Still groping for answers on caring for mentally ill [Milwaukee Journal Sentinel]

Jan. 08--The shootings of U.S. Rep. Gabrielle Giffords and 18 others in a Tucson shopping center a year ago highlighted the issue of getting care for people with untreated mental illness who are dangerous. But it hasn't settled the question of how to do so most effectively and fairly.

Jared Loughner, 23, charged with killing six people that day and wounding 13 -- including Giffords -- has pleaded not guilty to 49 charges against him. He awaits trial while a federal judge decides whether authorities can forcibly administer medication for Loughner's schizophrenia.

In Wisconsin, meanwhile, a committee is recommending several changes to the state's commitment laws, including ways to reduce the number of patients who are brought into hospitals by police and to clarify laws to allow parents to have more control over the care of their children.

And Milwaukee County administrators are shifting their focus from institutional care to more services in the community.

"This is such an urgent issue," said Lucinda Roy, an English professor at Virginia Tech who was academic adviser to Seung-Hui Cho, who ignored a court order for psychiatric treatment and killed 32 students and faculty members in 2007 before killing himself.

Roy is the keynote speaker Wednesday at a forum at Marquette University Law School, co-sponsored by the Journal Sentinel, to discuss ways to better identify those who are dangerous because of their mental illness and to get them help before they do harm to themselves or others. The forum is a follow-up to the Journal Sentinel's "Imminent Danger" series and documentary.

Roy said the attention on the need for better mental health care since the shootings on her campus and in Tucson has brought about improvements, but more are needed.

"There are far too few psychiatric beds for longer term care, spotty insurance coverage for students, and too few mental health personnel on campuses," Roy said. "There are still far too many cries for help from parents and teachers who are trying to get treatment for those they care for, too many young people in psychiatric crisis whose pleas go unanswered. The cost will be enormous if we don't respond to them better than we have in the past."

The threshold for getting most people with mental illness into care -- imminent danger -- was established in 1972 in a federal court case brought by Alberta Lessard, a West Allis schoolteacher.

Lessard had been committed to the Milwaukee asylum without notice of a hearing or the benefit of a lawyer to argue on her behalf. Before Lessard's case, a person could be detained without a hearing for up to five months on the signatures of three people who swore that the patient was sick and in need of care.

Wisconsin law has since been expanded to include a provision to commit those with a history of treatment who are not able to understand the consequences of refusing medication. But that provision is unevenly applied across the state and is rarely used in Milwaukee County.

A study committee of the Wisconsin Legislative Council is considering ways to apply the statute more uniformly from one county to another, including the use of a statewide ombudsman for emergency detention.

"It's effective when it's used," said Darold Treffert, a psychiatrist who lobbied for the reforms in 1995.

But others, including Robert Blondis, the lawyer who brought Lessard's case in 1971, say such expansions are an overly broad use of the state's powers.

"The label ' lack of insight' probably means that a person disagrees with the court-appointed doctor," Blondis said.

Who is dangerous?

Most people with mental illness are not violent. Fewer than 1% of people with chronic and severe mental illness are known to be dangerous, according to the most recent studies. But identifying those who are dangerous and getting them into care have been exceedingly tricky and contentious matters. A 2008 study found as many as 10% of homicides were committed by people with untreated mental illness.

E. Fuller Torrey, a psychiatrist, founded a national organization to track the cases of violence committed against people with untreated mental illness. A shift 50 years ago to a federal mental health care system weakened care for people with psychiatric illness, he says.

"Rarely in the history of the American government has a program conceived with such good intentions produced such bad results," Torrey said in a recent essay. "The patients were deinstitutionalized from the state hospitals, but most of the 763 federally funded community mental health centers failed to provide services for them."

Torrey's organization lobbies for laws that more easily allow state officials to compel patients into care -- either in hospitals or, more commonly, with court orders that allow patients to live in the community as long as they comply with treatment plans

Thomas Zander, a retired lawyer and psychologist who has worked for 40 years to limit the government's ability to commit mental patients, says civil commitment is the least effective and most expensive means of providing care.

"It requires the high costs of lawyers, judges, expert witnesses and inpatient hospitalization," Zander said. "By soaking up scarce mental health dollars, civilly committing one person means that 80 others are denied more effective voluntary care."

Care in the community

In Milwaukee County, mental health administrators are working to reduce the number of patients who are brought into the county Mental Health Complex by police on emergency detentions.

The number of emergency detentions spiked 33% over the past 10 years to a high of 8,274 in 2010, the most recent year for which full statistics are available.

"There is a great deal of agreement that we have too many emergency detentions here," said Paula Lucey, director of Milwaukee County's Behavioral Health Division.

The county has begun to stress care in the community over more traditional institutional settings. Lucey said she'd like to expand on programs like the Crisis Resource Center, a refurbished convent on Milwaukee's south side that provides temporary overnight care for seven psychiatric patients who probably would otherwise be kept at the Mental Health Complex.

The county has set aside $3 million in this year's budget to expand more programs like that.

Services include nursing care, help finding housing, peer support, group counseling, even arts and crafts classes. The cost there runs $450 a day, about one-third of the cost at the Mental Health Complex.

The need is tremendous, said Dan Baker, the center's director. Last year, the Crisis Resource Center had to turn away 220 people who fit the criteria.

On a recent day, a group of patients sat in the lounge discussing ways to ease stress. Billy, who declined to give his last name, has schizophrenia with paranoid delusions, convinced that someone is out to hurt him.

For years, Milwaukee police would coax him off the streets and take him to the Mental Health Complex where, for $1,400 a day, the medical staff would get him stabilized on medicine and let him go. Weeks later, Billy would return and the cycle would begin again.

Today, Billy is staying at the Crisis Resource Center, getting help recovering until he is well enough to go back on his own.

State examining law

A special committee of the state Legislature is reviewing ways to improve the state's commitment law.

The group is recommending that emergency detentions be reserved for people who are at high risk for violence and are uncooperative, not people who are seeking voluntary treatment.

The committee also recommends that emergency detentions not be used for people who have only dementia.

Wisconsin is the only state that requires police to bring in a patient for an emergency detention. The legislative panel is recommending that qualified doctors who have completed a training and certification process should be allowed to initiate an emergency detention in a hospital. It is also considering a provision to allow psychologists and other trained medical professionals to place patients in the hospital on an emergency basis.

The legislative group is also looking at ways to clarify commitment laws as they relate to children ages 14 to 18.

One suggestion is a separate mental health code for children and adolescents. The panel is also considering rewriting the law to make it more clear and understandable.

A law took effect on Aug. 1, 2006, that gave more authority in commitment matters to parents of minors 14 and older. But the law has been little understood. A committee report says misunderstanding, particularly in some areas of the state, "has resulted in necessary treatment not being provided that could have prevented harm."

The group suggests establishing a medical review process, rather than a legal review, to provide appropriate procedural safeguards to minors.

"It has been suggested that medical personnel, rather than courts, have more expertise to evaluate the need for, and appropriateness of mental health treatment for minors," the committee report said.

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