Shootings Spur Scrutiny of Mental-Health Care

Russell Weston Jr. is not the first person to fall through the cracks in the mental-health system. But his sudden, violent outburst on Capitol Hill last week raises questions about supervision of those diagnosed with mental illness - and how many might be dangerous.

It also sheds light on the patchwork nature of America's overburdened mental-health system.

Experts say few of those diagnosed with paranoid schizophrenia, like Mr. Weston, are a threat to public safety. Nationwide, an estimated 2.4 million people have been diagnosed with the condition - about 1 percent of the population. A recent MacArthur Foundation study found that people released from state hospitals are no more dangerous than their neighbors, unless they abuse drugs or alcohol.

While the health-care community has found many ways to deal with those diagnosed as mentally ill, gaps in the system continue to cause serious problems. "Somebody like [Weston,] if adequately treated, probably wouldn't have performed this horrible act," says Nancy Andreasen, a psychiatrist at the University of Iowa College of Medicine in Iowa City.

The very nature of schizophrenia has compounded some of the system's failures, according to experts. A large minority of people diagnosed with the disorder refuse to acknowledge there is anything wrong. And many, like Weston, resist treatment.

That can create a Catch-22 and a downward spiral that leads to an even greater break with reality. It's also responsible for the most contentious debate within the mental health community: When, if ever, should a person be forced to accept treatment?

"If someone is dangerous, I have no problem using my power to commit them," says David Pickar, chief of experimental therapeutics at the National Institute of Mental Health. "But I'm not sure I'm on the side of forcing someone to take medication, I'd be very judicious about that, because if they can force them to do that, they can force you or I to do something else."

Fifty years ago, people diagnosed with schizophrenia were locked up. In the early 1960s, medical researchers began to develop drugs for treating those diagnosed with the disorder.

At the same time, the nation began emptying its state hospitals of the mentally ill. The motives were partly humane; to give people an opportunity to try to live dignified lives. But they were also economic. Community health centers proved to be vastly less expensive than state hospitals.

But what developed was a patchwork of barely adequate services, particularly in rural areas. People often shuttle between state hospitals, homeless shelters, and the streets, living on disability, seeing different doctors, and getting different medications.

"It's very important to have a trusting relationship with the person that's helping you," says psychiatrist Dan Fisher, a recovered schizophrenic in Lawrence, Mass. "I think not feeling stigmatized is also a big factor."

Some local programs have proved successful in helping those diagnosed with mental illnesses. In Washington, the Green Door is a community-based program designed to provide dignity and the kind of consistent, caring relationship that Dr. Fisher says is key to helping people recover.

Mental-health community debate: When, if ever, should a person be forced to accept treatment?

It's called a "clubhouse," and it provides housing, job training, and case management to about 250 people diagnosed as seriously mentally ill. They're called members.

"The emphasis here is on high expectations ... and a mutual relationship," says executive director Judith Johnson.

Each person has a caseworker, and together they're responsible for keeping that member in the community and working.

The model has proven to be extremely successful. Nationwide, only 5 percent of people diagnosed with schizophrenia are employed. But 45 percent of Green Door's members go to work every day.

Nationally, about 50 percent of schizophrenics are rehospitalized every year. At the Green Door, the rehospitalization rate is only 12 percent.

One key to its success is assertiveness. If members don't show up for three days, their caseworker goes out to find them and be sure they're all right.

In the traditional mental health system, if people don't show up for an appointment, they're usually sent a letter. Ms. Johnson says that makes little sense, particularly if a person is becoming ill. "They're not going to open it, or they're going to think it's from the CIA," she says.

If people continually fail to show up in the traditional system, they're often labeled "treatment resistant" and discharged. "It's the most ludicrous remark," says Johnson. "I mean, by definition with this illness you're going to be treatment resistant."

Several years ago, member Roger Kokkos couldn't find a job. He was beginning to get frustrated. He decided to stop taking his medication. Then he stopped showing up at his appointments with his caseworker, Andrew Carpenter.

Mr. Carpenter, was determined not to let Mr. Kokkos slip through the cracks. He went to Kokkos's house to try to persuade him to restart treatment. Kokkos refused.

But Carpenter kept knocking at his door - every day, sometimes three times a day, for a week. "Eventually, when it got to the point that he saw how concerned we all were about him, he came to us and said, 'OK, now, it's time,'" says Carpenter.

Kokkos is deeply grateful to Carpenter now, although at the time, he was rather angry. The last thing he wanted was to go back to the hospital.

"It's sort of a starting over again, falling back, digging yourself into a hole and having to climb back out; you don't feel proud about it," says Kokkos.

He's now back at the Green Door, in treatment, happy, and looking for a job. He's also very proud of the strides he's made in working on his disorder.