Sunday, October 12, 2008

Washington State Task Force Recommends Changes to Laws

An article by Carol Smith in the Seattle Post-Intelligence discusses a task force's recommendation to the state's involuntary commitment laws after a man with a psychotic illness murdered Sierra Club worker Shannon Harps last year.
James Williams, a repeat violent offender with severe schizophrenia, has been charged with first-degree murder in Harps' death. Williams, who was under community supervision at the time of the murder, wasn't complying with court-ordered treatment and had been off the medications that helped control his violent hallucinations when he allegedly stabbed Harps to death.

Community corrections officers supervising Williams used every tool the system provided to try to keep Williams in treatment and out of trouble, said King County Prosecutor Dan Satterberg, who convened the task force to examine the case.

"The bottom line -- they ran out of tools, Mr. Williams was let out and 10 days later he was charged in Harps' death," Satterberg said.
Their recommendations noted in the story:
  1. Change the state's involuntary commitment laws to mandate treatment for those with a significant history of violence.
  2. Provide more tools for enforcing outpatient treatment in the community.
  3. Reduce privacy barriers so police can know the mental health histories of people they deal with in "real time."
  4. Allow those who make involuntary treatment decisions more leeway to consider past history of violence.
This issue of compulsory treatment is gaining more and more supporters, usually after this or a Virginia Tech-like story.  It is something our society continues to struggle with -- the balance between civil liberties and the right to control one's own body on one side, and public safety and the responsibility that society has to "help" vulnerable people.

I see the pros and cons on either side.  Personally, I think that when one's illness interferes with others, particularly other's safety (think epilepsy and driving, TB and isolation, STD and contact reporting), that is when society has a responsibility to intervene.


PS: My apologies to the readers for my extended absence.  If you knew what was going on in my life, you'd understand (all is well, though).  A big Thank You to Dinah for keeping the flame alive!!


Anonymous said...

We have Kendra's law in NY. We have people mandated to Assertive Community Treatment.

Anonymous said...

There seem to be more pros than cons to me.


Anonymous said...

I understand and would support mandatory drug treatment for schizophrenics with a history of violent CRIMES, but I am thankful that despite 1 psychotic break (no violent crime) I was not forced by the law into a lifetime on medications. I would only support VERY limited forced drugging and certainly not based on one mental health episode but based on violations of the law which were violent.

Also, I would not want the police to have access to my mental health history.

Why would having "real time" access to mental health history help? If somebody is shooting students and teachers on a campus you already know you have a problem with that person. Would knowing the mental health history of the pictured man have prevented his murdering? I saw a map of all the registered sex offenders. There are so many that the existing police force could never prevent sex crimes based on knowing who the former perpetrators are and the same would be true if there were a map of all former violent criminals.

Anonymous said...

This is one of the things the State hospitals used to be used for. People were often committed for long periods because they couldn't function in society without direct supervision.

Judges should be able to sentence mentally ill violent offenders to forensic facilities, and these people should not be released the moment they become stable on medication (especially since we know they're likely to dc meds once they're back in the community).

Welcome back, Roy. Hope we see more of you and Clink in the coming months.

Dinah said...

Welcome Back! I missed you.

Novalis said...

I agree with anonymous--while there rightfully is no return to the days of mass institutionalization, there are individuals out there for whom, despite the best community interventions possible, there seems to be no substitute.

And these violent folks are going to end up institutionalized anyway--at what point did we decide that prison somehow infringes less upon liberty than psychiatric treatment?

Anonymous said...

'Recommendation' #3 is absurd and would be horrible. What constitutes "dealing" with someone? The police, in some sense, deal with everyone in their jurisdiction all the time. Some people call them privacy barriers, but I call them inalienable rights.

Dragonfly said...

Welcome back.

Doc said...

Virginia has recently revised their commitment laws, and they are much similar now to Kendra's Law in NY. This change was brought about due to the failures in the system learned from the shootings at Virginia Tech. One of the significant shortcomings is the lack of resources and communication to ensure that those individauls who become identified as being "at risk" receive adequate services.

"Real time" histories are beneficial at the level of the treating facility. I honestly do not see much benefit in having law enforcement officers made aware of such histories. Law enforcement generally is called upon to stabilize a situation, and to transport individual to either jail or the hospital. At either of those facilities, adequate evaluation should occur, and at that point of service, I think all medical and mental health histories should be made available there. Virginia looked at that problem, and improved (hopefully) the standard to bring individuals to a hospital setting for immediate and short-term evaluation.

ClinkShrink said...

The problem here is that everyone is assuming that this person's violence is due to his mental illness. That's not necessarily the case. Even in folks with serious mental illnesses violence is most often due to co-existing substance abuse and personality disorders rather than the Axis I disorder per se.

And we have data specific to King County too---a friend of mine did a very nice study published here:

J Am Acad Psychiatry Law 26:3:393-402 (1998)

...which shows that mentally ill offenders released from the King County jail recidivate at exactly the same rates as non-mentally ill offenders.

And the MacArthur study, which showed that the presence of an Axis I disorder (other than substance abuse) does not significantly increase the risk of violence over the base-rate community sample.

I cringe when I hear about plans to "crack down" on the mentally ill, even referring to forensic patients. If you want to be tough on crime, be tough on all criminals not just my patients.

Dr. Pink Freud said...

As summarized by Walsh, Buchanan and Fahy, in their article, Violence and Schizophrenia: Examining the Evidence, "Risk factors for violence that operate in those without mental illness operate in schizophrenia, with strong predictors including a history of previous violence and substance abuse. However, no sizeable body of evidence clearly indicates the relative strength of schizophrenia or mental illness in general as a risk factor for violence compared with other risk factors (Mulvey et al, 1994b). Indeed, compared with the magnitude of risk associated with the combination of male gender, young age and lower socio-economic status, the risk of violence presented by mental disorder is modest (Monahan, 1997)." Some studies suggest schizophrenics are at a demonstrably increased risk of being victims of violence.

Anonymous said...

Not related topic but look at this:

Pa. widow sues US over Iraq vet-husband's suicide

By MARYCLAIRE DALE, Associated Press WriterWed Oct 8, 8:47 AM ET

The widow of an Iraq war veteran who committed suicide while in outpatient care for depression at a Veterans Administration hospital is suing the federal government for alleged negligence.

Tiera Woodward, 26, claims her late husband, Donald, sought treatment at a VA hospital in Lebanon , Pa. , after three suicide attempts but wasn't seen by a psychiatrist for more than two months.

She says doctors were slow to diagnose her husband with major depression, and that once the diagnosis was made, a psychiatrist failed to schedule a follow-up meeting with her husband after he informed the doctor he had gone off his medication.

Donald Woodward killed himself in March 2006 at age 23.

"I intend to make them make changes," said his mother, Lori Woodward. "I have too many friends whose kids are in Iraq . I have a nephew now in Iraq , in the same unit, and I can't have my family go through this again."

Alison Aikele, a VA spokeswoman in Washington , said the agency does not typically comment on pending litigation.

The lawsuit, filed in the Middle District of Pennsylvania, seeks an unspecified amount for funeral expenses, lost income and pain and suffering.

It echoes other lawsuits nationwide over VA mental-health services, despite legislation President Bush signed in November ordering improvements.

The family of Marine Jeffrey Lucey, also 23, has a federal suit pending in Massachusetts over his June 2004 suicide. And two veterans groups sued the VA in San Francisco seeking an overhaul of its health system, citing special concerns about mental health, but a judge dismissed the suit in June over venue issues.

More than 150,000 Iraq and Afghanistan war veterans have already sought mental health care from the VA, and 200,000 others have sought medical care, according to Veterans for Common Sense, one of the groups involved in the California lawsuit.

"Each tragic veteran suicide is yet another painful reminder of the human cost of the Iraq and Afghanistan wars and VA's abject failure to provide timely and appropriate mental health care," said Paul Sullivan, the group's executive director. "How many wake-up calls does (the) VA need?"

(This version CORRECTS year of Woodward's suicide to 2006, not 2003.)

Anonymous said...

novalis: psychiatric incarceration infringes on liberty far more than prison. Watch or read One Flew Over The Cuckoo's Nest - okay, it's fictionalised and out of date, but still very relevant. As far as I'm aware most prisoners of the justice system get a release date and aren't given dangerous drugs and treatments against their will.

Also, in the UK, when the smoking ban came in, it was decided that prisoners could smoke in prison, because it would be legally classified as their "home". Psychiatric patients, though, even ones in long-term high-security psychiatric hospitals (read: people who may never get out), have no such right. If any inpatient wants to smoke, they will have to do it outside. And guess what? Most psychiatric wards have no enclosed outdoor area, and not enough staff to accompany patients outside to smoke.

It's funny that if you're considered not to be responsible for criminal acts you've committed, you usually get punishd more than if you are held responsible.

Dr. Pink Freud said...

Although all prisoners of the justice system are given a PRD (projected release date in the Federal system), the Walsh Act (aimed at sexual "predators") permits civil commitment up to the course of the individual's natural life based upon the predication of dangerousness, and the fact that there is no proven evidence-based treatment that works for sexual "predators." Some of these individuals may indeed carry a valid Axis I/II diagnosis, but many will not.

As far as involuntary medication, this can be accomplished in correctional settings, though I'd argue the benchmark for doing so is higher than in non-correctional institutions. I wish it was easier to force medicate in this setting, especially given the high comorbidity of violent histories, and antisocial personality disorder. Properly administered neuroleptic medications are clearly necessary safeguards and not "chemical restraints." Individuals on such medications are monitored according to JCAHO/AMA guidelines for side-effects, etc.

Lastly, psychiatric inmates tend to exhibit a much higher utilization rate of staff time/effort. Anecdotal evidence suggests they are higher utilizers of non-psychiatric medical services as well.

Lastly, to not medicate a floridly psychotic individual, to me, is grossly unethical. We now know that medication non-compliance in psychotic disorders leads to more frequent relapses, and ultimately, medication becomes less effective. Some research suggests structural changes (damage) to the brain. How can we let this occur in a compassionate society, given the availability of safe and efficacious medications to prevent it?