More threads by David Baxter PhD

David Baxter PhD

Late Founder
The worst mistake of his life
By Treatment Advocacy Center

A recent article from the Pittsburgh Post-Gazette led to a powerful letter from Bill Shane, a former Pennsylvania legislator who called his work in passing the clear and present danger standard, ?the worst mistake of his life.?

Pennsylvania?s treatment standard is one of the most restrictive in the nation, requiring an individual to first pose a clear and present danger before receiving necessary care. The result is countless tragedies, and a system that is unresponsive to many of the most severely ill, despite being one of the best funded in the nation. We stand in awe of Mr. Shane?s honesty, and hope his words will help spur needed reform.

David Baxter PhD

Late Founder
Mr. Shane's letter

A lower threshold for commitment would better serve patients, society
Sunday, September 09, 2007
by Bill Shane
Letters to the Editor, Pittsburgh Post-Gazette

I have made thousands of mistakes in my life, but my worst mistake, the one I lament almost daily, is working with then-state Sen. Louis Coppersmith of Johnstown to pass the state's Mental Health Procedures Act (Mental Health Law Balances Danger, Rights, Sept. 5).

When I walk about Pittsburgh and Philadelphia and see the sad homeless in the streets, I realize the promise of sufficient community-based health services and facilities was a cruel illusion.

The "clear and present danger" test is a threshold that is too high. We can have a more pragmatic standard and maintain patient due process rights.

The patient privacy provisions have been used by a bunch of politically correct bumblers to protect their own mistakes, laziness or worst. We see the same abuse in children and youth services.

The patients at Torrance State Hospital used to grow their own food, and they seemed happy to have a daily purpose. But along came the politically correct psychology mandarins and called this "institutional peonage." Now, the patients still in hospitals sit around all day, heavily medicated and smoking.

Dr. Trevor Hadley Jr., head of the Office of Mental Health in the Shapp administration, said over the decades the pendulum swings from institutionalization to deinstitutionalization and back, and the "snake pit" cycle lurches on.

Indiana, Pa.

The writer was a state legislator from 1971-76.

David Baxter PhD

Late Founder
Mental health law balances danger, rights

Mental health law balances danger, rights
Wednesday, September 05, 2007
By Michael A. Fuoco, Pittsburgh Post-Gazette

The case of Troy Hill Jr., charged with stabbing his stepbrothers, highlights some of the challenges in crisis intervention

Having someone involuntarily committed for a mental health evaluation in Pennsylvania is not easy, and some experts say that's a good thing.

They say the state's 31-year-old Mental Health Procedures Act tries to balance individual rights against the need to protect society from those with dangerous illnesses.

The experts' comments came in the wake of claims by the family of Troy Hill Jr. that the mental health system had failed the 18-year-old because his parents sought help from Western Psychiatric Institute and Clinic the day before the youth allegedly stabbed his 11-year-old twin stepbrothers, one fatally, in the boys' Penn Hills home.

The family expressed concerns about his increasingly troubling behavior, including reclusiveness, but a Western Psych crisis intervention team advised the family only to observe the youth.

Western Psych said patient confidentiality precluded it from speaking about the case, so it's unclear exactly what transpired in the crisis intervention. But everyone involved could have done everything right, despite the fact that subsequently everything went so terribly wrong.

Under the law, for an involuntary commitment to occur, there needs to be an observed "clear and present danger of harm to others or to himself." Manifestation of what could be deemed mental illness is not enough for an involuntary commitment.

Troy Hill Sr., the youth's father, said his son had not harmed anyone in the home prior to the stabbing and had not posed a risk to himself but had been acting erratically.

Dr. Barry Fisher, a local psychiatrist and immediate past president of the Pennsylvania Psychiatric Society, said the law must strike a difficult balance.

"I think the law as it stands now strikes a good compromise between the two concerns, protecting society versus protecting individual rights," he said.

"It can never be a perfect law and the reason for that is the reality, contrary to popular mythology, is that no one is good at predicting dangerousness, including those in the mental health field. We may be a little better than other people but not much. It is just so hard to predict."

That view was echoed by Harriet Baum, executive director of NAMI Southwestern Pennsylvania, an advocacy group for people with mental illnesses and their families.

"No law can take into account every possible nuance," said Ms. Baum, who like Dr. Fisher spoke generally about the law and not about the Hill case. "[The law] is as good as it can be."

Under the Mental Health Procedures Act, a severely mentally disabled person may be subject to involuntary examination and treatment, generally known as a "302 commitment," so named for the number of the act's section dealing with that facet.

A person is legally deemed "severely mentally disabled" when, as a result of mental illness, "his capacity to exercise self-control, judgment and discretion in the conduct of his affairs and social relations or to care for his own personal needs is so lessened that he poses a clear and present danger of harm to others or to himself."

The "clear and present danger" to others must be established by showing that within the previous 30 days the person inflicted or attempted to inflict serious bodily harm on another and there is a reasonable probability that the conduct will be repeated.

A clear and present danger to himself can be shown by establishing that within the previous 30 days the person attempted suicide or mutilated himself or attempted to do so, and there is a reasonable probability that the conduct will be repeated, or has demonstrated that he would be unable to care for himself to such a degree "that there is a reasonable probability that death, serious bodily injury or serious physical debilitation would ensue within 30 days unless adequate treatment were afforded."

Physicians, certain county mental health personnel and police officers have the power to involuntarily commit individuals who meet the criteria. Individuals who have personally witnessed such behavior can file for an emergency commitment on a 302 Petition Form available at the nearest community MH/MR center. Staff there will contact a designated county official who will decide whether the petition passes legal muster for an involuntary commitment.

The law, dating to 1976, was an effort to eliminate the ease with which family members could have relatives committed to mental institutions.

"The current law was really done to protect ... the mentally ill from being forcibly hospitalized simply because somebody doesn't like what they're doing," Dr. Fisher said. "Before, you could trump things up and there wasn't due process. It didn't necessarily require dangerousness."

And as easy as it was for people to have others committed, it was just as hard for those institutionalized against their will to be released.

Now, the law provides that within five days of a 302 commitment, a hearing must be held to determine if a 20-day extension of the commitment is warranted, again based on dangerousness. If there is an extension, another hearing must be held, and so on, thereby providing continuing protection against "warehousing" patients.

Several years ago, Dr. Fisher said, there was a move to change the law so that a person could be involuntarily committed if he or she was behaving in a way that was "predictive" of future dangerous behaviors. Dr. Fisher testified before a legislative committee for the Pennsylvania Psychiatric Society, which opposed the change.

"Our feeling was that what would happen if a law like that passed is we'd go back to the old days, but this time with a medical liability risk," Dr. Fisher said. "My stance when I gave that testimony is that we arrived at the law in '76 because it was a good compromise, guaranteeing due process and hospitalizing people because they were both dangerous and in need of treatment.

"To force someone into treatment you really need both. It's not a crime to be mentally ill. I really think the current law is the best of all possible worlds."

Ms. Baum agreed: "You just don't want to tighten up the law because in tightening up the law you may end up committing people with really no grounds or basis for treatment."

The public may find the nuances of the law, and the stance that it requires of mental health workers, confusing.

The Rev. Jerome Vereb, a Pittsburgh native and Catholic priest who lives on Long Island, N.Y., said he and family members were frustrated by health care workers at Western Psych, the Allegheny County Health Department and other agencies when they recently sought help for a family member suffering a psychotic episode.

Father Vereb, 62, who holds a master's degree in psychology and has worked in the field, said his family relied on him because of his experience.

"The kind of reaction I got from [health care workers] is that there didn't seem to be a sense of urgency. You are frightened, especially because you don't know where to go next and what to do. You are looking for answers. You want to know what caused this. Instead, you are hurried through a process where people are shouting at you."

His relative, he said, "could not sit still. He could not find comfort. He would fade in and out, and he had outbursts of anger. He tore off the back screen door of his home for no reason and was agitated and disappeared for periods at a time."

That was when Father Vereb, who holds a doctorate in theology and has worked in the dioceses of Pittsburgh and Venice, decided it was time to try to get his relative committed to a mental health facility.

He was unsuccessful in getting an involuntary commitment. But when the relative was arrested during one of his episodes, a district judge ordered him to an evaluation at the county Behavior Clinic.

At every step of the process, however, Father Vereb and his family felt like they were being shuffled between agencies.

He said he was heartbroken when he learned of the case of Troy Hill Jr. and his family, especially because he and his family had likewise sought mental health help for a loved one.

But compared to what was happening 31 years ago, Ms. Baum said, the current law regarding involuntary commitments is the best that can be attained. "It's imperfect, but it's imperfect because of human nature."

See above for a dissenting opinion from one of the legislators who drafted this law.
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