I've been researching and writing this column for nearly two decades, but all good things eventually come to an end. This is my final column as Washington Editor for Behavioral Healthcare. While you read these words, I am fulfilling a lifelong dream on faculty at the University of Guam, America's westernmost land-grant college.
I am a former behavioral health clinician turned political scientist, and the past 20 years of observing policy have provided reason for both optimism and frustration. The truly positive aspect of policy has been our government's contribution to the scientific basis for effective behavioral healthcare. The National Institute of Mental Health and other federal research institutions have funded a remarkable series of breakthroughs. This research has illuminated the once mysterious biological, social, and psychological interactions of behavioral health. More importantly, increased knowledge has resulted in effective therapies that make real, measurable differences in the lives of people with behavioral health problems.
In contrast, public policy on behavioral healthcare during the past quarter century has not produced similar progress. Instead, we seem locked into a cycle of dramatic policy shifts driven by reaction to current events. When the national media highlights an individual who has succeeded in achieving recovery despite encountering barriers in the behavioral healthcare system, policy makers jump on the bandwagon of patient advocacy. Behavioral healthcare providers are asked to forget profitability and regulations, and concentrate on helping consumers and family members achieve more of this type of success. A wave of legislation and rule making to protect the autonomy of patients/clients often follows, as in state implementation of the Olmstead decision as well as the recent rush to require peer counseling in public-sector programs.
Pro-consumer euphoria rarely endures. Eventually, news media report on an individual with behavioral health problems who attempts suicide or commits a heinous crime, and then the pendulum swings in the opposite direction. Policy makers confront the behavioral healthcare field with questions such as, “Why don't you protect society from such people?” and “Are you ‘coddling’ potential murderers and sexual deviants?” Again, a wave of change results—focusing on insulating communities from the consequences of untreated addictions and mental and emotional illnesses.
The United States entered into the latter phase of the policy pendulum swing in reaction to the April 16 tragedy in Blacksburg, Virginia. The mass shooting on the Virginia Tech campus provided a vivid example of the public's worst fears about mental illness. Many of the event's details appear muddied in news coverage, but it is hard to forget the chilling posthumous videos of Seung-Hui Cho rambling as he blamed fellow students and society in general for his murderous rampage.
A formal state investigation of the murders and suicide in Blacksburg concluded in August without identifying any single factor that could have either triggered or prevented the deaths.1 The report found that Cho had a decade-long history of episodes of mental health treatment, which each resulted in brief periods of more normal behavior. Because of this history, Cho's decision to attend Virginia Tech was opposed by his family, who thought that life on a large institutional campus might overwhelm his emotional progress. Their concerns proved correct in December 2005, when campus police intervened with Cho in response to complaints from another student of harassment via instant messages. After Cho indicated a potential for suicide, a magistrate committed him to an overnight stay and evaluation at Carilion St. Albans Psychiatric Hospital in nearby Radford, Virginia.
Two mental health professionals independently evaluated Cho at Carilion on the morning of December 14, 2005. Both concluded that Cho did not represent an imminent danger to himself; one reported “no indication of psychosis, delusions, suicidal or homicidal ideation,” despite the suicide threat that triggered the hospital stay. A staff psychiatrist stated that Cho's “insight and judgment are normal.” Paul Barnett, a local attorney in the small town of Radford serving as special justice for commitment proceedings, nevertheless declared Cho to be mentally ill and ordered “mandatory” outpatient treatment; it is unclear whether Barnett specified a treatment provider or an expected treatment outcome. Cho subsequently attended one session at a campus counseling service, but was rejected as a long-term patient because the Virginia Tech facility had a policy of refusing to provide court-ordered care.
After the December 2005 incidents, Cho remained at Virginia Tech. An English instructor, alarmed by the murderous imagery in Cho's assignments, had him removed from her class. In the meantime, Cho began to purchase weapons and, apparently, practice the procedures he would later follow in committing mass murder. Neither the police nor any treatment facility knew that a special justice had ordered Cho to receive outpatient care, and Barnett was not informed that his order was not being followed until after April 16.