Virginia Tech's larger lessons: the shootings raise many questions about current state laws and practices.

The April 16 Virginia Tech incident focuses challenges and opportunities for Virginia and most states within their mental health treatment systems. Our nation has the opportunity to publicly recognize the prevalence of mental illness, which affects one in four adults and one in five children. We can admit how it impacts lives, emphasize yet again the need for access to treatment, and encourage early intervention and treatment.

The Virginia Tech incident also shined a national spotlight on mandatory outpatient commitment (also known as assisted outpatient treatment). Community services boards (CSBs) and behavioral health authorities (BHAs) are the local government agents that have responsibility under Virginia law for many of the clinical and administrative aspects of the involuntary commitment process.

Prior to April 16, outpatient treatment orders were rarely used in Virginia. The law was seen as lacking clarity in terms of enforcement and consequences. For the past four years, stronger mandatory outpatient treatment laws, based on New York's Kendra's Law, have been proposed in Virginia, but none has become law for reasons as varied as the organizations and individuals who supported or opposed the legislation.

In January of this year, with a new set of mandatory treatment proposals looming in the Virginia General Assembly, a stakeholder leadership group formed by the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services wanted to become as well-educated as possible about mandatory outpatient treatment. Marvin S. Swartz, MD, of Duke University Medical Center, was invited to present his research on mandatory outpatient treatment before the group. Dr. Swartz is neither a proponent nor an opponent of such treatment, but rather is a well-respected researcher. He presented data from studies in North Carolina and New York State, and he cited opposing groups' main areas of passionate disagreement on mandatory outpatient treatment:

* reliability of the evidence and outcomes that support the benefit of the approach;

* criteria for the size and nature of the population to be targeted; and

* the reach of mandated outpatient treatment, including length of time for an order, services needed, provisions, and sanctions.

What appeared to be effective in both studies are intensive services, assertive outreach and engagement, and access to community supports that promote stability. Questions continue to revolve around the effectiveness of a mandatory outpatient treatment law without such services in place to support the law. Questions also remain about the court infrastructure needed to support due process and the points of the court's intersection with the individual. The data appear to be inconclusive as to the effectiveness of an outpatient commitment law alone. Concerns about adequate resources (Virginia ranks in the lowest ten states for providing funds for community services), infrastructure, and the potential reprioritizing of populations, which would reduce services to those who voluntarily seek treatment, all have been considered during the past four years.

This year, persons receiving mental health services strongly objected to the latest proposed mandatory outpatient treatment law. Additionally, the Virginia Commission on Mental Health Law Reform had begun in late 2006 a comprehensive study of all involuntary commitment and treatment laws, with recommendations due to the legislature this fall. Considering these factors and many others, some having to do with available resources for mental health funding, the Virginia General Assembly decided against such proposals by February 24, and the current law remains in effect.

Then came the Virginia Tech shootings.

After April 16, Virginia Gov. Tim Kaine responded immediately to this incident by issuing an executive order to close a loophole in Virginia's gun laws. Additionally, the governor appointed respected individuals to the Virginia Tech Review Panel, charging them with fully investigating the incident. The investigation is under way, and I trust that its recommendations will be comprehensive and point the direction to preventing such tragedies in the future.

Yet what has received the most continued media attention has not been the incident itself but rather the commitment deliberations 15 months earlier. In December 2005, upon the recommendation of a CSB evaluator, a temporary detention order was issued for Seung-Hui Cho. He was detained involuntarily at a local psychiatric facility, examined by an independent evaluator with no ties to either the CSB or the facility, and came before a special justice, an attorney appointed by the chief judge of the circuit, for an involuntary commitment hearing. As of this writing, the outcome of the commitment hearing was being investigated, raising questions about Virginias involuntary outpatient treatment law and local practices. Yet with court orders for mandated outpatient treatment on the rise after the Virginia Tech incident, CSBs and other stakeholders are already in the process of working to address and develop more standard practices within CSBs and within the legal/court system.

It's important to recognize that under current Virginia law, a person ordered to outpatient treatment can refuse to adhere to a treatment plan. The CSB/BHA or private provider designated in the order must monitor and report to the court the person's adherence to the treatment plan. Nonadherence can lead to another commitment hearing, at which the special justice assesses if the individual meets the involuntary commitment criteria. The justice can order inpatient or outpatient commitment if those criteria are satisfied. Fortunately, nonadherence does not carry criminal consequences (at least not yet), since such a penalty creates a more volatile situation for the individual and further criminalizes mental illness.

There are no easy solutions to caring for people with mental illness who do not adhere to their treatment plan. Human resources, supported with adequate funding, can intervene with assertive outreach and engagement to prevent crises. Standardizing expectations for all involved in the involuntary commitment process and revising Virginia law to foster consistency of interpretation and practice are needed. The Commission on Mental Health Law Reform is actively considering these and many other proposals. The Virginia House of Delegates' Committee on Health, Welfare, and Institutions is examining what might be needed to effect positive change. The Virginia Association of Community Services Boards will be reporting to the General Assembly on improvements now in process and the gaps in rapid stabilization response for individuals needing urgent care, as well as the gaps in longer-term community supports.

Does Virginia have the will to do what is needed for mental health services before another crisis occurs? Can we challenge ourselves to reduce the discrimination associated with mental illness and make it easy and acceptable to seek treatment? As citizens recognizing a national health crisis, let's refuse to participate in the pejoration of mental illness in media, jokes, songs, comics, and entertainment. Let's find unacceptable laws, policies, and attitudes that elevate fear of mental illness. Above all, let's help end the isolation caused by mental illness and provide access to treatment that assists people into recovery.

To contact the author, e-mail mabergeron@vacsb.org.

ABOUT THE AUTHOR

Mary Ann Bergeron is Executive Director of the Virginia Association of Community Services Boards.

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