Wednesday, May 28, 2014

Will Changing The Commitment Standard Decrease The Rates Of Mass Shootings?

A colleague sent me an e-mail this morning about a story that focuses on changing the commitment standard to a need for treatment rather than dangerousness.  She asked me if I thought it would be an effective measure so that more people with psychosis are treated decreasing the risk of mass violence perpetrated by psychotic persons.  As a background, most states have civil commitment statutes that involve imminent dangerousness.  That literally means that the person in question has already done something dangerous or they appear to be at high risk for doing something dangerous in the near future.  My first reaction is that it would not do a thing and here is why - states routinely ignore lesser standards and default to dangerousness because it limits court and treatment costs.  At least until there is a "bad outcome" and then for a while the standard is broadened again.

Let me illustrate what I mean by using the statutes that pertain to civil commitment in the state of Minnesota.  The following are the statutory definitions of a mentally ill or chemically dependent person who could be considered for civil commitment in the state:

Subd. 13.Person who is mentally ill.


(a) A "person who is mentally ill" means any person who has an organic disorder of the brain or a substantial psychiatric disorder of thought, mood, perception, orientation, or memory which grossly impairs judgment, behavior, capacity to recognize reality, or to reason or understand, which is manifested by instances of grossly disturbed behavior or faulty perceptions and poses a substantial likelihood of physical harm to self or others as demonstrated by:
(1) a failure to obtain necessary food, clothing, shelter, or medical care as a result of the impairment;
(2) an inability for reasons other than indigence to obtain necessary food, clothing, shelter, or medical care as a result of the impairment and it is more probable than not that the person will suffer substantial harm, significant psychiatric deterioration or debilitation, or serious illness, unless appropriate treatment and services are provided;
(3) a recent attempt or threat to physically harm self or others; or
(4) recent and volitional conduct involving significant damage to substantial property.
(b) A person is not mentally ill under this section if the impairment is solely due to:
(1) epilepsy;
(2) developmental disability;
(3) brief periods of intoxication caused by alcohol, drugs, or other mind-altering substances; or

(4) dependence upon or addiction to any alcohol, drugs, or other mind-altering substances.

Subd. 2.Chemically dependent person.


"Chemically dependent person" means any person (a) determined as being incapable of self-management or management of personal affairs by reason of the habitual and excessive use of alcohol, drugs, or other mind-altering substances; and (b) whose recent conduct as a result of habitual and excessive use of alcohol, drugs, or other mind-altering substances poses a substantial likelihood of physical harm to self or others as demonstrated by (i) a recent attempt or threat to physically harm self or others, (ii) evidence of recent serious physical problems, or (iii) a failure to obtain necessary food, clothing, shelter, or medical care. "Chemically dependent person" also means a pregnant woman who has engaged during the pregnancy in habitual or excessive use, for a nonmedical purpose, of any of the following substances or their derivatives: opium, cocaine, heroin, phencyclidine, methamphetamine, amphetamine, tetrahydrocannabinol, or alcohol.



The first thing that should jump out at any reader is the fact that "dangerousness" most commonly defined as a "danger to self or others" is only one of several relevant criteria (see bolded sections).  A significant part of the statutory definitions for both mentally ill persons and chemically dependent persons has to do with self care.  Can they provide food, clothing, shelter, or medical care for themselves?  Can they manage their personal affairs?  I would suggest that the majority of people in this country with psychotic disorders and both substance use and psychotic disorders who are acutely disabled by those disorders meet this standard rather than threatening or aggressive behavior.  Suicidal ideation and behavior is also less common than deficits in functional capacity or self care.  There are also a number of important legal interventions that are as important as civil commitment to address these issues among them conservatorship or guardianship that provides substituted decision making for the person with impaired cognition due to mental illness.  I worked with an even better option in the State of Wisconsin and that was a parallel system of protective services and protective placement that could be used in place of civil commitment to assure that the person had adequate resources for their day to day needs and medical care.

The article I received today talks about mental health being the default position for legislators who do not want to take on the firearms issue.  The politics of this situation and the deadlock  are quite obvious so I won't belabor the point.  The legislator in this reference wants better training for the police and a commitment standard based on treatment considerations rather than "imminent dangerousness."  I have already demonstrated how imminent dangerousness is a de facto standard that the courts and managed care systems collude with, but it really has nothing to do with existing statutes on the books.  I will take a page from the gun advocates who claim we have enough gun legislation on the books it is just never enforced.  We have enough commitment standards on the books - they are never recognized or followed.  To say that the commitment standard is "imminent dangerousness" is simply false.    

The politics of civil commitment is always an interesting process and it does shed some light on why the standards are ignored.  It actually happens at all levels.  In Minnesota, if a person is on a 72 hold in a hospital they need to be seen during that time frame by a pre-petition screener from their county of residence. Pre-petition screeners come from many counties and they vary considerably in their clinical acumen and political orientation.  It becomes fairly easy to predict which counties will proceed with commitment and which will not.  Some counties have pre-petition screeners who actually consider themselves to be civil rights advocates and they will fight any suggestion of commitment.  That fight should occur at the next level and that is the county attorneys who represent the county in the commitments and the defense attorneys.  Outcomes vary with the personality of those attorneys and some of those outcomes are not good.  The final step is the probate court judge, commissioner, or referee responsible for making the determination of commitment.  The quality and experience at this level varies considerably ranging from judges who are consistent and handle cases very well to those who clearly make wrong decisions to judges who overstep their authority and start to make medical decisions such as ordering a specific medication or quantity of mediation per court order.  As far as I can tell there is no uniform training or standards for any member of the commitment process so variable outcomes should not come as a surprise.    

With the issue of civil commitment laws that use a treatment standard, they are already on the books but  they are rarely followed.  That has to do with the culture of rationing mental health services as much as anything.  How do I know this?  I have been part of conversations where staff involved in a commitment were told by a county bureaucrat that they were doing "too many commitments" and it was "costing the county too much money".  I never really understood that argument because all of the people involved are there, on salary, and show up every day whether there is anyone in commitment court or not.  The cost should be the same if one person shows up for a hearing or 20 people show up.  At 5 o'clock everybody goes home, so there is no overtime.  I have never seen the court so saturated that they could not move through the necessary hearings and decisions.  The only thing that this false economic pressure creates is a change in the way the commitment statute is interpreted.  Suddenly the ONLY rule is "dangerousness to self or others".  That also translates to "imminently dangerous to self or others".  Notice that the statute says nothing about "imminently" and any form of the word danger is limited to a special section at the bottom about "Mentally Ill and Dangerous".    

I conclude the changing the commitment standard and expecting that to have an impact on mass violence will not work, basically because that treatment standard is already on the books and it is routinely ignored.  In Minnesota, the entire chemically dependent person statute is frequently ignored and I often hear "we don't commit anybody for chemical dependency."  There are a number of financial, avoidance of work incentives, and lack of quality standards that have facilitated that process.  It is readily observable by any psychiatrist who sees their patient back, realizes that they did not receive any care in a hospital, and notes the patient was discharged at his or her request because "they were not imminently dangerous".  The financial interests of managed care systems and the counties involved overlap perfectly at that point.

Once again I keep coming back to the old term "quality".  Quality care never involves discharging a disabled person because it is convenient to do so and it can be rationalized by a "community standard" that is determined by everybody except the experts involved and in this case the state statutes..

The focus of psychiatric professional organizations should be on defining what that standard of care should be and how to optimize treatment instead of throwing in with a managed care model for rationing care.  Rationed care has resulted in a non-existent system of care for the patients with psychosis.  And as long as that system remains non-functional, the small percentage of people who are violent and psychotic will also not get the care they need.

The prevention of violence by individuals with psychosis starts with improving the standard of care for everybody rather then trying to pick the violent individuals out of the crowd. 

George Dawson, MD, DFAPA 

10 comments:

  1. A little history I personally observed: The inability to provide for food, clothing and shelter due to mental illness, called "gravely disabled," was one of three major criteria for involuntary commitment in California's groundbreaking Lanterman-Petris-Short Act of 1969 (along with danger to self or others). The LPS act was also the original source of the "72 hour hold" (or 5150 for any Van Halen fans). The LPS act became the standard for many states across the country.

    As you point out, the grave disability criteria gradually became itself gravely disabled, as a cardboard box on skid row gradually came to be seen as evidence of an ability to provide shelter. This was spurheaded not by managed care, as it is now, but by so-called patients rights advocates who took concerns about earlier abusive commitment practices in the field to a ridiculous opposite extreme.

    Sometimes when I was in LA during this process I was sorely tempted to hand out the patient's rights advocates' personal addresses to homeless schizophrenics, and then take bets on how soon the advocates would call the police if said person pee'ed on THEIR doorstep.

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    1. Dr. Allen,

      In 1987, I saw a violent young manic who had been stopped by the police and committed under a 5150. He rapidly responded to lithium and Haldol as he had done in the past, but he was chronically noncompliant.

      The 72 hours were up and I want to Court 95 in the San Fernando Valley to continue treatment involuntarily as I felt he was gravely disabled. He flatly denied any suicidal or homicidal ideation but I pushed the latter point since he had only recently got into it pretty heavily with the police.

      The judge accepted the cardboard box on the street corner plan as sufficient shelter and he was released since in her mind that was enough to prove he wasn't gravely disabled.

      Two days later he was shot dead by cops in a violent confrontation, which might have been suicide by cop.

      The next time I saw the judge she could not even look at me without looking away in disgrace.

      That was right about at the end of my time working in a hospital setting. I realized the LPS law was a joke in the way it was being interpreted. This is one of a handful of unpleasant experiences I had with Court 95 in the 1980s. It saddened and depressed me, and the only consolation I had was that I had covered my ass and the families knew I did everything I could.

      I am a civil libertarian by temperament, but only a fool fails to see how this logic does not apply to the severely mentally ill.

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  2. David,

    My experience echoes yours and I have lost count of how may times I have reminded county and court officials of the "gravely disabled" standard. They of course look at me like I am a dinosaur and continue to talk of "imminent dangerousness" even though it is not in any statute.

    For a while we had some counter rhetoric to the cardboard box as a residence scenario and people would refer to it as "dying with your rights on". But as you point out this is another significant area of conflict of interest - can you get somebody "off" in a commitment, conservatorship, or guardian proceeding or can you get them the help they need. Attorneys experienced in these matters seem to opt for help rather than dismissal.

    My guess is that is because of the bad outcomes they witnessed and the number of clients who followed them out to the parking lot looking for help afterwards.

    With the reset of the lowest possible standard that we have now, everybody is less guilty. We just can't do anything if a person is not "imminently dangerous" or "holdable."

    What a travesty.

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  3. Hi Dr. Dawson,

    I think it will take a long time for many older people to forget what Psychoanalysis did to hundreds of thousands of people, depriving them virtually totally of any access to medical care and using ablative treatments for more then 40 years. My parents had friends who were killed in that system. Although things have certainly changed since psychoanalysis fell out of favor all the way back in the 1970s, the Mental Health system is still nearly totally devoid of specialists from other medical fields.

    From what little was published in state Psychiatric hospitals in the 80's and 90's, the diagnosis of physical illness was not good.
    http://www.ncbi.nlm.nih.gov/pubmed/7235058
    http://www.ncbi.nlm.nih.gov/pubmed/2787623
    http://www.ncbi.nlm.nih.gov/pubmed/1997369

    I'm not sure what the case is today, very little is published on the occurrence of physical illness in Psychiatric hospitals. From what I gathered, the majority of patients presenting with psychiatric symptoms to an emergency room had an organic etiology,
    http://www.ncbi.nlm.nih.gov/pubmed/7235058

    I'm not sure where Psychiatric patients actually come from. If Psychiatrists are finding 15-20% of their patients have medical illnesses in involuntary wards, then those individuals must not have received proper medical examinations before admission. A GP can only expect to find about 20% of physical illnesses in an emergency room; a team of specialists are required to find the rest. The use of Mental Disorders as a diagnostic end point is probably counter productive, most notably in private practices where the majority of patients receive mental health care. If physical illness in private practices are similar to emergency rooms, that that's truly scary.

    I find it disturbing that not one mass shooter had a physical illness diagnosed that caused their psychosis. Yet, all were forced drugged by the court to make them 'sane for the court'.

    We need to vastly improve the standard of care for everyone.
    To see politicians use the sick as scapegoats to avoid taking responsibility for their own actions is absurd.

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    1. The current legal approaches make the issue of medical illnesses in the context of mental illnesses even scarier. People end up with no care for mental illness based on an inflated commitment standard and they end up with no medical care based on an inflated guardianship standard.

      To illustrate, in the last county I practiced no emergency guardianships were available for medical treatment. Each county had their own standard, but in the county where I worked - a private legal firm had to be paid $1,000 in order to do the case and the paperwork to get the case considered. Even then it would take 2 - 3 months. In that environment, I found myself caring for people with acute medical problems that needed urgent treatment that they were refusing. The specialists involved refused to do anything without the guardianship in place out of the fear they would be "assaulting" the patient without adequate substituted consent. They were of course correct.

      In the most absurd cases, people were bleeding on the floor and I was told: "Call us when they pass out and we will make a decision about emergency treatment."

      That is a good example of the extreme state of neglect that occurs as a result of legal and business systems preventing indicated care of the mentally ill.

      That contrasts with my ability to get appropriate medical care when I started out 30 years ago. At that point I had a patient with cancer who did not believe he had cancer due to a delusional system. I was able to get a court hearing at no cost to the patient or her family and within a week she was being seen and treated by a cancer specialist. I don't know why nobody else seem to talk about it, but treatable cancer is a significant cause of mortality in people with severe mental illness. And over the past three decades our society has decided that it is an acceptable standard to allow people to die, based on the fact that severe mental illness has affected their decision making.

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    2. Your comment stopped me dead in my tracks. I didn't know it was this bad.
      And, I am one for choosing my own care, but this is possibly the worst I have ever seen related.

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    3. Sorry, I apparently posted the same abstract twice.

      Personally, I think it goes back at least 100 years; the original charity medical system of Psychiatry (staffed by physicians from all existing fields) was lost to history, and nothing ever replaced it.

      I wish there was more public discussion about the treatment of physical illness causative to, and co-occurring with, mental illness. We need specialists to be able have access to, and treat, the mentally ill for their medical illnesses.

      I'm not sure what society's problem is; there was so much public and government support 200 years ago when medicine was too primitive to accomplish anything. Yet today, when we can actually do so much more, there's just no interest... It's utterly bizarre.

      thanks for the reply.

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    4. Clark,

      I don't see it as a big mystery.

      There is a clear cultural movement in the US to bring increasing numbers of people under the control of inefficient managers. The financial system is an obvious case in point for everyone except the managers. But it is also the reason I keep bringing up the way medicine is managed. Medicine has become one of the largest taxes that any person or family pays in their lifetime and like many investments that we are locked into - it is a bad one.

      The interest today is in making sure unnecessary managers and the people at the top make money. That comes at the high price of rationing or just not providing service and a much less enthusiastic and inquisitive physician workforce.

      I think I was one of those physicians you are writing about. I always paid close attention to existing medical conditions and making sure they were treated adequately. I was told many times that my approach was "too expensive" and I was targeted by administrators and insurance companies. I can recall treating a complicated delirium only to be told by the insurance company that "delirium is not a psychiatric condition".

      It probably is when other specialists are sending you the cases.

      I agree with you that in today's "cost effective" environment - there is a lot less time and effort allocated to complicated problems. It will only get worse as business consolidates its power with the help of politicians.

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  4. I work in California and it is next to impossible to keep someone in the hospital involuntarily for more than a 72 hour hold. And I have zero confidence that there is any followup to weapons removal if and when it ever happens. Even if the police hadn't botched the check up, I don't know if it matters in the eventual outcome.

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    1. I think that the so called commitment standards have basically become a way to rubber stamp inadequate psychiatric care. When you think of it as a service industry - there is no other such industry out there that will keep you somewhere for a day or two doing absolutely nothing positive for you and then tell you that we don't have to provide you with any service because you don't meet our "imminent dangerousness" standard for service. In the meantime any discharge before the DRG designated date is money in the bank.

      It is an absurd world where medical care is dictated by businesses and governments. All of the incentives are aligned to provide the maximum profit for hospitals and healthcare systems and less work for the counties involved. It is a perfect world for everyone except the patient. That is after all how Greyhound Therapy got started:

      http://real-psychiatry.blogspot.com/2013/05/greyhound-therapy-suddenly-wrong.html

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