NYT: When Someone Appears to Unrave

[Guest guest]

http://mobile.nytimes.com/2011/01/19/us/19mental.xml

Gee, how much good did Cho's involuntary hospitalization do us? What good was

his " treatment? " I'm still waiting to see what Loughner's attorneys put forth as

a defense to see if they claim " involuntary intoxication " or any other

pharma-related defense. I am not convinced that he wasn't on meds.

Terry

U.S. NEWS

Getting Someone to Psychiatric Treatment Can Be Difficult and Inconclusive



Pima Community College, via Associated Press

A YouTube video by L. Loughner touring Pima Community College alarmed

officials there.

By A. G. SULZBERGER and BENEDICT CAREY

Published: January 19, 2011

TUCSON -What are you supposed to do with someone like L. Loughner?

That question is as difficult to answer today as it was in the years and months

and days leading up to the shooting here that left 6 dead and 13 wounded.

Millions of Americans have wondered about a troubled loved one, friend or

co-worker, fearing not so much an act of violence, but - far more likely -

self-inflicted harm, landing in the streets, in jail or on suicide watch. But

those in a position to help often struggle with how to distinguish ominous

behavior from the merely odd, the red flags from the red herrings.

In Mr. Loughner's case there is no evidence that he ever received a formal

diagnosis of mental illness, let alone treatment. Yet many psychiatrists say

that the warning sings of a descent into psychosis were there for months, and

perhaps far longer.

Moving a person who is resistant into treatment is an emotional, sometimes

exhausting process that in the end may not lead to real changes in behavior.

Mental health resources are scarce in most states, laws make it difficult to

commit an adult involuntarily, and even after receiving treatment, patients

frequently stop taking their medication or seeing a therapist, believing that

they are no longer ill.

The Virginia Tech gunman was committed involuntarily before killing 32 people in

a 2007 rampage.

With Mr. Loughner, dozens of people apparently saw warning signs: the classmates

who listened as his dogmatic language grew more detached from reality. The

police officers who nervously advised that he could not return to college

without a medical note stating that he was not dangerous. His father, who chased

him into the desert hours before the attack as Mr. Loughner carried a black bag

full of ammunition.

" This isn't an isolated incident, " said J. Ranieri, president of La

Frontera Center, a nonprofit group that provides mental health services. " There

are lots of people who are operating on the fringes who I would describe as

pretty combustible. And most of them aren't known to the mental health system. "

Dr. Jack McClellan, an adult and child psychiatrist at the University of

Washington, said he advises people who are worried that someone is struggling

with a mental disorder to watch for three things - a sudden change in

personality, in thought processes, or in daily living. " This is not about

whether someone is acting bizarrely; many people, especially young people,

experiment with all sorts of strange beliefs and counterculture ideas, " Dr.

McLellan said. " We're talking about a real change. Is this the same person you

knew three months ago? "

Those who have watched the mental unraveling of a loved one say that recognizing

the signs is only the first step in an emotional, often confusing, process.

About half of people with mental illnesses do not receive treatment, experts

estimate, in part because many of them do not recognize that they even have an

illness.

Pushing such a person into treatment is legally difficult in most states,

especially when he or she is an adult - and the attempt itself can shatter the

trust between a troubled soul and the one who is most desperate to help. Others,

though, later express gratitude.

" If the reason is love, don't worry if they'll be mad at you, " said Robbie

Alvarez, 28, who received a diagnosis of schizophrenia after being involuntarily

committed when his increasingly erratic behavior led to a suicide attempt. At

the time, he said, he was living in Phoenix with his parents, who he was

convinced were trying to kill him. In Arizona it is easier to obtain an

involuntary commitment than in many states because anyone can request an

evaluation if they observe behavior that suggests a person may present a danger

or is severely disabled (often state laws require some evidence of imminent

danger to self or others).

But there are also questions about whether the system can accommodate an influx

of new patients. Arizona's mental health system has been badly strained by

recent budget cuts that left those without Medicaid stripped of most of their

services, including counseling and residential treatment, though eligibility

remains for emergency services like involuntary commitment. And the state is

trying to change eligibility requirements for Medicaid, which would potentially

reduce financing further and leave more with limited services.

Still, people who have been through the experience argue that it is better to

act sooner rather than later. " It's not easy to know when we could or should

intervene but I would rather err on the side of safety than not, " said H. e

Romans, executive director of the local chapter of the National Alliance on

Mental Illness, an advocacy group, who had a son with schizophrenia.

The collective failure to move Mr. Loughner into treatment, either voluntarily

or not, will never be fully understood, because those who knew the young man

presumably wrestled separately and privately about whether to take action. But

the inaction has certainly provoked second-guessing. Sheriff Clarence Dupnik of

Pima County told CNN last Wednesday that Mr. Loughner's parents were as shocked

as everyone else. " It's been very, very devastating for them, " he said. " They

had absolutely no way to predict this kind of behavior. "

Rosenberg, president of the National Council for Community Behavioral

Healthcare, said, " The failure here is that we ignored someone for a long time

who was clearly in tremendous distress. " Ms. Rosenberg, whose group is a

nonprofit agency leading a campaign to teach people how to recognize and respond

to signs of mental illness, added, " He wasn't someone who could ask for help

because his thinking was affected, and as a community no one said, let's stop

and make sure he gets help. "

At the University of Arizona, where a nursing student killed three instructors

on campus eight years ago before killing himself, feelings of sadness and anger

initially mixed with some guilt as the university examined the missed warning

signs.

The overhauled process for addressing concerns is now more responsive, even if

there are sometimes false alarms, said M. Vito, vice president for

student affairs. " I guess I'd rather explain why I called someone's parents than

why I didn't do something, " she said.

Many others feel the same way.

Four years ago Junck watched her 18-year-old son return from community

college to their Phoenix home one afternoon and, after preparing a snack,

repeatedly call the police to accuse his mother of poisoning him. She assumed it

was an isolated outburst, maybe connected to his marijuana use. In the coming

months, though, her son's behavior grew more alarming, culminating in an arrest

for assaulting his girlfriend, who was at the center of a number of his

conspiracy theories.

" I knew something was wrong but I literally just did not understand what, " Ms.

Junck, 49, said in a recent interview. " It probably took a year before I

realized my son has a mental illness. This isn't drug related, this isn't bad

behavior, this isn't teenage stuff. This is a serious mental illness. "

Fearful and desperate, she brought her son to an urgent psychiatric center and -

after a five-hour wait - agreed to sign paperwork to have him involuntarily

committed as a danger to himself or others. Her son screamed for her help as he

was carried off. He was diagnosed with paranoid schizophrenia and remains in a

residential treatment facility.

This week Goldman, a suicide prevention specialist with a mental

health nonprofit organization in Tucson, is teaching the first local installment

of a course that is being promoted around the country called mental health first

aid, which instructs participants how to recognize and respond to the signs of

mental illness.

A central tenet is that if a person has suspicions about mental illness it is

better to open the conversation, either by approaching the individual directly,

someone else who knows the person well or by asking for a professional

evaluation.

" There is so much fear and mystery around mental illness that people are not

even aware of how to recognize it and what to do about it, " Ms. Goldman said.

" But we get a feeling when something is not right. And what we teach is to

follow your gut and take some action. "

A. G. Sulzberger reported from Tucson, and Benedict Carey from New York.

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