 Virginia Gov. Tim Kaine with Mary Ann Bergeron, VACSB executive director; photo by Michaele White, Virginia Governor's Office |
The life of every Virginian, perhaps every American, changed as a result of the tragedy and loss of life at Virginia Tech on April 16, 2007. Those individuals who were killed and wounded will be remembered with reverence and honor, not only by their families and friends but by all citizens throughout the Commonwealth.
Immediately following April 16, Gov. Timothy Kaine named a panel of experts with broad powers, the Virginia Tech Review Panel, to conduct a thorough investigation of the tragedy. During those hearings, the poignant testimony from parents and families, even in their pain and grief, contained their overwhelming requests to ensure that within the public mental health system people receive the treatment they need. Perhaps, just perhaps, Virginia has begun the task of creating the most significant legacy to the individuals who died: a vital and dynamic system of mental health services.
The Virginia Tech Review Panel's August 2007 report made broad recommendations that included:
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campus and law enforcement security procedures at state universities;
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mental health practices and procedures relating to emergency services, temporary detention, and civil commitment processes;
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needed legislative changes;
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changes in information exchange; and
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improved coordination among involved agencies and the courts.
Seung-Hui Cho's family made his health and school records available to the panel (not to the public), which allowed for deeper insight and led to recommendations around information sharing and coordination of efforts between and within school systems. Amazingly, Cho did well with special accommodations in school and intensive and consistent counseling outside school hours during his school years in Fairfax County, well enough to be accepted by Virginia Tech.
Kaine, in his initial response to the panel's report, publicly affirmed that community mental health services, when provided appropriately, work well. There was near universal acknowledgement that the public mental health system is severely underfunded. The governor stated that Virginia must be prepared to invest in community services that work and produce results. A legislative response from the Virginia General Assembly echoed the need for investment in such services.
As has been the history of most community mental health systems, Virginia's community system has not only been severely under-resourced but, in hard economic times, a target for budget reductions or budget conversions. Such policy actions have been complicated given Virginia's stringent Medicaid eligibility criteria; Virginia has one of the country's least inclusive state systems for people with disabilities. More than 20 legislative studies conducted in Virginia, from the 1950s up to this century, reflect the same systemic issue: Scarce and fragmented resources, and varying levels of these scarce resources across the Commonwealth, contribute to an uneven and often piecemeal service system, even for mandated services.
As the panel worked tirelessly on its report to Kaine, the Virginia Inspector General for Mental Health, Mental Retardation, and Substance Abuse Services, as well as the Commission on Mental Health Law Reform, initiated by the Virginia Supreme Court, were formulating reports and recommendations regarding reform. The commission, at work since 2006 through five well-organized task forces, included all stakeholders in its review of the entire process of involuntary civil detention and commitment. It is noteworthy but not surprising that the recommendations in all the reports were similar, if not identical, in terms of the needed legal reforms, services, clarity of roles and responsibilities, and changes in practice by courts, providers, public safety officials, facilities, and evaluators.
Within weeks of the tragedy, each of Virginia's 40 community services boards (CSBs) had examined in minute detail its own process of emergency services response in coordinating efforts with magistrates, private and state hospitals, law enforcement, and the local court systems of special justices (attorneys appointed by the respective circuit courts to preside over involuntary commitment hearings). CSBs, the local authorities designated by the Code of Virginia, are mandated to ensure, within every Virginia locality, provision of emergency services for psychiatric issues. Among their broad spectrum of services, CSBs can recommend individuals for involuntary temporary examination, detention, diversion, and outpatient treatment. Internal scrutiny by CSBs produced revisions in local practices and additional evidence for necessary changes in the law.
True to his word, Kaine announced last fall that his biennial budget for 2008-10 would include allocations for a $42 million “down payment” to begin upgrading mental health services. It is significant that funds were designated to CSBs to improve the following community services: emergency, outpatient, case management, and crisis stabilization capability for youths and adults suffering from psychiatric disorders. Kaine specified the need for identifying problems, intervening, and treating them as early as possible, so that individuals with mental illness can engage in services quickly and begin a path to recovery that could avoid psychiatric crisis and the trauma of involuntary detention or commitment.
In a year of declining revenues, which were producing gaps in the state budget, this “down payment” proved how serious the governor was in pledging to improve the system. Standing with him as he made the announcement were key legislators of both parties, state officials, family members of Virginia Tech victims, the Virginia Association of Community Services Boards (VACSB), and the Virginia chapters of the National Alliance on Mental Illness and Mental Health America.
With the governor's announcement, mental health reform had begun in a nonpartisan and meaningful way. It continued as Democratic State Sen. Janet Howell and Republican State Delegate Phillip Hamilton, both members of the Commission on Mental Health Law Reform and leaders in services for behavioral health, agreed to introduce the governor's omnibus bills for mental health reform. The bills would bring the recommendations of the Virginia Tech Review Panel and the commission into a legal framework within the Code of Virginia.
The omnibus bills clarified the ability to share vital information while preserving confidentiality and remaining in alignment with federal laws, including HIPAA and FERPA. Major roles and responsibilities for CSBs, the courts, facilities where individuals are detained involuntarily, and for independent examiners who recommend treatments to the courts were clarified in the bills. Additionally, a section of the bills outlined a new and quite specific mandatory outpatient commitment process (see sidebar).
Finally, the omnibus bills proposed a major change in the criteria for involuntary detention and inpatient/outpatient commitment. Virginia Code prior to July 1, 2008, had required that the person “presents an imminent danger to himself or others as a result of mental illness or is so seriously mentally ill as to be substantially unable to care for himself.” As of July 1, 2008, the language of the Code is as follows:
[T]here exists a substantial likelihood that, as a result of mental illness, the person will, in the near future, (a) cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting, or threatening harm and other relevant information, if any, or (b) suffer serious harm due to his lack of capacity to protect himself from harm or to provide for his basic human needs, (ii) is in need of hospitalization or treatment, and (iii) is unwilling to volunteer or incapable of volunteering for hospitalization or treatment.
As the omnibus bills and approximately 50 other related bills proceeded through Virginia's legislative process, changes were debated, revisions made, and compromises achieved with the culmination of House and Senate bills that could be supported by, or at least accepted by, the governor, General Assembly, advocates, providers, and most of the stakeholders in Virginia. Even as state revenues continued to plummet, Kaine and the General Assembly retained almost the entire proposed down payment for reform. Kaine signed the legislation into law on April 23, 2008.
Some voices dissented regarding the involuntary commitment criteria and the increased involvement of law enforcement and the courts. Others did not believe the law went far enough and would have preferred an outpatient commitment law more like New York State's Kendra's Law. Advocates on both sides of the debate did agree that in state after state, the more available appropriate community services are, the less often compulsory treatment is needed.
Individuals with mental illness proved to be exceptional advocates and successfully convinced the General Assembly that language supporting recovery should be included in the final bills, as well as language that promoted consumer preferences for treatment. These advocates were not in favor of the broadened criteria for involuntary detention and commitment. Even though the new criteria were adopted, these individuals educated legislators and others about the potentially serious and permanent side effects of psychotropic medications and what it takes to engage people in the mental health system in a positive, voluntary way.
Some may argue that the new law and the new funding reflect a propensity to detain and commit more individuals to psychiatric facilities. The governor; commissioner for the Department of Mental Health, Mental Retardation, and Substance Abuse Services, Jim Reinhard, MD; and VACSB and its member CSBs hope to offer and achieve a different approach. Our shared goal is to intervene, engage, and stabilize individuals early; provide vehicles for adequate follow-up treatment; promote recovery-oriented services; and avoid individuals' cycling in and out of emergency rooms and psychiatric facilities.
Accomplishing our goal will be a challenge of huge proportions, even if the stigma and discrimination attached to mental illness were not ever-present:
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The down payment will have to be followed with continuing biennial “mortgage payments.” Such funding will have to remain a priority even if state revenues continue to decline.
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Such “mortgage payments” will be complex as federal actions gnaw at the delicate balance in state and federal partnerships of funding sources such as Medicaid.
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Local agencies and stakeholders will have to stretch, tug, and overcome discrete agency agendas in their efforts to coordinate and implement the new law.
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Individuals with mental illness will be asked to take some responsibility for their own disease management and recovery.
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Communities at large will be called upon to recognize that mental healthcare is a responsibility of the entire community.
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Mental illness, in its complex and unique impact on each individual, does not fit neatly into a law, however thoughtful and reasoned. Almost every psychiatric crisis produces an exception that demands flexibility to meet and accommodate specific individual needs.
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A massive training effort will be taking place, inclusive of every participant in the involuntary civil commitment process, to help in understanding changes and new parameters in the Code. Training cannot guarantee that interpretation and implementation will be as intended, but training will be of great assistance in achieving the intent of the legislation.
Despite the multiplicity of challenges Virginia faces, the vibrant and positive response to the Virginia Tech tragedy allows us the opportunity to create a lasting legacy to those who were slain, to their families, and to all the citizens of Virginia. We shall never forget what occurred at Virginia Tech on April 16, 2007, but we can be immensely proud of how the Tech family members and citizens demanded an improved public mental health system and how Virginia produced a stunning and positive response.
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