Unfortunately, public policy has yet to reflect this change. Policy makers are more likely to listen to advocates who offer attractive slogans with low price tags, such as more widespread reliance on spirituality, government restrictions on violent video games and movies, and increased use of peer-led counseling. All three of these solutions have been proposed to prevent future tragedies like the mass murder in Blacksburg, but none has the demonstrated record of evidence-based therapy tailored to the needs of patients. There may be a role for spirituality and peer-led counseling for many patients, but public officials need to accept that behavioral health solutions that protect both patients and society often require real dollars and real expertise.

Reference

1. Mass Shootings at Virginia Tech. April 16, 2007. Report of the Review Panel, Presented to Governor Kaine, Commonwealth of Virginia. August 2007. https://www.vtreviewpanel.org.