Guest Host: Marc Fisher

In the wake of a violent episode in which Virginia state Sen. Creigh Deeds was reportedly stabbed by his son, who then fatally shot himself, many are asking about the efficacy of mental health treatment locally and nationally. Just a day before the incident, Deeds’ son, Austin, was committed to a local hospital for a mental health evaluation. Yet, Austin was released hours later when a psychiatric bed could not be found nearby. We look at how mental health services currently do and should work and consider changes coming to the system through President Barack Obama’s health care reform bill.

Guests

  • George Braunstein executive director, Fairfax-Falls Church Community Service Board.
  • Dr. Aradhana "Bela" Sood professor of psychiatry and chair of the division of child psychiatry, Virginia Commonwealth University.
  • Dr. E. Fuller Torrey psychiatrist; founder, Treatment Advocacy Center; author, “American Psychosis: How the Federal Government Destroyed the Mental Illness treatment system.”
  • Pete Earley journalist; and author of Crazy: A Father's Search Through America's Mental Health Madness (Putnam)

Transcript

  • 13:06:39

    MR. MARC FISHERFrom WAMU 88.5 at American University in Washington welcome to "The Kojo Nnamdi Show," connecting your community with the world. I'm Marc Fisher of the Washington Post sitting in for Kojo. The news about Virginia State Senator Creigh Deeds was tough enough, a well-liked politician and former candidate for governor stabbed by his son who then shot himself dead. But the more we learn about what preceded the violent attack, the harder the questions about whether it could've been prevented.

  • 13:07:14

    MR. MARC FISHERThe Senator's son needed emergency psychiatric care on Monday. But just 12 hours before he attacked his father, Gus Deeds was released from a local hospital because hospital workers said they couldn't find him a psychiatric ward bed. A day after the attack, however, three hospitals said they indeed had available space and could have taken Gus Deeds in but no one had asked them for help. Virginia officials are now scrambling to understand what actually happened, what went wrong. And once again, questions are being asked about serious flaws in the nation's struggling mental health system.

  • 13:07:51

    MR. MARC FISHERHere to discuss this with me are George Braunstein. He's executive director of the Fairfax-Falls Church Community Service Board. And Pete Earley, a mental health advocate and journalist. He's the author of "Crazy: A Father's Search Through America's Mental Health Madness." And joining us by phone from Virginia Commonwealth University is Dr. Bela Sood, a professor of psychiatry there. She was a member of Governor Tim Cain's review panel that was established after the Virginia Tech massacre in 2007 in which 33 people were killed.

  • 13:08:24

    MR. MARC FISHERAnd later in the hour we'll be joined by Fuller Torrey, the founder of the Treatment Advocacy center in Arlington. But first of all, George Braunstein from the Fairfax-Falls Church Community Service Board, there's been some confusion over whether there were indeed available psychiatric beds when Gus Deeds was in crisis on Monday of this week. Obviously you weren't there but from your experience, do you have any sense of what may have happened? Why we are seeing this confusion about whether or not there were beds?

  • 13:08:57

    MR. GEORGE BRAUNSTEINWell, one of the most important points to make about all this -- and I really don't know all the details about what happened there in Beth County -- is that taking someone into hospitalization involuntarily is a very complex process. It involves the legal system and the clinical service system. It is -- it involves the police involved in doing a custody. It involves clinicians who are trained and certified to make a determination that the person is both dangerous and mentally ill. It involves finding an available bed.

  • 13:09:42

    MR. GEORGE BRAUNSTEINThere can be beds available to the commercial private sector but are not available to people in the public sector because they're concerned about involuntary and the behavioral problems that sometimes come with that.

  • 13:09:58

    FISHERIn other words, there are beds available but the hospital doesn't want a disturbed or violent patient coming in.

  • 13:10:04

    BRAUNSTEINThat can happen, yes. And then finally, once you find a bed, a magistrate has to approve all that and approve making this person involuntarily, taking their freedom away. And then you have to arrange for the police or the sheriff, some public safety official to transport the individual to the hospital. So that process and -- that all CSBs go through involves a period of time.

  • 13:10:32

    FISHERAnd briefly explain what a Community Service Board is.

  • 13:10:36

    BRAUNSTEINA Community Service Board is the public mental health, substance use and treatment, as well as the service coordinator for all services for people with intellectual disabilities. They were formerly known as people with mental retardation. So the Community Service Board is the public mental health or behavioral health system for the State of Virginia. There are 40 of them in the state. Each of us cover a certain territory and provide services for citizens who need that public sector level of service.

  • 13:11:14

    FISHERAnd Dr. Bela Sood, this must feel a bit of deja vu to you. I mean, you went through an enormous research project after the Virginia Tech shootings looking into the role of these Community Service Boards and looking into their performance. At least two of the hospitals involved in the Deeds case say that no one called them in looking for a place to hold Gus Deeds and give him treatment and further examination. How common is this kind of communication breakdown in the system?

  • 13:11:45

    DR. ARADHANA "BELA" SOODWell, I think that I don't know how common it is because one would have to really objectively go and study it. Nevertheless, there are pockets within the state where this is certainly a possibility and pockets in the state which do a, you know, wonderful job with finding beds. And so I think that this really begs the question of looking at solutions as we go forward. And there have been times in the past where people have suggested having, you know, a triage in process where there is a central bed registry, which is electronically managed and kept up to date real time so that there is a sense of what is the bed structure looking like?

  • 13:12:30

    DR. ARADHANA "BELA" SOODBecause, as you probably know, that with the deinstitutionalization movement, the number of psychiatric beds in the state have reduced, and as we have pushed for more community-based care, those beds have (word?). So there's -- this is perhaps a very important time to begin to get a good sense of where the beds are. So that's specifically speaking to this particular issue where this individual was identified as having the type of emotional problems that met the criteria for an ECO, which say to me -- and again…

  • 13:13:03

    FISHERMet the criteria for an ECO?

  • 13:13:06

    SOODEmergency commitment order...

  • 13:13:07

    FISHEROkay.

  • 13:13:08

    SOOD...which is sort of -- kind of tells you that the person was -- based upon the behavior and the kind of problems they were having, they were meeting sort of that level of need that was identifying them as needing an emergency intervention. And so it is not as if no one identified it, they did. But then the fact that there was no identified bed in that region of the state really begs the question that was this indeed a lack of beds or simply lack of communication? So I think that these are opportunities.

  • 13:13:42

    SOODAnd as we understand -- as you were kind of pointing out that since 2007, the nation's sort of view of mental health has certainly evolved and it's an iterated process as we look at these very difficult areas. And it behooves us to begin to start looking at solutions.

  • 13:14:00

    FISHERYou can join our conversation about mental health system in Virginia and across the nation at 1-800-433-8850 or email us at kojo@wamu.org. Let us know if you think better mental health care could've prevented any of these recent tragedies to hit the Washington region? What experiences have you had with mental health services locally in Virginia, Maryland or the district?

  • 13:14:23

    FISHERAnd Pete Earley, looking back at a piece that you wrote in the Washington Post three years ago, and already at that point -- and that was itself three years after the Virginia Tech shootings -- already three years ago you were saying that many of the reforms that came after Virginia Tech had essentially been erased from the books. That because of funding cutbacks and there was still a severe shortage of psychiatric beds and that the $42 million in additional spending that was coughed up after Virginia Tech had fallen victim to a shell game and was gone.

  • 13:15:00

    FISHERSo you knew three years ago that we were already in a bad place. When you heard about the Deeds shooting, what did you think?

  • 13:15:07

    MR. PETER EARLEYI thought, here comes another tragedy and I felt terrible because I had been in that situation as a parent. It's difficult to imagine as a parent watching someone you love in crisis, psychotic and not being able to help them. And you have to go through so many barriers before you even get to the CSB level. And I agree with what the doctor said. We don't know if this is a bed problem or a communication problem. But the truth is, this has been studied. In 2010 the IG did a report. And he said that streeting -- I mean, 200 people in Virginia had been pushed out in the streets because there were no beds available. And the hospitals used the word streeting as slang.

  • 13:15:52

    MR. PETER EARLEYSo, yes, that's in different pockets but we know that that is a problem -- was a problem at that time in certain areas. We know nationally most people recommend 50 beds per 100,000 persons in an area. Virginia has 22 beds. The national average is 17. I was in Iowa. They have to drive sometimes out of state to find beds. In Seattle, excellent mental health care, they have people waiting 24 hours in emergency rooms because there's no treatment. So the lack of beds is a national problem but it's only a tip of what someone has to go through in order to get help.

  • 13:16:32

    SOODAnd I would totally agree. I certainly think we are nowhere near where we need to be as far as mental health services go. But I think the past five years have really sort of pushed us as a society and a community to begin to start examining all of these issues, which are really reflective of system gaps. We have major system gaps. And the link between private, public, academic sectors and the fact that there are really no levels to make them collaborate and work together is, to me, one of the biggest sort of barriers and challenges aside from the stigma that goes along with mental illness and seeking help.

  • 13:17:12

    FISHERWell, Dr. Sood, it must be frustrating. I mean, you were part of this review panel that the governor assembled in response to the shootings at Virginia Tech. You came up with a whole bunch of proposals. And many of which were adopted. And then you saw that psychiatric bed availability actually decreased and budget cuts from 2009 to 2012 erased what had been put into the mental health system after Virginia Tech. Nationwide the number of beds has gone down by 14 percent over a five-year period. So why do you think -- the same society that reacted fairly well to Virginia Tech was so willing to rollback everything?

  • 13:17:55

    SOODWell, I think that, you know, we have to acknowledge first of all the fact that we are a society and a nation -- and I think probably the same thing is true in the world with news -- is that we have become a society of soundbites and whatever sounds good at that point in time. I think it really begs the macro question of looking at systems and seeing where, you know, the problems are. Because when you respond to things, like for example with this one, is it really a psychiatric bed or is it the way the mental health service delivery is fashioned?

  • 13:18:26

    SOODSo you really begin to look at -- if you begin to look at it from a systemic standpoint you begin to look at the need for inpatient psychiatric beds. But along with that you're looking at crisis stabilization units which are different gradations, meaning severe ones or mid-level ones or low-level ones which can stop a person from destabilizing. And then most importantly, which gets the least amount of attention, is the development of excellent community outpatient resources which provide treatment before the person destabilizes.

  • 13:18:59

    SOODIt has to be looked at in a systemic fashion. And each of these sized according to the needs of the community, as Mr. Earley's pointing out, that we have to begin to scientifically look at what is the amount of necessity of these services per 50,000 people or 100,000 people. And then begin to right size it rather than, you know, give mental illness and help a short shift in that process.

  • 13:19:23

    FISHERBella Sood is professor of psychiatry at Virginia Commonwealth University. George Braunstein is executive director of the Fairfax-Falls Church Community Service Board. Go ahead, George.

  • 13:19:32

    BRAUNSTEINI just want to agree with Dr. Sood that we can't be -- we have to be careful about looking at this as just a bad problem. There are not enough willing psychiatric beds in probably any part of the state at times. Even the northern Virginia region, which is one of the wealthier areas in our local government provides an enormous amount of support for the Community Service Board. We don't have enough beds. We have to send over 200 people to other parts of the state to be hospitalized every year, who we can't find a bed in northern Virginia that's willing to take someone from the public sector.

  • 13:20:20

    BRAUNSTEINAnd we also have to look at all the other alternatives and grow those as well. We have crisis stabilization services, we have partial hospital programs, we have mobile crisis teams. We train the police in crisis intervention training, which is very important. And there are other kinds of programs that could be available along that continuum that need to be in place as well because we have to be careful not to try to look at this over simplistically.

  • 13:20:55

    FISHERWell, okay. But in this case you had someone who was determined on Monday to need inpatient treatment. And this phenomenon of streeting -- of throwing people out onto the street after some professional has already said, they don't need any of those lesser forms of treatment. They need this very serious form of commitment. Isn't there -- I mean, isn't there a problem just with the resources to take care of the worst cases?

  • 13:21:22

    BRAUNSTEINWell, and I agree, there needs to be more beds available. But I am also saying that there's a number of people who are -- have very acute symptoms whose needs can be met by some of these alternatives as well.

  • 13:21:37

    FISHERPete Earley.

  • 13:21:38

    EARLEYBut, you know, what he just said -- what Mr. Braunstein, who I have a lot of respect for, just said is really -- should be shocking. Fairfax County is one of the richest counties in the country. And we're sending 200 people out of our county because there's no beds? And it's not just -- one of the things that I think the doctor said, which is right on target, you've got to look at the system. Part of the reason there are not beds in Fairfax County is because in 2005 HMOs closed down 22 percent of their psychiatric beds. Why? Because they don't make money so they take surgical beds.

  • 13:22:12

    EARLEYAnd the problem -- one of the problems we have in this is we look at mental health and we isolate it from the rest of the society around it. And you can't do that. You have to understand that mental health is an education issue. It's a veterans' issue. It's a drug issue. It permeates all these differents, but instead we look at the CSB and say, oh you solve all our problems. And I can give you a perfect example. I was just in San Antonio. They were going to build a new prison. They said, no, we've got 16 percent of our people in jails who don't need to be there because they're sick.

  • 13:22:43

    EARLEYThey set up a crisis center where people go and are channeled out of the jail into treatment. They saved over $6 million. They have 1,000 empty beds now. You could do that in Fairfax County. That's not up to Mr. Braunstein. That's up to the leadership of Fairfax judges. That's the criminal justice system. And if you don't have any leadership there, that affects the overall beds.

  • 13:23:06

    FISHERWe're going to take a call now from Clay in Silver Spring. Clay, you're on the air.

  • 13:23:10

    CLAYHello. I just wanted to say that I have a family member who is in Oregon and has been part of the Oregon system for quite a few years. And she's bipolar and she needs to take lithium. And I know this just from the experience I have. And to impart it to the doctors in the system in Oregon is very frustrating -- over the years has been very frustrating because the law states in Oregon that you can't make her take what she doesn't want to take. And so she's been on like a substitute that does not work.

  • 13:23:50

    CLAYAnd at one point she was in Salem, Oregon, which is where -- she was right there where "One Flew Over the Cuckoo's Nest" was filmed. And she was there -- part of the reason is because she cycled and went manic and it could've been avoided. And this is one of the frustrations I have. They have a very open society. They have great facilities, very caring people. But, I don't know, the liberties of a human being seems like it's gone out of whack in this situation.

  • 13:24:24

    FISHERDr. Sood, this is one of the central tensions obviously in the whole discussion of mental health, which is the right of the patient and the right of the patient not to be treated if they don't want to be. How much of a hindrance is that in protecting the larger society?

  • 13:24:39

    SOODAbsolutely. And there are no easy answers because the very complex nuanced issue of people's rights, their privacy as well as public safety. And nothing brought that better, you know, to bear than the Virginia Tech tragedy in which people knew about this young person's illness. And yet nothing happened with it which then led to very strict, you know, sort of statutes related to college mental health. So I think tragedies happen and then the community reacts.

  • 13:25:11

    SOODAnd I think there needs to be a rational sort of approach to all this, particularly with mental illness. Because the organ of interest which is the brain, where logical reasoning sits, is the part which sort of goes away. So say for example if you have hypertension, high blood pressure or diabetes and you choose not to take your medications and you are considered competent, you know, that’s a decision you make. Although we know that diabetes causes you to lose your eyesight and your kidneys to become bad.

  • 13:25:37

    SOODBut in mental illness, you know, unless you have -- you know, you are having command hallucinations which are telling you to kill someone or hurt someone or kill yourself, up to that point your liberty pretty much at determining whether you are going to take the medication or not is yours. And that is partly the whole sort of laws around assault and battery. Because if a physician pushes that or gives them a depo preparation of an antipsychotic, that is considered assault and battery if there's no consent.

  • 13:26:08

    SOODSo there's a legal element to all of this. There is an ethical and social moral element to some of this. And that it that all of these issues which have to do with public safety -- which really are affected when the person's seat of reasoning, which is their brain, is no longer functioning. These are very, very complex issues and there's no yes or no about it. But we have the ramifications of unraveling minds which then leads to -- you know, for us to have these very important discussions.

  • 13:26:41

    FISHERWe'll get more into this question of the tension between the treatment of those unraveling minds and the protection of their individual rights when we come back, and more of your calls as well. I'm Marc Fisher sitting in for Kojo Nnamdi. We'll be back in a moment.

  • 13:28:37

    FISHERWelcome back. I'm Marc Fisher of the Washington Post sitting in for Kojo. And we are talking about the Creigh Deeds case, the shooting of -- the stabbing of the State Senator in Virginia by his son who then killed himself. And this, just hours after the son was released after psychiatrists had determined that he ought to be held for treatment. And so we are talking with Bela Sood, professor of psychiatry at Virginia Commonwealth University, George Braunstein, executive director of the Fairfax-Falls Church Community Service Board, and Pete Earley, the author of "Crazy: A Father's Search Through America's Mental Health Madness."

  • 13:29:18

    FISHERAnd Pete Earley, your encounter with the mental health system began when your son was in need of treatment and was unable to get it.

  • 13:29:28

    EARLEYThat's exactly right. And the reason was, I took him to a Fairfax hospital and he wasn't considered dangerous enough. He didn't meet -- at the time Virginia law was imminent danger. We sat in a room for four hours and nobody hurt anybody so they said, bring him back when he tries to hurt you or someone else. He got sicker and sicker. He broke into a stranger's house, he took a bubble bath, he got arrested. Luckily no one was in the house but all of a sudden I face this dangerous criteria.

  • 13:29:54

    EARLEYAnd I was angry. I was adamant. And I ended up being on the taskforce that helped rewrite Virginia's imminent danger. We changed it. We lessened it. It's much more a substantial likelihood of danger. And I think in Europe they do better with a need for treatment rather than danger with safeguards built in. They recognize somebody needs treatment, they offer it to them. However there's an important fact that people overlook in this argument. We changed the danger in the statute. And what good did it do? Absolutely none when it came to involuntary commitments.

  • 13:30:28

    EARLEYThere are no more or no less involuntary commitments in Virginia today than there were under the old statute. Why? Well, you have to suppose that either the judges are not enforcing the new law or they're choosing not to do it because there's no place to send anyone. And that is the whole point. You can change the law. You can say tomorrow, anybody who thinks that God's talking to them, which is an extreme, can be sent to a mental institution. But if you don't have any institutions it's not going to do any good.

  • 13:30:59

    EARLEYAnd that's a -- I mean, that’s a silly example but my point is, we don't have the capability to serve the people who need it. So the dangerous statute has gone from protecting people to becoming a red herring for only doing triage work.

  • 13:31:13

    FISHERGeorge Braunstein, you have been working in this field through the whole redefinition of the law thee that Pete Earley just explained. Did you indeed see no greater treatment of people who previously had been let loose?

  • 13:31:29

    BRAUNSTEINNo. We have seen an increased volume. But I'd like to believe that part of that has been the fact that we are providing more earlier intervention with more people. And we provide more intensive community-based alternatives. Part of the solution -- and that's why I'm concerned including with the courts -- even working with the courts -- part of the solution need to be define ways of catching people earlier and engaging them in treatment before the involuntary process has to take place. I don't disagree with the fact that there has to be reasonable standards for using the involuntary standards. But I am concerned that we get caught in a situation where all we do is hospitalize. Because that in itself is not a long term solution.

  • 13:32:31

    BRAUNSTEINThe other thing to keep in mind is the whole resource issue. It's not a local issue. It's not whether it's a wealthy or a poor area. It's an issue that involves local, state and federal governments working together around trying to fund a better standard of service in the community.

  • 13:32:54

    FISHERLet's bring into the conversation now E. Fuller Torrey by phone from his office in Arlington where he's the founder of the Treatment Advocacy Center and the author most recently of a book titled "American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System." And Fuller Torrey, the center that you founded estimates that Virginia has only 37 percent of the psychiatric beds that it needs for its population. Why, after Virginia Tech, did that remain the case? And will it remain the case even after this Deeds incident?

  • 13:33:26

    DR. E. FULLER TORREYYes, it will. And unfortunately because -- and the shocking thing about this, Marc, is it -- a fellow like Mr. Deeds who's one of the major politicians in the state could not get help for his obviously acutely mentally ill son. If he can't get help for him, who can in the state on it? This is not a new problem. We have had problems now for 200 years of involuntarily hospitalizing people who are acutely psychotic and who need care. The bed issue is an issue really of state money.

  • 13:33:56

    DR. E. FULLER TORREYWhen Virginia closes down, as they have continued to do, the beds in Eastern State Hospital and Western State Hospital, what they say is, well we're going to make it easier for people to get care in community hospitals closer to home. That's what they say but what they really mean is, we are going to do this because we are saving state money by closing down the beds in Western and Eastern State Hospital. And forcing hospitalizations onto the community hospitals, they effectively shift the cost of the care from the State of Virginia to the federal government. And that's really the whole game that's being played underneath this.

  • 13:34:31

    DR. E. FULLER TORREYNow, as George Braunstein points out, many of the community hospitals don't want people like Gus Deeds. They want fairly easy patients who have depression or substance abuse or eating disorders. And so the hospitals will selectively take patients on which they think they can make money. And they will selectively not take people like Gus Deeds. And that's why it's so difficult to find somewhere to put people like that when they get sick.

  • 13:34:55

    FISHERAnd when they turn someone like Gus Deeds away for the reasons you've just explained, what's the mechanism for doing that? Do they have to -- any obligation? Do they just say no, we don't want this guy?

  • 13:35:06

    TORREYThey could say, no, we don't want this guy and they do that.

  • 13:35:10

    FISHERAnd one more thing, Dr. Torrey, the -- we've seen these large budget cuts and, in fact, the per capita state psychiatric bed population in the United States in 2010 was identical to the figure in 1850. And across the country states have cut $4 billion for mental health services over the last few years, eliminating about 10 percent of all the beds in the country. So clearly this is an area of budget cutting that is easy and attractive to politicians because there just, I guess, isn't much of a constituency for demanding greater resources. Is that the problem?

  • 13:35:47

    TORREYThat's very much the problem. And Pete Earley's also been very articulate about that. There had been really no strong groups that had been advocating for more beds and that have been pushing to get the kind of care that we need. There's another problem in Virginia as well, Marc, that we should point out, is they have a reasonable commitment standard but they have a very strange law, this four hours or six hours that you have to get somebody into a bed.

  • 13:36:10

    TORREYWe don't know -- the Treatment Advocacy Center studies these things -- we don't know of any other state that has that kind of four- and six-hour provision. So it makes it more difficult to get people in. Now that kind of a provision was put in to protect the rights of people who we are involuntary hospitalizing because they have a brain disease and they don't know that they need care. But that is also something that makes it very difficult to get people in care. And I think that's one reason why the law has not been used anymore now than it was before Virginia Tech.

  • 13:36:40

    FISHERAnd Alan in Richmond is on the line. And he wants to follow up on that question. Alan, you're on the air.

  • 13:36:46

    ALANYes, thank you. Yes. I was going to ask specifically about that four-hour limit. I just wanted to bring something up about the Washington Post story is that the hospitals that the reporters called -- you have to realize it's a very rural mountainous area out there. Bath County is right on the border of West Virginia. And it's at least an hour (word?) from that county, an hour-and-a-half to Charlottesville. So we're talking about, you know, a real ticking clock. And I think it's the news report's health professionals who characterize it as a race to get a bed before the four-hour limit. So I'd like to ask your guests whether the four-hour limit should be increased and perhaps substantially.

  • 13:37:31

    FISHERDr. Sood, was that something that your commission looked at?

  • 13:37:34

    SOODNo. Actually, it was increased from four to six hours. And I think that as someone else was pointing out earlier, laws are made by man. And these are not God, you know, developed laws. And we really need to take a look at these, the tension between, you know, how long the sheriffs stay, you know, holding onto a person and then have to leave versus, you know, really looking at the clinical situation at hand.

  • 13:38:00

    SOODAnd that whether it can be sanely sort of -- not to use a pun -- but how can we sort of look at this issue logically and begin to look at what the needs of the patient are. And then make decisions rather than have a statute which dictates whether the person needs to -- this particular incident to me is a travesty. That it should have been -- it's simply the law that you couldn't keep him beyond the six hours and he had to be let go. And had we approached this more sanely and appropriately, then finding a bed, if this person met that criteria, should have been the more prudent thing to do.

  • 13:38:40

    SOODAnd I think that that is what we get caught in. And so certainly I know that Richard Bonnie's commission for, you know, mental health reform had looked at this issue, and it had been extended from four to six hours. But I think it is all this tension between law enforcement and the mental system that needs to be looked at.

  • 13:39:01

    SOODBut I do want to go back to the issue of beds versus, you know, mental health care per se. I think it is extremely important to again look at the system because when we talk about deinstitutionalization, which is where really this problem is arising from, which is that inpatient stays -- or inpatient settings are not the right venue for providing treatment, you have to look at alternatives. What is it that we are doing in the community system of care? And that is really the central problem, that we do not provide comprehensive systems of care within the communities, which then take the place of people -- of venues such as inpatient settings.

  • 13:39:47

    SOODSo what we have in Virginia right now has been, at least in child mental health, the rising up of in-home services. And although it is great that these services are funded, we see the quality of them being terrible, and there is no system which really looks at the quality of the services.

  • 13:40:12

    SOODSo in theory the person is getting in-home services, but the outcomes of these services are so poor that people end up destabilizing, and what ends up happening is that there are these major service gaps which cause people to not either access care or, you know, get the right kind of care. So we have to look at what should be there in place of these in-patient beds if they have to go simply because they're so expensive. And we have to put into communities levels of services which actually produce outcomes where people do get healthy, remain well, and don't destabilize so that they needs these inpatient beds.

  • 13:40:57

    FISHERThat's Dr. Bela Sood, she's the professor of psychiatry at Virginia Commonwealth University. And Pete Earley, when you hear about these various efforts, short of commitment to take care of folks in a community setting, and then kind of at the other end of the spectrum, there's this -- I mean, all of these four-hour rules, and these six-hour rules, were all an attempt to give people the max freedom and take people out of institutions, and so there's this sort of convenient fiction that we've freed people to be at liberty with their mental illness, but, in fact, we are really still warehousing the mentally ill, we just put them in prisons instead.

  • 13:41:39

    FISHERI mean, there's an interesting statistic study done in New York just recently that found that somewhere in the order of two-thirds of the teenagers in solitary confinement were mentally ill, seriously or moderately mentally ill. So the whole spectrum of holding folks in different settings still exists, but we've criminalized one big chunk of it.

  • 13:42:02

    MR. PETE EARLEYAbsolutely. And Dr. Torrey has led when it comes to research on this. I spent 10 months in the Miami jail. There are 365,000 people with bi-polar disorder and schizophrenia in our prisons, over 1.2 million in our prisons and jails. These are people who are not Hannibal Lectors, they are sick people like my son who got caught up in the system. And what we've done is transinstitutionalization. We've simply moved them -- people out of these horrible hospitals onto the streets, homeless, shoddy assisted-living facilities, and jails and prisons.

  • 13:42:36

    MR. PETE EARLEYBut I'd like to go back to something which the doctor said earlier. When I finally got my son committed, I thought, wow, now he's going to get great care. He was in the hospital the first time for four days, and the care was take your meds, take your meds, take your meds. He was turned loose. There was no outpatient. Now, in fairness, after his fifth hospitalization, George Braunstein here got me a fabulous case manager. He didn't do it just for me.

  • 13:43:01

    MR. PETE EARLEYThat woman had saved my son's life. She got into an apartment with two guys with schizophrenia. She helped him get a job. She helped him get to a doctor who actually talked to him. And you know what? My son today is stable six years, he is a peer-to-peer person like Alcoholics Anonymous has a mentor, he has mental -- he helps people with mental illness. So don't tell me recovery doesn't work. It's just so darn hard to get it.

  • 13:43:27

    SOODIt is very hard to get. And I absolutely think that that is where we need to focus our attention, but how do we bolster those kinds of things which are the gaps in our system which keep people well. Because in-patient hospitalization is a very, very brief stay that's -- that stops you from destabilizing to the point where you hurt yourself or hurt someone else, but it really does not get at those elements of a person's mental wellness which really would occur if it had the right kind of support, the right kind of case managers who can put people into the right things, like -- and these are low-hanging fruits.

  • 13:44:06

    SOODThese are like mentoring programs, these are like connections to things like football, baseball, things that people can doing, and I'm talking about children particularly. But these are those health-promoting things as well as having a psychiatrist and a counselor who actually produce good outcomes, meaning that they just don't sit there and give out medications but it is couched in ways of getting the person to participate in the wellness and get better, and if that's not working, you know, what do you next and what do you next?

  • 13:44:37

    SOODA much more active process of treatment which I feel connects to the workforce issue which is well-trained people out there who are providing mental health treatment, and as well as, if I'm in crisis and I have to wait three months to see someone, I'm way out the crisis by the time I get ...

  • 13:44:55

    FISHEROkay.

  • 13:44:56

    EARLEYMark, can I add something?

  • 13:44:57

    FISHERYes. Quickly. Go ahead.

  • 13:44:59

    EARLEYIt's very nice, community services of course we need, but the bottom line is there are people like Gus Deeds who needs to be hospitalized. At one time this was a state responsibility. That's why we had state hospitals. We definitely need those hospitals for short-term stabilization and ultimately the Virginia legislature and the governor is responsible for this, and they should be held responsible.

  • 13:45:20

    FISHERWhen we come back after a short break we'll take a look at the potential impact of some of the new regulations in Obamacare on some of these mental health issues, and take more of your calls as we continue our conversation. I'm Marc Fisher, and this is "The Kojo Nnamdi Show."

  • 13:47:23

    FISHERWelcome back. I'm Marc Fisher of the Washington Post sitting in for Kojo Nnamdi, and we are talking about the case of Virginia State Senator Creigh Deeds who was stabbed by his son earlier this week. The son then shot himself dead and this has, of course, raised significant questions about the Virginia mental health system and that of the nation at large, given that young Gus Deeds had been released from a local hospital just 12 hours before he attacked his father, despite the fact that he -- physicians had decided that he needed to be in a psychiatric facility.

  • 13:47:58

    FISHERWe are joined by George Braunstein, executive director of the Fairfax Falls Church Community Service Board, which is a public agency that administers mental health in the Fairfax area. Pete Earley is a mental health advocate and journalist. Bela Sood is professor of psychiatry at Virginia Commonwealth University, and E. Fuller Torrey is founder of the Treatment Advocacy Center in Arlington.

  • 13:48:22

    FISHERAnd Dr. Torrey, if you could -- obviously, after every one of these spasms of violence there is a rush to try to do something to change the law, to change the standards by which people can or cannot be held. Is that kind of piecemeal approach to amending legislation, does that produce any change, and what -- are there more systemic changes that are necessary?

  • 13:48:49

    TORREYSo far it's producing remarkably little, and I think we've been talking about the effects of the Virginia Tech which really hasn't changed anything, shockingly so, in fact. What we really need to do, I think, Marc, is to put the responsibility back at the state level and where we can both give them the money and then hold the governors responsible, hold the state legislature responsible. At this point, the funding system is so chaotic, nobody's responsible. Everyone just kind of keeps pointing in the other direction on it.

  • 13:49:15

    TORREYWe've got to have a point of responsibility as we had 50 years ago before the feds got involved on this, and I think the solution actually is to hold the governors responsible, hold the state legislature responsible for any bad outcomes like this.

  • 13:49:29

    FISHERGeorge Braunstein, there's been significant budget cuts on mental health over the last several years, especially since the economy went south, and now we have under the Affordable Care Act, under Obamacare, new regulations that require insurers to cover mental health. Will that produce any increase in the resources that are available, or is this -- will this create even more frustration as people are told that the care will be covered but it just doesn't exist?

  • 13:49:57

    BRAUNSTEINWell, I think there's a possibility of greater frustration as people have an insurance card, but depending on whether it actually attracts more mental health providers, I don't know that, and I question whether people will have an insurance card without a promise of actually getting the service. That could also be true with primary care. But let me make sure that I get one point across right now, which is that whether it's in-patient care or community care, just being assigned to a provider or just being placed in a facility doesn't guarantee quality of service.

  • 13:50:42

    BRAUNSTEINThere has to be some standards that people can understand what they are, even if you're not in the field, and there is -- and there has to be a way of measuring and communicating with the public about those standards of practice. Because otherwise we will have these very inconsistent services where some of them are very high quality, and I believe Fairfax is an example of that, and some of them are questionable quality, and then you get this back and forth about we should have more of this of less of this without talking about what they really accomplish.

  • 13:51:20

    FISHERThat question of quality is on the mind of Sarah, a listener who emails us and says, "I am a community support specialist. As a frontline worker, and the person right beside someone who's potentially going to harm themselves or others, I agree with the professor that the issue is not where the beds are. It's one thing to have this poor young man get into a bed and get stable and have meds pumped into him without his consent. Once he gets out, all that work is useless without the support of the community at large."

  • 13:51:50

    FISHERAnd she talks about the system creating a revolving door effect and the stigma of mental illness and the way the community treats those with mental illness does not recognize this revolving door. Peter Earley?

  • 13:52:03

    EARLEYWell, of course. And that's -- the revolving door is not only in the healthcare system, it's really acute in the jail system where you see people are picked up on trespassing. They're the homeless. They are the serious mental ill who have been through all these systems, been burned by these systems. They don't want care. They're very, very sick, and so they end up being taken to jail for two or three weeks, then turned back and back and forth. And those people cost -- in Washington DC, they're costing you about 60,000 a year.

  • 13:52:33

    EARLEYNow -- and they're not getting any better. Now, if you provide them services, you can actually save money and actually help them. The trick though, goes back to what Dr. Torrey talks about, is how do you get that person to want the care that they need to actually get better and that -- we know 40 persons who have a serious mental illness don't think they're sick.

  • 13:52:57

    FISHERAnd as mentioned earlier, there is also the other side of the equation which is the hospitals that may not want to treat them, and prefer the easier cases. And we have Cassandra on the line from Mount Rainier, and Cassandra, it's your turn.

  • 13:53:12

    CASSANDRAHi, thanks for taking my call. My comment is that several years ago I was living in Pittsburgh, and I was one of those so-called easy patients. I went in to the ER at UPNC with suicidal ideation and was made to sit for almost 24 hours before anyone even did a basic evaluation for me. And after that, I was told to come back as an outpatient for two hours a day. So I don't think it's just about so-called easy patients and about necessarily the lack of beds, but how people view the people who are coming in who need support. I think it's a several-tiered problem.

  • 13:54:00

    EARLEYMark, I just want to point out, Pittsburgh is known for having excellent mental health services, and this lady's just told us, and that's supposed to be excellent.

  • 13:54:09

    SOODWell, and I think the same thing is true with North Carolina, the dismantling of the public system there is -- these are all travesties. I just want to sort of make a point, sort of bringing it back to the ACA, the Affordable Care Act, and there are a lot of detractors, and a lot of people pro it and so on and so forth. But I do think that there are possibilities here with the ACA, particularly when you are looking at outcome-based payment reform and those kinds of things.

  • 13:54:38

    SOODI think that this ought to -- given, you know, if it's going to stay, I think this ought to push the different systems, public, academic, as well as the private to come together to say how do we share the risk, because if we share the risk, then you begin to start developing systems which will keep the person well. Because right now the onus is either on the inpatient setting to take the patient, stabilize them and they spit them out, you know, within four days doing nothing literally, and then the patient goes out.

  • 13:55:09

    SOODThe treatment plan that was developed on the inpatient setting never gets articulated because there is no one to hold on to it and really take it beyond, and so the patient comes back again. But if the public system and the hospital systems, the private systems all sort of sat down and said we are all in it to really move the person towards wellness, then the ACA is a level, perhaps, for people to being to start working together to share risk, and that shared risk is going to, I think go a long ways in us collaborating.

  • 13:55:41

    SOODBecause you can hear sort of the -- the teams that you hear from this conversation this past one hour are really, you know, sort of divisive, and I think that that is really a metaphor for the healthcare system as it sits. We are a divided land, and we really need to put our heads together. We have collective intellectual power to solve these things.

  • 13:56:04

    FISHERDr. Torrey, do you have any optimism that the Affordable Care Act will, and it's requirement that insurers cover mental health treatment that that will push the system in a positive direction or do anything to lessen the stigma around mental health?

  • 13:56:20

    TORREYI sure wish it would, Marc, but I have no hope at all. I think most of the people who we're talking about, severely mentally ill people who need hospitalization are not like Gus Deeds who had, obviously, family protection and family coverage on it, but most of them are under Medicaid and most of the folks under Medicaid will not be affected much by the Affordable Care Act. So I think the Affordable Care Act will do other things to other people, but I don't think it's going to help the kinds of problems we're talking about very much at all.

  • 13:56:48

    FISHERAnd Pete Earley, as you -- I mean, we're in a country where 50 percent of children in the child welfare system have mental health problems. Nationally, one in five children has diagnosable mental disorder, and so clearly there are massive numbers involved here.

  • 13:57:02

    EARLEYAbsolutely.

  • 13:57:02

    FISHERSo is there -- does stigma still hold people back?

  • 13:57:07

    EARLEYAbsolutely. Absolutely holds people back. Look, again, this is an issue that crosses every possible part of our community. We have 22 veterans a day, almost one an hour, killing themselves, and we have this massive need, and instead of addressing it, we're trying to break it into silos and everybody point fingers the other way. And don't let the insurance industry off the hook. People contacted me this week, they took their kids to the emergency room, they said, well, we don't have your insurance policy. They went to another one.

  • 13:57:38

    EARLEYThey got the doctor to agree to put that person in, and it was the insurance company that said, no, we're not going to pay for it. So they -- I hope the Affordable Care Act actually forces the insurance company to do the right thing here.

  • 13:57:50

    FISHERPete Earley is a mental health advocate and journalist. He's the author of "Crazy: A Father's Search Through America's Mental Health Madness." We're also joined by George Braunstein, executive director of the Fairfax Falls Church Community Service Board. Bela Sood, professor of psychiatry at Virginia Commonwealth University, and she was part of Governor Kaine's review panel after the Virginia Tech massacre. And E. Fuller Torrey is founder of the Treatment Advocacy Center in Arlington.

  • 13:58:16

    FISHERThanks very much to all of you. I'm Marc Fisher of the Washington Post sitting in for Kojo. Have a good day.

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