By Tammy Worth, Heartland Health Monitor, February 09, 2016
Rebecca Schunck tried to commit suicide dozens
of times before an involuntary commitment at
Osawatomie State Hospital helped her turn her
life around. (Photo by Tammy Worth
/Heartland Health Monitor)
The first time Rebecca Schunck tried to commit suicide she was 25. She called the police following a fight with her father, threatening to kill him and then herself.
Over the next decade, she says she tried to end her life more times than she can count – possibly 75 to 100 attempts. Her preferred modus operandi was medication overdose, but she also tried drowning, hanging herself and injecting air into her veins. During her final attempt in 2011, she got into her car with the windows up and turned the engine on. A concerned friend called the police, and officers arrived at Schunck’s house just a couple of minutes before she would have likely died.
Following that attempt, Schunck was committed – involuntarily – to Osawatomie State Hospital for mental health treatment. As a teenager she was diagnosed with major depressive disorder, but at Osawatomie doctors confirmed she had bipolar disorder and put her on lithium, which she says was life-changing. She hasn’t attempted suicide since then. She went to welding school and now has held a job for longer than three months for the first time in her adult life.
“I can tell now that this is the person I was meant to be… born to be … but the disease didn’t allow that to happen,” she says. “It’s weird to just be coming into myself at 39.”
Being sent to Osawatomie worked for Schunck, but involuntary commitment has been, and remains, a controversial topic.
Involuntary commitment is regulated at the state level. Now an alliance of individuals representing mental health providers, the judicial system and government officials in Kansas has crafted a proposed bill that would change how the current system works. The legislation is expected to be presented to the House Corrections and Juvenile Justice Committee this session by Rep. John Rubin, a Shawnee Republican.
The proposal aims to direct people into the mental health system and out of the revolving door of jail, courts and emergency rooms – the twilight world in which Schunck repeatedly found herself. Proponents say it works for people who are too sick to understand they are in the midst of a mental health crisis. Detractors worry it will violate patients’ civil rights and funnel even more people into a mental health system that’s already filled beyond capacity.
Nuts and bolts
The bill would change Kansas law to give local communities authority to build “receiving centers” that could hold mentally ill people in crisis – i.e., those who are a threat to harm themselves or others or whose condition has deteriorated to the point they can’t take care of themselves -- involuntarily for up to 72 hours. During that time, patients could only leave if a mental health professional determines they are safe and unlikely to cause harm.
Under the current system, people found to be in crisis in Johnson or Wyandotte counties have four options: They can agree to go to Rainbow Services Inc., a site offering short-term observation, triage, sobering and stabilization;, they can go to an emergency room; they can go – involuntarily – to jail, where they can be held for 24 hours; or they can go involuntarily to Osawatomie after being screened at a community mental health center.
“People in crisis are cycling in and out of the system and not getting help,” says Julie Solomon, one of the proposal’s authors and chief strategic officer of Wyandot Inc., the parent organization of the designated community mental health center for Wyandotte County. “I’ve been consulting with people from other states and it’s clear it has been critical in their criminal justice system and making the system work,” she says.
Once a person is brought into a receiving center, he or she would be assessed within an hour by medical personnel. Anyone deemed unsafe would be held on site and evaluated again within four hours. The patient would be assessed again at 24 hours and wouldn’t be placed in front of a judge until 72 hours after arrival at the facility.
“I really think it’s better to have a person treating mental illness, as opposed to a judge, making that decision,” says Wyandotte County District Judge Kathleen Lynch. “If it is handled appropriately, they don’t ever get to criminal court.”
Similar legislation allowing longer involuntary holds is on the books in Texas and Arizona. Carol Olson, executive chairwoman of the psychiatry department at the University of Arizona College of Medicine in Phoenix, says the 72-hour mark is important because people can usually be stabilized in that period.
Olson says it takes time to get people in crisis stabilized. Individuals who come in on drugs and are psychotic need to detox for a couple of days in order to determine if their mental state is caused by the drugs or an illness. Olson says about half the people who come to the “care centers” in her state involuntarily end up staying on a voluntary basis or are released because their condition improves within that time.
“Twenty-four hours is too short,” she says. “Seventy-two seems to work better.”
Johnson County Sheriff Frank Denning often says he runs the largest mental hospital in Kansas, a claim that’s not far from the truth. Of the 700 or so inmates in jail at any given time, about 120 are being treated with psychotropic drugs, he says. That doesn’t include inmates who may need medication but aren’t taking it.
These inmates come at a high cost to the system. Denning says the typical stay is anywhere from 72 hours to 18 days, at a cost of $80 a day. The average length of stay for someone in the middle of a mental health crisis is 78 days, at a cost of up to $180 a day. The cost is higher because of treatment and the stay is longer because the inmate has to be stabilized and evaluated to find out if he is capable of defending himself in court.
Denning says a “port in the storm” – place where officers know they can take someone in crisis – would be a welcome change. But he has reservations about the proposal’s constitutionality.
Under current law, a judge decides whether a person poses an imminent danger to himself or to others. The decision has to be made within 24 hours or the person is released.
The new proposal keeps judges out of the process altogether by allowing a physician or the head of a receiving center to assess whether someone qualifies for commitment.
Denning says that gives too much power to police and mental health facilities.
“If we have these facilities holding people without judicial oversight, it’s ripe for abuse,” he says. “I think we are going down a dangerous path.”
Susan Crain Lewis, president and CEO of the heartland chapter of Mental Health America, says the organization takes a “very, very strong” stance against any legislation that makes it easier to hold people against their will because of mental illness.
“We are not saying it (involuntary commitment) should never happen, but the circumstances have to be dire,” she says.
Crain Lewis argues the bill weakens the standard for determining if a person is a threat to herself or others and doesn’t clearly say who is responsible for determining when a person should be detained. She also maintains that most people can be stabilized within 24 to 48 hours and that 72 hours is an unnecessarily long time to hold people against their will.
“We are probably going in the wrong direction,” she says.
Moreover, she says, the bill treats people with mental health conditions differently from others. For instance, her husband has a physical illness – diverticulitis, an infection of the colon. His fear of surgery has kept him from getting treatment, although she has pleaded for him to do so.
“It is in his best interest to get surgery, but it is still his right to decide,” she says. “I can be mad and scared but I can’t force him into treatment against his will.”
Under the bill, people with mental illness could be held longer than others arrested for the same crime. For minor misdemeanors, Kansas residents are typically given a notice to appear in court and not taken into custody. If the charge is for a felony or related to domestic violence, they are typically seen by a judge the next business day and released on bond, usually within 24, not 72, hours.
“Should we be willing to take away the civil rights of someone who is sick longer than we are to lock up someone else who has broken the law?” Crain Lewis asks.
The hard truth
Even if the bill passes, it won’t necessarily change the current system. Communities that don’t have receiving centers will not be forced to build them; rather, they will continue operating under the current statute. Currently, there are no area facilities set up to be receiving centers for people being held involuntarily.
Rainbow Services in Wyandotte County is a likely candidate to become a site if the bill becomes law. But even it would require adjustments, such as locked and padded cells and staffing that’s authorized to give additional medications and therapies.
Those changes would cost money, which the state has proven reluctant to provide. Funding through a state-funded grant program created in 1990 dropped from $31 million in 2007 to $10 million in 2010. Those funds are provided to community mental health facilities to treat people who are uninsured, helping keep them in their own communities and out of state facilities.
Without state funding, the financial viability of these centers is questionable.
“There may be a small pot of money to do this, but it’s not tenable over time … we don’t have ongoing money for it,” Crain Lewis says.
As if to prove the point, in Kansas City, Missouri, Truman Medical Centers’ behavioral health emergency department recently closed its doors after treating 30,000 patients during its six years of operation. The site was set up to hold and treat patients on an involuntary basis.
Because it was the only mental health emergency facility in the area, patients from all over the region were brought to the site – whether it had beds for them or not, according to Dr. Jeffrey Metzner, medical director of psychiatric services at Truman’s Hospital Hill campus.
Truman wasn’t allowed to turn patients away, even if the facility was full, because it was initially funded with state money. The funding ended, but the patients didn’t stop coming. That led to financial strain and the department’s eventual closure, Metzner says.
Under the new proposal, designated recovery centers on the Kansas side will also be required to take all patients brought by law enforcement. The patients will have to be treated regardless of the availability of beds or funding.
And while the bill mandates the creation of receiving centers, there is nothing in it that addresses the shortage of these treatment facilities. Because it’s an unfunded mandate, the bill doesn’t address how to pay for new facilities or to fund upgrades of existing ones. Nor does it address how the state would license or oversee the centers.
Despite these manifold shortcomings, supporters say the bill addresses major deficiencies in the state’s mental health system. It will keep people in a mental health crisis out of jails and emergency rooms, reduce the burden to the judicial system and sheriff’s department, and expedite care for people needing help by sending them directly to the care they need the most, they say.
“I do hope they change the law,” Schunck says. “Twenty-four hours isn’t long enough to change someone’s life … You need more time than that.”
Editor's note: This story has been clarified to make it clear that people found to be in a mental health crisis in Johnson and Wyandotte counties can be sent to Osawatomie State Hospital on an involuntary basis after being screened at a community health center.
Tammy Worth is a freelance journalist based in Blue Springs, Missouri.