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Virginia Tech Panel Raises Questions About Mental Health, Law

August 30, 2007 at 12:00 AM EDT
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JIM LEHRER: Now, more about those questions surrounding mental health and the law, and to Jeffrey Brown.

JEFFREY BROWN: And for that, we turn to David Shern, president of Mental Health America, a not-for-profit group that represents patients, professionals and families; and, Dr. Anthony Lehman, chair of the Department of Psychiatry at the University of Maryland School of Medicine.

Well, Dr. Lehman, the report — and Tom Ridge just now talked of various points where there were breaks in the information chain, one between high school, where a lot of people seem to be involved and active with Mr. Cho, and college, where suddenly no one knew anything at first. Is this common? And what should be done to address it?

DR. ANTHONY LEHMAN, University of Maryland School of Medicine: Well, I think it is common, and I would say I was very impressed by the report and its thoroughness and its fairness. The general story, I think, that we see here is the problems of what we call transition-age youth. These are kids who have a significant amount of emotional problem when they’re growing up and often have access to good services in the school systems and the mental health system while they’re minors.

But once they reach age 18, two things happen. The first is the service system available to adults is often nowhere near as good as it is for children. And, secondly, because the person’s now an adult, they have more autonomy in deciding who can be involved, so in this particular case, for example, this young man’s parents, who obviously were very significant support for him.

And so it is a common story to have these folks have this problem at this transition between adolescence and adulthood and the loss of the support network that helped them get there.

JEFFREY BROWN: And, David Shern, once he’s in college, there is what we heard from Tom Ridge and we heard it all day long in this report, no one is connecting the dots. How can that be?

DAVID SHERN, President, Mental Health America: Well, you know, it’s actually very common, in terms of the mental health system, for people to enter at various points, to receive care, and to be discharged with the expectation that they’ll continue care in another point and often not to make those connections themselves.

And oftentimes the system, as Dr. Lehman just pointed out, doesn’t assertively or aggressively reach out to engage persons in care, particularly people who are having a really hard time, as Cho obviously was.

It was pretty clear — and I agree with Tony Lehman — I was also very impressed with the thoroughness of the report. It was clear that Cho’s problems were identified early and that he received care in secondary school that was effective for him. But that transition didn’t occur to college. And, as Governor Ridge said, no one connected the dots, and this happens lots of times in public mental health systems.

Evaluating information cohesively

David Shern
President, Mental Health America
There's lots of confusion about what exactly the federal law requires. And it called for -- and I think this is also another very sensible recommendation -- for those ambiguities to be clarified and for clear direction to be given.

JEFFREY BROWN: Governor Ridge talked about a threat assessment team, to give somebody the responsibility for making the call that it's an emergency situation, and also that everybody, a lot of people, would know what's going on. Is something like that viable, given the privacy concerns that you and others have been aware of and concerned about?

DAVID SHERN: Yes, I think it is a viable strategy, because I think what we need to do -- both in the general mental health system and in this particular instance -- is we need a place where this information can all be evaluated cohesively and coherently, so that an overall decision can be made and so those dots can be connected.

As I reviewed the report today, and from my understanding of the law, there is no prohibition against sharing information for medical purposes. There clearly is no prohibition against sharing information in emergency situations.

But the report was also quite clear in pointing out that there's lots of confusion about what exactly the federal law requires. And it called for -- and I think this is also another very sensible recommendation -- for those ambiguities to be clarified and for clear direction to be given.

Now, a threat assessment team, a team that literally was charged with understanding these issues, with connecting the dots, obviously would also understand the vagaries of the law and would itself help clarify those things, I think.

Confusion over the law

Anthony Lehman
Univ. of Maryland School of Medicine
I think there's probably also a need to educate professionals...about what the law says and what the law does not say about these kinds of communication.

JEFFREY BROWN: What do you think about that, Dr. Lehman, about the law itself? Because the report was very blunt, saying that there is widespread confusion over what the law says, and therefore restricting how much people are willing to act.

DR. ANTHONY LEHMAN: I think that's absolutely true; there's a great deal of confusion. And what we see in the report is actually descriptions of a large number of very caring people who tried to help Mr. Cho on an individual level but did not actually talk to each other, perhaps know how the talk to each other. And then when there are these concerns about confidentiality, unfortunately, we often err on the side of being overly conservative, meaning we don't actually share the information for fear of lawsuits and so on. But I think there are plenty of opportunities to be able to share at an appropriate level the information.

And a couple of things. I think this kind of team they've talked about is a very good idea. I think there's probably also a need to educate professionals -- in this case, the professors and administration of the school, but also health care professionals again -- about what the law says and what the law does not say about these kinds of communication.

One other great gap in the communication here, which I think could have easily been overcome, is communication with the family. When you think about this young man, the people who knew him best over the longest period of time were his parents and his sister. And they were unaware, apparently, of the problems that he was having at college.

And it seems like, if they in some way have been contacted at a variety of points just to inquire or to let them know about the problems he was having, they would have been an outstanding source of information about his history and would have been able to contribute much more to sort of the care plan, if you want, for him while he was in college.

Balance between privacy, protection

David Shern
President, Mental Health America
It's critical that, when we talk to our doctor, that we are assured that that's private, confidential information. And there are criteria and standards for when those privacy rights should be violated.

JEFFREY BROWN: Well, everything, David Shern, everything we're talking about is this balance between privacy and protection. This suggestion from the report seems to be that there was an over-concern for his privacy and a lack of weighing the balance in terms of protection. Is that a fair reading? Or do you think we have slipped too far in that direction and we need to balance it out better?

DAVID SHERN: Well, I think that privacy is a very important concern. It's critical that, when we talk to our doctor, that we are assured that that's private, confidential information. And there are criteria and standards for when those privacy rights should be violated.

In hindsight, it's clear that there was imminent danger; in fact, a horrible event occurred. And in hindsight, it's clear that that criteria of imminent danger was met. Hindsight is always 20/20, and that's what makes things very difficult. And I think that law as it's currently construed, and if it's accurately understood -- again, the major point from the report was the fact that there was a lot of misunderstanding and ambiguity about the federal law in education, the laws covering health care...

JEFFREY BROWN: That the problem is not the laws so much as the understanding and implementation?

DAVID SHERN: I think that that's the case.

JEFFREY BROWN: Do you agree with that?

DAVID SHERN: So I don't think this is really -- many people try to cast this as sort of a civil liberties issue versus a need-to-know issue. And I really think here it has more to do with clarification, ambiguity, single point of responsibility, and connecting the dots.

Symptom of a larger system

Anthony Lehman
Univ. of Maryland School of Medicine
I think there is a systemic problem, not just in Virginia, but in most states with this kind of communication. And so folks, as we often say, fall between the cracks.

JEFFREY BROWN: What do you think about that, Dr. Lehman, the balance of privacy and protection, and the reassessing that's going on in your community and the legal community right now?

DR. ANTHONY LEHMAN: Yes, I agree with what Dave Shern is saying. And, unfortunately, these kinds of events bring our attention to this and force us to look more closely at what is acceptable and what's allowed and to keep in mind there are consequences no matter what we do, and that, certainly in this case, unfortunately, I think we were overly conservative in communication.

JEFFREY BROWN: And having looked at the report now, do we describe this as a breakdown of a system or one instance within a system that generally works OK?

DR. ANTHONY LEHMAN: Well, I think there's -- it's a symptom of the larger system. For example, I was struck that this young man had -- in the state of Virginia, there's involuntary outpatient commitment. And he had been committed by a court to outpatient therapy.

But there was a breakdown even in the communication of that to the clinic. And I think that's probably, unfortunately, a common problem in these kinds of systems. So I think there is a systemic problem, not just in Virginia, but in most states with this kind of communication. And so folks, as we often say, fall between the cracks.

JEFFREY BROWN: Very briefly, what do you think, a systemic problem?

DAVID SHERN: Oh, absolutely. And I think what we saw here is a microcosm of what we see in our systems generally. People fall through the cracks all the time. The president's commission on mental health a few years ago characterized the mental health system as in "shambles," and it largely relates to this discontinuity among these various places where persons may be seen for care.

JEFFREY BROWN: All right, David Shern, Anthony Lehman, thank you both very much.