The Magazine

Sane Mental Health Laws?

Don't hold your breath. Federal "advocates" are standing in the way of reform.

May 28, 2007, Vol. 12, No. 35 • By SALLY SATEL
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It often takes a tragedy to inject some sanity into mental health law. The death of Kendra Webdale is an unforgettable example. In January 1999, Webdale was pushed in front of a New York City subway train by a man with schizophrenia. In her memory, the state legislature quickly passed Kendra's Law to enable courts to compel psychotic individuals with a track record of violence to take their medication.

The Virginia Tech massacre last month will surely prompt changes in commitment laws too. Virginia governor Timothy M. Kaine has created a panel to review events and issue recommendations. The governor's panel will join several other Virginia bodies already reviewing the state's mental health laws.

The most prominent is the Task Force on Civil Commitment. It was established six months ago by the chief justice of the Virginia Supreme Court to scrutinize the state's unusually narrow standard for committing someone to a psychiatric facility against their wishes. (A patient must be "imminently" dangerous--in short, clearly ready to kill himself or someone else--before a judge can mandate treatment.)

The task force proceedings are bitterly contentious. On one side are civil liberties lawyers and disgruntled patients who insist that lowering the "imminent" danger threshold would threaten individual rights. On the other side are psychiatrists caring for people with schizophrenia and bipolar illness and their relatives who have lived through the nightmare of not being able to get timely treatment for desperately ill loved ones.

Contests like this have played out in almost every state at one time or another. But determining the proper scope of involuntary care of the severely mentally ill is not exclusively a state matter. The federal government plays a surprisingly influential role in shaping treatment laws--and in undermining their reform. In fact, a lot of the financial and ideological firepower obstructing common sense reforms comes from the nation's lead agency on mental health, the Substance Abuse and Mental Health Services Administration (SAMHSA), which is part of the Department of Health and Human Services.

Consider a program called Protection and Advocacy for Individuals with Mental Illness (P&A). Established in 1986, the P&A program began with a laudable mission--to investigate allegations of patient abuse, neglect, and rights violations on hospital wards or in residential facilities. The announcement last month of a federal probe into overcrowding and maltreatment at Georgia's state mental hospitals shows this shameful problem is very much alive. However, the program mission soon began tilting away from protection of institutionalized patients toward an autonomy-at-any-cost version of advocacy. As Rael Jean Isaac and Virginia Armat documented in their 1990 book Madness in the Streets, the P&A quickly devolved into a "playground for anti-psychiatric activists."

The P&A program operates as 50 state agencies working with $34 million a year from SAMHSA, or about one-tenth of the agency's discretionary mental health budget.

Some examples of P&A activities include:

* In 2006, the New Mexico P&A helped stall state legislation for court-ordered outpatient treatment. To help move things along, the city of Albuquerque passed its own compulsory outpatient treatment law following a spate of local tragedies, including a 2003 incident in which a police officer was shot in the head by a psychotic man who wrested her gun away. The New Mexico P&A rushed in again, this time to sue the city, claiming it did not have authority to pass such a law. A judge agreed, saying that the statute had to be passed by the state. Legislators responded by introducing another bill in the 2007 session--only to have the P&A help kill it in committee this March.

* In California, the P&A sought to undermine Laura's Law, named for Laura Wilcox, a 19-year-old college sophomore shot to death along with two others in 2001 by a paranoid man who had refused treatment. When Los Angeles County experimented with outpatient commitment in 2004, the P&A sued to stop them. The case was settled the next year, but now other California counties are leery of implementing the law for fear of being sued by the P&A.

For its part, SAMHSA is silent on the subject of court-ordered outpatient commitment. The agency promotes a treatment philosophy called the "recovery model," which holds that with sufficient therapy, housing options, and employment programs, patients with schizophrenia or manic-depressive illness will be able to take charge of their lives.