When Should Mentally Unstable People Be Committed? : A HealthCentral Explainer

by Amy Tudor Patient Expert

Members of the public, law enforcement officials and mental health professionals are asking tough questions about whether the Aurora, Colorado shooting that left 12 people dead and 58 wounded could have been prevented.

Like many people who commit mass shootings, 24-year-old James Holmes had been in contact with mental health professionals before he went on his killing spree. He had seen a psychiatrist, Dr. Lynn Fenton, while a student at the University of Colorado Medical School.

In fact, according to news reports, Fenton was so concerned about Holmes that she alerted the campus’ threat-assessment team that he could pose a danger to himself or others. Unfortunately, Holmes had already begun the process of withdrawing from the university, which made it impossible for Fenton and the threat-assessment team to follow up on his condition. Once he stopped being a medical student, he was no longer under their care or jurisdiction. .

Op-ed pieces and numerous public comments on news websites have raised the question of how mentally unstable people such as Holmes can be identified as a threat to others and still remain on the streets.

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The Rule, not the Exception

Holmes’ case is, after all, just another in the long line of mass shooters who have been “flagged” in some way as threats before going on to kill. Here are just three recent examples:

- Virginia Tech shooter Seung-Hui Cho had been involuntarily committed to a psychiatric facility after sending threatening messages to other students more than two years before he killed 32 people and wounding 17 on that campus.

- Jared Loughner was a student at Pima Community College in Tucson who had been reported to campus officials for unsettling, bizarre behavior when he opened fire at a political rally for Rep. Gabrielle Giffords, killing six and wounding 13, including Giffords herself.

- Nidal Malik Hasan, the U.S. Army psychiatrist who killed 13 and wounded 29 when he went on a rampage at Ft. Hood in Texas, had also shown signs that he could be a threat. However, the Army’s response had been to shift him from assignment to assignment rather than confine him.

So what keeps mental health professionals and law enforcement officials from forcibly confining people who are mentally unstable enough to be considered a threat?

The answer is a complicated one.

The Problem With Involuntary Commitment

Generally, people qualify to be involuntarily committed to a psychiatric facility (i.e. put in against their will) if they demonstrate one of three criteria: they are a threat to themselves, they are a threat to others, or they are incapacitated to the point that they cannot provide themselves basic needs such as food and shelter. A person who meets one of these criteria can be committed if at least one psychiatrist who has seen the patient “signs off” on a petition filed with the court.

Though this sounds cut and dried, it’s really not. Some of the difficulty lies in the culture itself. Americans are big believers in “innocent until proven guilty,” and we are very reluctant to forcibly take away the freedom of someone who has not committed a crime. This reluctance shows in the lack of consensus on what constitutes a serious enough threat to forcibly remove someone from the streets. For example, the amount of concrete evidence a health care professional or law enforcement official needs to prove one of these three points varies from state to state. In some cases, even a patient explicitly telling his or her doctor that he intends to do harm isn’t enough proof to have him taking off the streets.

Other difficulties arise from the limits of what a private mental health practitioner can do. If a psychiatrist or psychologist believes a patient in his or her office is a threat, she can suggest voluntary hospitalization, but if the patient refuses, she has no way to hold the person against his or her will. By the time law enforcement personnel arrive, the patient may be gone.

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Also, even if a person is involuntarily committed – as in the case of Virginia Tech shoot Seung-Hui Cho – this isn’t a guarantee that he or she will no longer be a threat when they are released. Cho was diagnosed as being mentally ill during his involuntary hospitalization, but he managed to convince his doctors that he was not a threat. After being referred for outpatient treatment, Cho was discharged and he never followed through with his outpatient care. He became lost to the system.

Who’s to Blame?

Some blame the strapped mental health industry for their poor oversight, while others blame parents and family members for not paying enough attention or turning a blind eye to problems with their loved ones. Some think the constant media attention on mass killings inspires other mentally unbalanced people to seek their “15 minutes” of fame. And still others believe it’s the easy access to guns that allows these attacks to take place.

But while experts say there is, in fact, no way to completely prevent these attacks, they also say there are things the public can do to help prevent some of them. Almost all mass shooters leave clues that are later seen as clear “red flags” in hindsight. Experts say if those were heeded and reported by those who see them – not just police and mental health professionals – there might be time to intervene.

What Can You Do?

According to Peter Langman, a psychologist who has studied the school shooting in Columbine and other school-related shootings: "…We may not be able to stop all of [these shootings], but I think we could stop more than we do.” Just as we’ve been taught to be alert for suspicious packages and behavior post-9/11, we should exercise the same vigilance with people who give signs that they may pose a threat on a smaller scale.

If someone tells you they have plans to harm themselves or others, take them seriously. Try talking to them about it, but only if it seems safe to do so. If they seem serious about their intentions, contact someone in authority such as school administrators, company supervisors, or law enforcement officials right away.

Sources: ABC News; MedPage Today; Wikipedia.

Amy Tudor
Meet Our Writer
Amy Tudor

Amy wrote for HealthCentral as a patient expert for Psoriasis.