To treat mental illness, we need a more reasonable civil commitment law: Guest opinion

Guest Columnist By Guest Columnist The Oregonian
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on February 09, 2013 at 12:00 PM

By Christopher J. Lockey

The recent shootings in Newtown, Conn., and here in Clackamas have caused enormous grief for families and friends of the victims and left many in our nation despondent. Public debate about them quickly focused on ways to prevent such tragedies from recurring. One step for Oregon should be to reform the state's unreasonable civil commitment laws and put a stop to the criminalization of people struggling with severe mental illness.

Mental health professionals are often asked to put these violent events into context and explain what role mental illness might have played. This is not an easy task. A good start is to look at what we know about mental illness and violence, and use this understanding to make better decisions about mental health care. This helps to prevent uninformed solutions from becoming law -- for instance, the National Rifle Association's call to create a registry for individuals with severe mental illness.

The majority of people with mental illness are not violent, but some illnesses do carry an increased risk for violence, especially when alcohol or drug use is involved. For example, untreated people struggling with paranoid ideas or hallucinations are more likely to be involved in violence than those with anxiety. Alcohol use carries the highest risk by a large margin. Research clearly shows that successful treatment greatly reduces this risk regardless of illness.

Even though we know that treatment reduces the risk of violence, the number of public hospital beds in the United States for those suffering from psychiatric illness has declined dramatically in the past 50 years, from 560,000 to about 38,000. At the same time, publicly funded and self-described advocacy groups in Oregon and other states have pushed hard for laws that make it nearly impossible to provide psychiatric treatment for some at risk.

Right now, people cannot be committed for psychiatric treatment in Oregon unless they are imminently dangerous to themselves or others, or they are gravely disabled (about to die). We have this rule despite the fact that the best experts are poor predictors of dangerousness. It's like trying to time exactly when to slam on the brakes of a bus speeding toward a brick wall so it just touches the wall without causing damage or injury. Do we wait until the last possible moment to treat a heart attack or stroke? Because of our current laws, it is much easier now for communities to arrest those with severe mental illness to keep them safe than to provide them with treatment.

The majority of beds at the Oregon State Hospital are now used to treat people with mental illness arrested for a crime. This number continues to grow and parallels similar trends in other states. The three largest psychiatric facilities in the United States are correctional institutions: Rikers Island in New York City, Cook County Jail in Chicago and the Los Angeles County Jail. In effect, this is the criminalization of mental illness, and it is very expensive.

There is much we can do to modernize Oregon law. It makes sense to replace our imminent-danger threshold with a standard that is flexible and respects our rights. After all, even though we are notoriously poor predictors of violence, we are fairly good at recognizing when someone is suffering and needs help. Research shows that states with more flexible policies regarding psychiatric treatment have about a one-third lower homicide rate. Additionally, a flexible assisted-treatment policy will help ensure that individuals have access to treatment to prevent prolonged and recurrent hospitalizations.

This is just one part of a broad solution to dealing with violence in our society and preventing the next massacre.

Christopher J. Lockey is a board-certified forensic psychiatric physician who practices at Oregon State Hospital. He is the president of the Oregon Psychiatric Association and an assistant professor of psychiatry at OHSU. The views expressed are his own.