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VA Tech Shooting Report Points to Inadequacies in Mental Health Care System

Natalie Staats Reiss, Ph.D. Updated: Sep 1st 2007

As you are probably aware, the report of a panel convened to investigate the circumstances surrounding the VA Tech shooting was released Thursday. I have had a chance to scan portions of the document (available at http://www.governor.virginia.gov/TempContent/techPanelReport.cfm). It's a very large and detailed document that covers a wide array of issues surrounding the shootings and their aftermath. I am certain, over the next days and weeks, we will continue to hear stories related to the information contained in this report.

Late this morning, as I was thinking about the report, I overheard two people at my local coffee shop discussing their reactions. I was particularly struck by two of their questions. One person said to the other, "Do you think stuff like this will happen again?" I didn't respond (I didn't want them to know that I was eavesdropping), but my internal answer was, that unless there are some fundamental changes in our country's mental heath system (and relevant laws) that are put into place quickly, YES! And unfortunately, it's probably only a matter of time before some other tragedy occurs.

Why do I say that? I am not simply echoing the panel's findings that "Virgina's mental health laws are flawed and and services for mental health users are inadequate." If you have spent any time involved in the mental health system (either as a patient, clinician, law enforcement officer, or concerned friend or family member), you know that this problem is not limited to the state of Virginia. We have serious gaps in our national mental health system that allow people to "fall through the cracks" all of the time.

The second question that caught my attention was "Why didn't they lock him up?" The answer is related to my comment above, so I'd like to address that issue here.

One of the major problems in our mental health system has to do with "commitment," or admitting someone to the hospital for a mental disorder. Commitment can either be voluntary (i.e., the person is willing to go to the hospital and receive treatment) or involuntary (i.e., the person is unable or unwilling). Involuntary hospitalization is carried out through a legal procedure called civil commitment. All states have a specific civil commitment legal process that includes 3 steps: a petition or request for a hearing, the hearing itself, and a judge's decision.

Contrary to what you may believe, putting someone who needs help in the hospital "against their will" is relatively difficult. Frequently, this process starts with the police. In the case of the VA Tech Shooter (Cho), the police were called after he made the statement "I might as well kill myself" after being told to avoid contact with a young woman that he had been bothering/stalking. Cho was taken to the VA Tech police department, where he was assessed by a licensed clinical social worker.

The civil commitment process cannot move forward unless there is evidence that people are 1) suffering from a serious and disabling mental illness, and 2) are in imminent danger of harming themselves or others. #2 is often a significant stumbling block. I have treated many people who would probably have benefited greatly from hospitalization, and were savvy enough to pull it together when the police arrived, because they didn't want to be admitted. There is often a gray area where people are clearly too ill to function independently, but are not quite ill enough at the time of assessment to be committed.

The social worker who assessed Cho felt that he met both criteria, and recommended involuntary hospitalization. Now, the procedure becomes a bit more complicated. The next step is to find a psychiatric bed in a local hospital and a legal official (a magistrate, in VA) to authorize the request. There is also typically a time constraint. In VA, a person can legally be held for no more than 4 hours, during which time the assessment must be completed, a bed must be located, and the magistrate contacted. Many times, it is difficult to find an available psychiatric bed in a hospital, because there aren't very many around. Almost 90 % of the state psychiatric hospital beds that existed in 1960 have been eliminated. As a result, approximately 2.2 million severely mentally ill people do not receive needed psychiatric treatment.

Back to Cho. The social worker was able to find a bed in a nearby hospital, and a magistrate issued a Temporary Detention Order (sometimes referred to as a "hold" by clinicians). At this point, a person must be re-assessed by an independent evaluator (a clinician not treating the patient) and the treating psychiatrist in the facility. Again, there is a time constraint; both evaluators must assess the person within a legally specified period of time (in VA, this period is 48 hours).

You might think that 48 hours is tons of time. However, the main purpose of these assessments is to try and make a judgment about whether someone, if discharged, is going to harm themselves or someone else. Consider what should be involved in making an fully-informed decision: 1) Assessing a person's current medical condition(s) that might be impacting their mental health, which requires an exam, interview and/or lab tests or procedures 2) Investigating alcohol or substance use, which might require a toxicology screen 3) Obtaining information about current psychosocial conditions (mental illness, stressors, current level of functioning, living situation, etc.), which requires an interview and/or tests, and 4) A psychosocial history which requires an interview, talking to family members and acquaintances, as well as obtaining previous medical and mental health records.

Due to HIPAA regulations (the Health Insurance Portability and Accountability Act of 1996; a set of rules governing medical records, medical billing, and patient accounts to ensure that certain standards regarding documentation, handling and privacy are met) and time limitations, the evaluators often do not have access to much of this material and must do the best that they can with available information. In Cho's case, the independent evaluator only had access to the information from the pre-screening social worker. He had no knowledge of Cho's long and complicated history of mental illness and treatment, nor his recent history of increasingly violent and suicidal thoughts and behavior. The independent evaluator spent approximately 15 minutes coming up with a conclusion. We can only speculate at this point, but more complete information might have led to a different decision about Cho's condition.

The final step in this commitment process is the hearing. At this hearing, a judge weighs the presented evidence and decides whether the patient should be committed involuntarily. Theoretically, at this hearing, the patient, the patient's attorney, family members, the relevant assessors, the police, and/or anyone else involved with the patient can testify. Practically speaking, this often does not happen. Again, the judge must make due with whatever information is available (and whoever can appear) at the time. Cho and his attorney were the only ones to testify at his hearing. The judge had only the pre-screening form (from the social worker), a partially completed form from the independent evaluator, and a psychiatric evaluation form from the treating psychiatrist. No psychosocial history, lab tests, physical exam, etc. were presented, because they had not been completed and transcribed at that point. Parents and acquaintances were present, because Cho denied permission to have them contacted. In addition, the judge did not know that Cho had access to a firearm.

In Cho's case, the judge ruled that he did present an imminent danger to himself as the result of mental illness, but that he should be treated on an outpatient basis. Here's another interesting twist in our current mental health system. About 40 years ago, there was backlash against the number of people that were being involuntarily committed. Many groups suggested that this was a violation of people's rights. As a result, involuntary commitment laws became more strict, and included language requiring that people be treated using the "least restrictive alternative. " In most states (such as VA), people can be ordered to take medication and to keep mental health appointments rather than being hospitalized.

Again, in theory, this is a good idea. However, in practice, it does not work well. Most communities have poor mental health networks designed to supplement hospital systems. We also have limited subsidies for outpatient care and case management (particularly in the case of people who have limited or no health care insurance). Often, the specifics about the number of sessions required, who will treat the patient, and who will coordinate/monitor all of this mandated care is not ironed out (as with Cho). If people are ill enough to require court-ordered treatment, they are probably too ill to be in charge of coordinating and self-monitoring their care. If our laws are going to allow this option of mandatory outpatient treatment, then we MUST fund adequately fund and plan a system that will facilitate this type of care.

Cho was discharged from the hospital with the condition that he was required to keep his appointment with the VA University counseling center. He did go to this first session. However, there was no one in charge of ensuring that he kept attending these appointments. In addition, privacy laws prohibited information sharing. So, neither the police, Cho's roommates, his family, nor the VA Tech administration received a copy of the court order mandating treatment. None of these individuals were aware of the judge's ruling.

Not surprisingly, Cho did not return to the Counseling Center after his first appointment.

Please understand my point in writing this blog. I am not blaming "the system" for the tragic loss of lives that occurred at VA Tech. No one else bought those firearms and forced Cho to go on a homicidal and suicidal rampage. However, he did come into contact with a mental health system (and relevant information sharing laws) that is cumbersome, unwieldy, and ultimately ineffective. We must fix it.

Reader Comments
Discuss this issue below or in our forums.

pro-reform - Lewis - Sep 4th 2007

I'm all for reforming the system, depending upon what is being recommended of course. 

Last time I felt I was a danger to myself and others and needed hospitalization they turned me away because I had no insurance, so I had to come back and threaten a nurse with a knife to get myself a three week stay in a state ward to get my medicine regiment aggressively modified.  I've even got a criminal record with a small amount of violent crime on it, so it isn't like they had reason to think I was bluffing when I told 'em I needed to be committed. 

Personally, I worry about the fact that if I can go and ask for help to save myself and others from me, what hope do we have of stopping anyone that doesn't want to cooperate with the system?

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