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Mental Health Commitment

May 16, 1996
State Capital Bureau
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JEFFERSON CITY - Hundreds of people are turned away from the care they need in Missouri's mental health system. They beg. They plead. They ask for help. The only way they can get help is by physically harming themselves or others, and the only care they can get is by being locked up.

There's no way they can get treatment through out-patient treatment.

For people suffering from mental illness, like Glenn Westphale, it's his very illness that keeps him from neglecting the care he needs.

It was to address the needs of Missourians like Westphale - and his family - that Missouri's legislature approved this year a massive reorganization of the laws governing treatment and involuntary commitment of the mentally ill.

Westphale's Story

Glenn Westphale loves the outdoors. Sitting on his apartment's front porch, he turns his face to the sun. He strokes his red beard, then props a tennis racquet on his green pants. He says he's had a full life outside: summers fishing in Alaska, years on the East Coast studying wildlife, and working at the National Park in Springfield.

Things changed six years ago when the 37-year-old Springfield resident was diagnosed with schizophrenia.

His mental illness - with symptoms of withdrawal, hearing voices and seeing images - sometimes makes him deny that he's sick, he says. That means in instances like last November, his wife, Susan, had to call the police to force him to get treatment.

"At the time I was thinking `I've got some right, I've got some place in society,'" Glenn says. "Even if it is as demented as putting the cops to work."

His wife, Susan, 28, walks out the door and sits on a plastic lawn chair. She shades her eyes from the late afternoon sun.

"It's like I've had to be wife and caregiver," Susan says. "I've had to make medical evaluations. I've had to make my personal evaluations, had to make sure the doctors listen and had to make sure the treatment was fair."

She's gone on welfare, so she could be at home to take care of him and their daughter. But having to call the police on her own husband, was humiliating, she says.

Glenn is one of 264,750 Missourians diagnosed with some form mental illness. He's lucky. He's able to get treatment, but only by locking him up when he refuses treatment.

Their only hope, says Susan, is by changing current law.

Present Law: Physically Impossible

If a person with schizophrenia, or other mental illness needs to be put into a hospital against their will, the only way they can be committed is if they pose a threat of serious physical harm to themselves or others.

For those who do the enforcing, like Becky Hartley, one of Missouri's 20 mental health coordinators, the word physical is a check and balance system.

"If I commit everyone that everybody thought needed to be committed, then we would be overflowing," Hartley says, who covers the central region, including Cole and Callaway counties.

That means she has to scrutinize every case in her designated area, and judge each situation in context.

"I have to make the judgment call in my mind," she says. "I ask myself, `Can this wait five more days?'"

When there's a borderline case, she asks herself, "Does this person require being hospitalized 24 hours a day due to the illness?"

If they do, then the first place they might go is somewhere like Mid-Missouri Mental Health Center in Columbia.

With an average adult stay of 13 days, it's a quick-fix for stabilizing a mental illness. They get people back on their medication, assess them for long-term treatment, and constantly petition courts for how long to keep those who need more treatment.

A person initially is committed for 96 hours for review. Then it can increase to 21 days, then 90, then up to one year. At each stage a Missouri court reviews the case.

"For the crisis at hand, yes, involuntary commitment works," says Mark Stansberry, superintendent of Mid-Missouri Mental Health Center. "It's a system that works for the short-term."

But because people are fighting for space and treatment in a system with limited funding, sometimes having that check and balance can be a stumbling block.

"I know of patients who volunteer to get treatment. There may not be any available beds, so some will use involuntary commitment as a loophole," Hartley says. "That's a real shame, having law enforcement use shackles on you when you really want treatment."

The Persistent Problem

Although people with mental illness now have more civil rights to wander the streets, unfortunately, that's exactly what many do.

Rev. Louis Carney has seen it. The Kansas City minister, who founded Reach Out Ministries, which helps the homeless, says about three-fourths of the people with whom he comes in contact have mental illness.

"The main reason they're on the streets is that they don't know how to get to the resources that are available," Carney says. "And a lot of them don't know they have a mental illness."

He says he's seen them put in prisons because it's cheaper than them being put in hospitals. He says he's seen people arrested for crimes that "the voices told them to do."

Carney says because Missouri can only do so much with limited resources, and the state can't take people's rights away by locking them up, its only role now is to educate the public.

"Before they had mental institutions, you didn't have this problem, because the churches dealt with it. Government took it over, and then when the government cut it loose, the churches don't know what to do now," Carney says.

Neither do families.

"Families end up having to sit back and watch while the sickness takes over," says Cindi Keele, executive director of Missouri Alliance for the Mentally Ill. "Families need to know information. They have no right to know medication side effects, if there's a diagnosis or what the diagnosis is as it stands now."

Her network, made up of 3,000 families, can only do so much to educate people, she says.

"Now the options are either being out on the streets or being locked up," she says. And that, she says, needs to change.

"People are allowed to deteriorate until they fall apart," Keele says. "But it's completely preventable. If people get back on their meds earlier, it can't be cured, but it can be controlled."

Carney agrees.

"The main thing that people with mental illness need is continuity. They need to know that something is always there," Carney says.

For people with mental illness and family members, just knowing something is there is not enough. They've got to have access, they say.

The McBride Commission's Solution

For Mark McBride, not having the proper access to mental health care caused his life to change completely.

On Sept. 19, 1994 Mark's 26-year-old brother, Matthew, killed his parents, James and Nancy McBride. The St. Louis family had difficulties finding treatment for Matthew, who had been diagnosed with schizophrenia five years prior.

In four years, Matthew went into mental health facilities three times. Thirteen hours prior to the killing, Matthew was released from St. Anthony's Medical Center in St. Louis County.

Present law addresses state facilities, but does not hold private facilities accountable.

"There are plenty of laws on the books that might have prevented the McBride murders," Mark says. "We were failed by a doctor and a hospital."

Presently, the McBride family is seeking a lawsuit against St. Anthony's.

But the lawsuit won't go back and change the past, Mark says. Now Missouri must take preventive measures so that what happened to his family won't happen to others, says the 35-year-old automotive dealer.

That meant going to the state level.

Six months after their murders, Gov. Mel Carnahan appointed a 19-member committee to study Missouri's involuntary commitment laws. After six-months of study and public meetings across the state, the committee made recommendations to change current law, including review of a person's case history rather than depending on the act of "physical" harm to determine involuntary commitment.

That change may have made a difference in the five years prior to his parent's death, says Mark. The family would not have had to struggle to keep Matthew in treatment.

Matthew never physically hurt himself when his schizophrenia set in. He never physically hurt his parents.

But when Matthew went off his medication, the harm began. Thinking his parents were controlling his thoughts, Matthew made threats to kill them. He heard voices. He became homeless. He refused to care for himself.

"Matthew's patterns of behavior were always directed toward my parents," Mark says.

That was harm enough, Mark says.

"Physical harm begins when the medication stops for some people," he says. "Now the taxpayers are going to foot the bill."

"It seems to me that it would have been a whole lot smarter if my parents could have kept my brother on his medication, that would have been a far less costly way of treating this disease."

Matthew was charged with two counts of first degree murder and one count of armed criminal action. He was found permanently incompetent, and the state dropped the charges. He currently lives at Fulton State Hospital.

"The McBride Commission provides the leverage to persons and caregivers like my parents to help their loved ones," Mark says.

That means if a person with a mental illness goes off their medication and begins the same patterns as before, family members would have some way to get treatment for them.

"It's not going to make it easier (to commit someone)," Mark says. "It's going to create an accountability system."

Trying to balance a person's rights with how to be a responsible society, was difficult, says the Commission's chairwoman, Lori DeRosear, who also is the medical director for St. Louis State Hospital.

"It's a fine line between right and wrong," DeRosear says. "The issues we grappled with were moral, ethical issues. Those are hard issues to grapple with."

"There's no intent to hospitalize people and to milk them for their money," DeRosear says. "Our objective is to catch (people with mental illness) before they fall."

Mark agrees. "The way it is now, a person has to get to the edge of the cliff and jump before anybody does anything."

The McBride Commission's recommendations cleared the legislature with almost no opposition. But there have been some concerns expressed about possible unintended effects.

Some warn that changes in mental-health commitment procedures could increase the number of people committed to mental health facilities, they say.

Being required to have out-paitent treatment could be an infringement on rights, says Marsha Richeson, a lobbyist for the American Civil Liberties Union.

"They can tell someone where to live, who to associate with, what medication to take. It's not much different than being on parole," she says. "Certainly it's not as bad as being on a ward, but it's not like a picnic either."

But the Mental Health Department says they don't expect any more people will be committed against their will. The media attention surrounding the McBride incident pushed the numbers up, says Turner.

"According to the numbers I have," he says. "The impact has already happened."

Others say making the private industry answer to the same regulations of the state would increase costs. If private mental health facilities have to set up another independent review board, it's going to create excess burden.

"It's going to make it more costly and more time-consuming," says Tom Anderson, a Columbia private psychiatrist. "Hospitals already have these kinds of procedures in place."

Anderson, former president of the Missouri Psychiatric Association, says he fears a backlog of minor complaints.

"Someone could complain about not liking their food or the way their bed was made," Anderson says.

But he says the good points of the legislation are things he's been wanting for some time. It's about time for the 180-day outpatient treatment alternative, he says.

Out is where Glenn Westphale would like to stay.

He would like to continue canoeing on the weekends, he says. Take his daughter to the park. Continue getting help without being locked up.

Susan agrees. There's a lot of stigma they have to battle, she says. But it all translates.

"They're on the inside looking out," Susan adds. "We're on the inside looking in."