"People had one level of care and now have a different level of care. To think those cuts didn’t have any effect would be foolish." - Sue Walther
Every week, Roger Morgenthal has to make the choice.
Is the person sitting in front of him an immediate danger to themselves or others because of severe mental illness? Should this person be kept in a hospital to receive treatment, even if it is against his or her will?
Morgenthal has served as the mental health hearing officer for Cumberland and Perry counties since 1976. In that time, he estimates he?s held between 9,000 and 10,000 such hearings for 5,000 to 6,000 people. He felt he had reason to worry that maybe 10 of those people, all in the throes of psychotic disorders, might be dangerously violent toward others.
Since Adam Lanza murdered his mother, 20 school children and six adults in Newtown, Conn., public officials from President Barack Obama down have talked about the need for a new dialogue on guns. Somewhere in those statements, the officials make vague mention of improving mental health care.
Gun laws have a Presidential task force. Mental health care, as usual, is receiving lower billing.
Gun control is controversial, but comparably simple. With one piece of federal legislation, Congress could install a national assault weapons ban.
Mental health care is vastly more complex, governed largely at the state level, with 50 different sets of laws that reflect dramatically different philosophies and levels of funding.
So far, we don?t know Lanza?s mental health history. It?s unclear if stronger commitment laws or better treatment options would have prevented the massacre in Newtown.
But other mass murderers, like Arizona shooter Jared Loughner, did have a history of mental illness. Some experts say better treatment and intervention measures might have kept Loughner from shooting former Rep. Gabrielle Giffords and killing six people.
The politicians talking of improving care don?t specify if they mean for the very few people whose illness might prompt violence, or the majority of those living with mental illness who are more likely to be the victims of violence and crime.
Few are talking about the slipover affects of mental illness that touch our society.
According to the Treatment Advocacy Center:
? A third of the homeless population has untreated mental illness.
? About 16 percent of people in state prisons have untreated mental illness.
? About the same percentage of people living with bipolar disorder or schizophrenia will eventually take their own lives.
No major public official has yet to call for a significant increase in spending on psychiatrists, social workers, group homes, peer support services or pharmaceutical research to better treat the six percent of Americans living with serious mental illness.
Here in Pennsylvania, advocates say the lack of housing and other resources makes it difficult for those recovering from breakdowns to maintain necessary stability. That was made worse by budget cuts last year.
Most people who have never had contact with the mental health system through a family member or friend do not understand how it works. That ignorance, and the evil stigma that has long surrounded those with illnesses of the brain, has made it difficult for any reforms to gain popular support.
What?s more, the groups of advocates that care passionately about improving mental health care disagree about how far the state can go to compel people who are clearly not well to receive treatment. Some want the reach of the state?s commitment law expanded, others think it goes far enough.?
Resources needed
Any attempt to reform the mental health care system begins with a question:
What scale do leaders want to aim this reform?
A small scale reform, aimed only at the minority of those living with severe mental illness who are potentially violent, would do nothing to lessen the other forms of human misery that plague the chronically untreated. Such narrow measures, advocates argue, would do nothing to prevent those with worsening conditions from deteriorating until they became a potential danger.
Reform on a larger scale, a combination of education, treatment, housing, support services and better drugs, could keep people off the streets, out of jail and safe. It would also be costly.
Advocates argue we?re not doing a good job of paying the mental health bills we already have.
Beginning with former Gov. Tom Ridge, Pennsylvania has closed many of its large mental health facilities.
That program continued through Gov. Ed Rendell?s administration, including the closure of Harrisburg State Hospital. At the same time, the state built smaller facilities in each county. Numerous studies have shown people with severe mental illness are more likely to recover in the least restrictive settings.
These new facilities were aimed at treating people with specific needs. In theory, a person could move from a crisis center to a residential treatment center to a structured group home to outpatient treatment.
But the system doesn?t always work that like.
Instead, waiting lists have been common at most of the midstate?s residential facilities since they opened. People wind up staying at inpatient hospitals ? designed to house someone for a few days ? for months.
And that was before last year?s budget.
The state cut payments to the county mental health offices by 10 percent. There was also a 10 percent cut to the Community/Hospital Integration Program Projects ? money specifically designated to pay to treat people in residential facilities and through outpatient services instead of state hospitals.
?For the first time in the modern history of hospital closures, the commitment was not honored because the dollars were cut, and they were cut significantly,? said Sue Walther, executive director of the Mental Health Association in Pennsylvania.
?People had one level of care and now have a different level of care. To think those cuts didn?t have any effect would be foolish.?
By eliminating the general assistance fund, the state also removed the payments that advocates said often covered co-pays on drugs for people waiting to qualify for Social Security disability.
The state Department of Public Welfare said that by allowing 20 counties ? including Dauphin County ? to accept the funding in block grants, the counties had more freedom to better use the money they were given.
However, most counties, including Adams, Cumberland, Lebanon, Perry and York, were not invited to participate.
When asked if services were cut along with the funding, Donna Kirker Morgan, a welfare department spokeswoman, wrote in an email: ?This would be up to the individual counties to determine how they would make changes, so I am going to defer to them.?
Kirker Morgan did not respond when asked if agency was doing anything to determine the potential impact of the cuts.
With the state facing serious financial challenges ? and little political will for a tax increase ? the welfare department was given a smaller budget last year. Many of the services it oversees, like Medicare, could by law not be cut, Kirker Morgan said. Mental health care was one of the areas that could.
She noted that, according to a Kaiser Family Foundation survey of 2010 data, Pennsylvania spent the fourth most per-capita on mental health care of any state in the country.
Advocates counter the lack of housing affects even the most serious cases.
When he has to decide if a person should continue to receive involuntary care, or what level of involuntary care they should receive, Morgenthal often finds his options limited.
?Honestly, I don?t have the option of saying I want this person in outpatient group care because the options just aren?t there,? Morgenthal said. ?If a social worker says we don?t have any place to put this person ? there?s a waiting list in structured group homes for six or eight months ? I don?t have a place to put this person.?
Change the law?
?Only a small percentage of people with untreated severe mental illness are prone to violence, but those that are can have a disproportionate impact on society.
Ten percent of homicides in America are committed by people with untreated severe mental illness, according to the Treatment Advocacy Center.
By the letter of the law in Pennsylvania, a person can only be treated against their will if they present a serious harm to themselves or others in the past 30 days. Technically, a person would not just have to threaten to harm someone else, they would need to have attempted to carry out an act.
If the person does not meet the standard ? even if he or she has clearly decompensated and is not thinking rationally ? they can refuse treatment, including medication.
In theory, if the first time a person seriously attempts to carry out a violent act was a mass shooting, there would be no legal way to intervene before that.
Some advocates feel it?s time to change the law.
?There needs to be an expansion of the definition of a danger to self or others,? said Taylor Andrews, a longtime mental health advocate from Carlisle.
?For an individual that has a known condition, who has responded to treatment in the past, and is deteriorating and will likely continue to deteriorate if they aren?t treated, and you know they cannot make a rational decision about treatment, they should be considered a danger to themselves.?
Other states, like New York, allow for earlier intervention.
Since changing the law, and investing significant money, New York has seen a 74 percent drop in homelessness among the mentally ill, a 77 percent drop in hospitalizations, an 83 percent drop in arrests and an 87 percent drop in incarcerations.
State Sen. Stewart Greenleaf, R-Montgomery, has introduced legislation that would change Pennsylvania?s law, though it does not include new funding. Greenleaf estimates his bill would affect about 400 people a year.
The biggest problem with the law as its currently written, Greenleaf said, is it does nothing to help people with anosognosia ? a condition that prevents people with mental illness from recognizing the effects of the disease.
The way the law is written in Pennsylvania and other states, people with irrational minds need to keep making the rational choice to continue treatment in order to stay well, said Doris Fuller, the executive director of the Virginia-based Treatment Advocacy Center, which backs Greenleaf?s bill.
Many people who did not recognize their condition until after they were involuntarily committed said they would not have been able to recover without the initial ruling, Fuller said.
At the extreme end, Loughner, the Arizona shooter, was forced into treatment after his arrest. By the time of his sentencing, he said he understood what he had done and deeply regretted it.?
Medication isn?t enough
Many in the mental health community do not agree with Greenleaf or the Treatment Advocacy Center.
The consumer movement began in the bad old days of mental health care, which were exactly that bad, and not that old.
Supported by research saying peer support groups, housing options and other support services were as important to successful long-term recovery as medication, they helped push treatment out of the large state hospitals and into the community.
The consumer movement also led the fight against the stigma that those with severe mental illness were evil or inherently dangerous.
When those in the consumer movement hear Greenleaf?s proposal, they see society trying to take a shortcut, instead of building holistic treatment options that help those with severe mental illness fully establish their lives.
?We need to look at what we?re offering and tailor the offerings to meet their needs,? Walther said. ?There?s evidence to suggest peer support and things like that can move people toward recovery.?
MHA and the Pennsylvania Mental Health Consumers? Association both oppose Greenleaf?s bill. So does DPW?s Office of Mental Health and Substance Abuse Services, which believes the current standard is sufficient, Kirker Morgan said.
Walther is skeptical that anosognosia exists. Instead, she said, it?s a question of creating an environment where people are willing to be treated. Pennsylvania?s current commitment laws can protect a person in the most acute cases, she said.
?I understand why this has an appeal,? Walther said. ?But even if I could accept this argument, if you don?t have the support services there, forced medication is not going to be enough.?
It requires money
Morgenthal, the hearing officer, says both sides are right.
He has between 50 and 100 people he sees two or three times a year, his regulars. He also has another 100 or so he sees every few years, after their recover breaks down.
He believes the law as currently written does give him wiggle room when deciding to continue a commitment, especially in these cases.
?Frankly, if it?s a patient that I know well and they have a pattern, I?m not going to disregard their medical history,? he said. ?I?m going to say to the court, ?This is what?s likely to happen, let?s try and prevent that.??
He also thinks the law needs to go further.
A man or woman shouldn?t need to be able to carry out a plan to kill themselves in order to be committed.
?I think a good psychiatrist or psychologist has the ability to tell if someone has a sincere intent to harm themselves instead of just a cry a help,? Morgenthal said.
Most of the people he sees couldn?t carry out a violent attack in the actual world. But if they are having delusions telling them they should and are unwilling to be helped, he should be able to order them into treatment. He should be able to order they continue that treatment after they have been discharged.
But without a real investment in treatment options and support services, he said, simple changes in the wording can only matter so much.
Source: http://www.pennlive.com/midstate/index.ssf/2012/12/as_gun_control_controversy_rag.html
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