Time to Mandate Reporting of Mental Health Concerns

By now, mental health experts have performed extensive post-mortems on whether Arizona had adequate involuntary treatment laws for people like Jared Lee Loughner, the alleged gunman in the recent shootings.

The answer is yes.

Arizona, it turns out, has admirably progressive mental health statutes that permit involuntary evaluation and treatment of someone who desperately needs it. Loughner, 22, whose delusions of mind control, agitated outbursts, bizarre preoccupations, and paranoia are highly consistent with a diagnosis of schizophrenia, fit that description.

In fact, under Arizona law, any concerned party can petition the court for an Order for Treatment. If Loughner had been found "persistently and acutely disabled" by severe mental illness and "likely to benefit from treatment"--regardless of whether he had a weapon or was suicidal--an evaluation and subsequent care could have been court mandated.

What responsibility does an institution have to the wider community when it has identified a deeply disturbed individual?

Of course, hindsight is perfect. As incidents unfold in real time, most people are rightly skittish about infringing on a person's freedom. But given Loughner's troubling track record--the number of times the campus police were called to intervene; the pressing concerns of his teacher and of other students; and the very fact that the college would not re-admit him after his suspension without psychiatric clearance--it seems that a court petition could have been justified.

Good laws only work when applied, of course. And when Loughner did not return to school, Pima Community College was rid of a very troubled young man and his problems. It did what so many colleges, universities and businesses have done before: passed the problem along.

No-man's land

This brings us to a no-man's land where even strong commitment laws, when they mercifully exist, are not enough. What responsibility does an institution have to the wider community when it has identified a deeply disturbed individual?

Mental health organizations are no place to look for solutions. Their job includes raising public awareness of mental illness; championing the virtue of treatment and implementation of commitment laws; and lobbying for more desperately needed treatment resources. Excellent causes all. As for psychiatric facilities, they can only treat those who have already come through their doors.

Even commitment statutes are, in a sense, permissive--that is they give concerned parties and the courts the authority to do something but do not require anyone to do anything.

Perhaps it is time to require action. When a school or business feels the need to protect itself from someone who is mentally ill, perhaps it should be required to try to protect others, too.

Thus, if a school or a business ejects or otherwise removes a student or employee out of concern about behavior and dangerousness, the principal, dean, or head of the Human Resources department would be required, under a mandatory reporting law, to inform the medical director of the appropriate public health jurisdiction. This public official would then have to initiate an evaluation which might lead to a face-to-face evaluation and, depending upon its outcome, possibly involuntary treatment.

When to break confidentiality

Precedents exist. There are mandatory reporting laws for child abuse. Teachers and medical professionals cannot just look the other way when they see a child with multiple, suspicious bruises. The same logic applies here: a severely ill person battered by psychosis should not be left at the mercy of a condition that causes others to be worried for their safety.

As for the legality of breaking professional confidentiality, a 1976 Supreme Court decision (Tarasoff v. Regents of the University of California) allows a doctor to warn intended victims of a patient's planned attack with no fear of breaking confidentiality. A school or business could be similarly insulated, especially since there is no clearly defined right to confidentiality in these situations.

Weighing individual rights against protection of the general population invokes a vexing social calculus, indeed. Preventing extremely low base rate behavior like the Tucson tragedy is always difficult--many people seem at risk for violence toward others, but so few actually are. And once a reporting requirement exists, will newly accountable institutions inevitably become more cautious and conservative than they need to be?

Then again, if a school or business community is so fearful for its safety that it evicts one of its own, it is clear that a serious threshold of concern has already been reached. A requirement for mandatory reporting at that stage might prevent some tragedies with only minimally greater intrusion on an individual's rights than is now permitted.

Jeffrey Geller is Director of Public Sector Psychiatry at the University of Massachusetts Medical School. Dr. Sally Satel is a resident scholar at AEI.

Photo Credit: Flickr user Rob Shenk/Creative Commons

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