The national mental health provider shortage, especially of psychiatrists, continues unabated. More and more large mental health organizations are now joining the national vocal chorus highlighting this decade and a half (in my own estimate) crisis.
The article I read of August 15, 2019, by Brent Johnson, which stimulated my thoughts on this shortage,”More people know they need mental health services, but facilities cannot find staff to treat them,” was published in a regional business-oriented periodical “ROI” (I guess for Return on Investment). The article featured thoughts from the CEO of a local, regional New Jersey mental health provider agency, Robin’s Nest, Mr. Anthony DiFabio.
Mr. DiFabio is well positioned to speak authoritatively on these issues. He is also board president of the New Jersey Association of Mental Health and Addiction Agencies.
He details that all types of agencies in all service sectors are having enormous troubles recruiting and maintaining practitioners at all levels of expertise, training and professionals. This goes beyond the all too well known national shortage of psychiatrists. Psychologists, social workers, and counselors-therapists at all levels of training from bachelors to master’s level are increasingly hard to recruit and retain. One issue he highlighted I was less aware of, was that agencies now have significant retaining practitioners due to staffers leaving for other positions in other areas of work. Salaries again are touted as causing losses of staff on a continuing basis. I have this as social workers and psychologists, especially the younger ones to their professions, leave public mental health jobs for more lucrative positions, especially in federal systems.
In my journey through my training centers becoming a psychiatrist, I was accidentally graced that my medical school and subsequent residency centers had medical libraries with superb historical collections. There are a number of other medical school libraries who have similar collections. At Michigan and then at Duke, I found myself spending empty hours reading histories of medicine and then psychiatry in the rarefied collections rooms. These left an indelible mark in my reading appetites that have lasted my entire professional life.
The past five decades of exposure and experience have faced me with the enormous shifts in practice models, the wrenching changes in mental health service delivery since the 1950’s, and continuing dilemmas posed by seductive national solutions that brought with them worsening problems. The overall shift in western mental health care has swung from outpatient care for the well-off seen by private practitioners, the subsequent mental health center movement for the general populace from the 1960’s through the 1980’s, and the even larger but mostly unseen segment of public inpatient psychiatric hospital care that dwarfed all other portions of the mental health care pie. This last “market” underwent the most severe changes of all. By the latter 1960’s the movement to close state psychiatric hospitals was underway fueled by the new sociologic analyses of authors like Erving Goffman and the emergence national awareness of the wretched, medieval conditions of state hospitals and wretched treatment of patients. Commitment laws came to be humanized with respect for patients’ rights to legal representation after the 1974 Supreme Court Wyatt vs. Stickney decision. De-institutionalization, the discharging of inpatients from state hospitals proceeded through the 1990’s, eventually emptying states’ psychiatric hospitals of roughly 4/5 of their beds, closing old hospitals in wholesale fashion.
Many figures played major roles in this profoundly important movement. R. D. Laing in the UK tried treating schizophrenic patients in more open, experimental settings. Typical of those times, whether in state hospitals or a number of private free-standing hospitals, patient governments were formed. Patients were encouraged and helped to make many personal and treatment decisions for themselves. The “therapeutic community” movement arose out of, and in parallel, grew from this non-authoritarian, more democratic hospital life. Hospitals were opened up to the community. Echoing rehabilitation practices of nearly a century before, patients were permitted to work and earn money. Social activities were begun with the return of art, dance, crafts, and musical pursuits.
One very influential source of the de-institutionalization movement in psychiatric hospital care came from Italy in the 1960’s. This piece of psychiatric history is little known in the USA.
The Italian psychiatrist who pioneered many of the components of radical change in public psychiatric hospitals was Dr. Franco Basaglia. His story is nothing short of fascinating. As is so often the case in the culture of Italian figures no matter what their field of endeavor, his crusade began to take shape in his younger years being exposed to different mass political movements and periods of social upheaval in Italy. He was born into the fascist periods of Italy before and through World War II. He absorbed radical social concepts from the communist and socialist movements of post-war Italy. These concepts guided him to become the effective psychiatric reformer that led to his national fame and regard. This kind of personal development would be viewed as heretical, treasonous and would prevent any achievement in this conservative America. But in Italy, Basaglia’s social-intellectual development made perfect sense.
Basaglia did all the things we think of radical in a wretched state hospital. He empowered patients, tore down fences, did away with tortuous physical treatment, had patients go into the community and so on. He did all this in a true backwater town on the northern border away from any and all big cities and centers of thought and social change. He worked for several years in isolation and obscurity. Then through a fascinating chain of fortuitous events, his efforts began to be noticed and the powerful beacons of the press and celebrity status quickly enveloped him, his work and his staff.
His efforts came quickly to be acclaimed and trumpeted nationally and internationally. His influence in Italy was far beyond that of any of America’s famous reformers such as Dorothea Dix, Nelly Bly, Erving Goffman, Laing and all the others. Italy responded with the national social change that has only been equaled in the Scandinavian countries, not France, nor the UK and especially not in the United States.
With a few years, a reform law was passed in Italy named after Basaglia. It set the national goal of the closure of ALL the public state psychiatric hospitals!
This was indeed fully accomplished, a feat that is beyond astounding in the annals of national social change. For several decades now in Italy, there have been no mass hospitalizations of the chronically mentally ill. There do not seem to be hundreds of thousands of “CMI” (chronically mentally ill) persons everywhere on the streets of Italy. Somehow Italy with all its frequent political crises, changes in governments, scandals, raucous politics and all the other tumult that seems par for the national life of Italy, has done what other western societies cannot care pretty well for the nation’s mentally ill.
I would refer the reader who might be interested in the history of Dr. Franco Basaglia and the “reformation” of Italy’s national mental health de-institutionalization and revolution to the writings of Prof. John Foot of the University of Bristol in England. His book, The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care is well worth the read. An online article published in VERSO, “Closing the Asylums,” gives readers a worthy overview into Dr. Basaglia, the times and his accomplishments.
Realizing what Basaglia accomplished forty years ago leaves this student of psychiatry, its history, and observer of our current national crises, sad for where we have been trapped by our own hobbling prejudices, resistance to social change and pattern of quickie formulas that led to the all too familiar conundrum of “unintended consequences,” and bigger and more complex messes with each year in mental health care delivery.
A somewhat new trend has been emerging over the last 1-2 years and is becoming more of a force in mental health reform. That trend is the efforts of private and state-private psychiatric care systems to try to preserve and add psychiatric inpatient beds in their areas. The efforts testify to the need for more psych inpatient beds almost everywhere. They are also confirmation of the huge national mistake that has been made in the previous 40 years or so nationally to close inpatient state hospital psychiatric beds.
I will first set the stage, reviewing some of the factors leading to a national inpatient bed shortage. Second, I will discuss two recent differing state systems’ efforts to add or preserve inpatient psychiatric services. One is a novel success story that bears study, and the other is a looming failure that illustrates some of the factors that persist that impede this kind of mental health care system delivery. Lastly, I will conclude this lengthy piece, reviewing why the national loss of inpatient beds happened, contrasting what occurred in the public arena, which is so well known, with what happened in the private psychiatric treatment bed world. Continue reading “New Psych Beds Still Needed Nationwide; Two Differing Solutions”
The means by which I came upon this article entitled, “The Door To A Revolution in Psychiatry Opens,” is worth detailing. The author of the blog post is Robert Whitaker, a journalist and author of two books about the history of psychiatry, one of which I have and have read with great enjoyment, fascination and a good for the soul dose of humility, Mad In American: Bad Science, Bad Medicine, And The Enduring Mistreatment Of The Mentally Ill [click link for Amazon review etc.]. Mr. Whitaker is in the foe of psychiatry camp along with perhaps better known anti-psychiatry physician Peter Breggin MD. Mr. Whitaker’s book focuses on the failings and disasters, failed theories, bad side effects of many psychiatric medicines and so on. In all fairness I follow him with searchbots on the Net and this turned up. If you loathe all things psychiatric, then this is one of the books for you in truth. Form my point of view it is a needed viewpoint and one to help us in the guild…though I do not think of myself as all that nefarious and evil, and talented writers such as he are to be commended and accepted for their necessary work.
Several weeks ago I was incredibly saddened by the news from a colleague and dear friend of mine, also a Duke child psychiatrist, that one of our mentors had passed away in his mid-80’s. He meant so much to me, I wish to mention and memorialize his name in my own little way in this humble esoteric blog. He was Dr. Marc (Marcelino) Amaya (with ‘Amaya y Rosas’ being his full last name).
He was one of the original child psychiatrists in a group that came down to Durham NC from Northeastern training centers to help start the department and to staff it. The other faculty was as were in all major medical centers of the last 50 years, superb instructors and fantastic clinicians that often left us rookies with our veritable mouths open at their insights.
Dr. Amaya started a complete children’s psychiatric hospital I think in the early or mid-1960’s to house what Duke could not offer on its grounds because it was private and not state affiliated and for funding issues. The Children’s Psychiatric Institute (CPI) was a fabulous training center on the level of such other state hospital affiliated and also lesser known than the more celebrated upper crust programs, but every bit as good as any of the Ivy League (Boston, NYC, Philly, etc.) centers such as the late and venerated Dr. Ralph Rabinovich of the University of Michigan at Ann Arbor. CPI has a short term and long term outpatient clinic, a family therapy program that was expanded by this writer and one of the veteran incredibly skilled social workers at CPI, Anne K. Parrish ACSW, LCSW, into a training program for child mental health trainees from Duke and UNC-Chapel Hill medical and graduate schools. Dr. Amaya was a superb supervisor and I always learned untold concepts, techniques, and gems at his feet so to speak. I also accompanied him to the testify in the Golden Days of Psychiatry and Psychology in this country to testify annually before the NC General Assembly (state legislature) as we would advocate for our state funded programs, but also for the private inpatient and outpatient programs at Duke and UNC! So there we would be harassing clinically and statistically the legislators (who in those days seemed to listen better..no matter their party affiliation). It was quite ironic but demonstrated the dedication that Dr. Amaya had to the delivery of mental health services to ALL children of the state and to any agency, institution, training program that was trying to provide such. His program was not his first concern in the statewide scheme of things, it was just another important part of the overall system of resources he foresaw for the state decades before some of them came into existence. He was a short man with a lyrical Hispanic accent that I as a Southwesterner could listen all day long and always feel like, when I was with him, I was a little bit ‘back home’ in the Southwest.”
May 11, 2017
In today’s AJC Online publication of the Atlanta Journal-Constitution, entitled: “Deaths, delays paint grim picture of Georgia mental health reformState still discharging patients to extended-stay motels, homeless shelter” authored by Allan Judd of the AJC, a despicable, but tried and true shameful expedient method of discharging and placing discharged psychiatric patients has come to light once again. Before I identify it, I would like to cite a few of its historical predecessors that were also once ‘standard practice,’ that tried to make one segment of our long “broken mental health system” work.
Several years ago, a private psychiatric hospital in Nevada gained notoriety in the news by the discovery that for two years or so, it had been discharging chronically mentally ill patients to the ‘foreign’ territory of California. Patients would be given a starter set of clothes and belongings in a suitcase, an amount of cash money whose exact amount I can not at this moment recall, and plunked down after a short plane flight from Henderson NV I believe to the airport and streets of San Francisco as a means of “placement.” This is of course set off much moralizing, scandal, and opprobrium, corrective and punitive action was taken and the practice stopped.
Now a story emerges from Georgia that it is doing something close to that by discharging “mental patients” from its state hospitals to makeshift former motels and shelters with just a bus fare token and little else,…like follow up, a ready and waiting clinical post-discharge treatment team and program? Perhaps, perhaps not.
This also reminds me of the practice of New York approximately two decades ago, in which such patients were discharged to welfare hotels; these were abandoned, closed, bankrupted, foreclosed, gone out of business hotels from another era who could not compete anymore in the glitzy market of tony New York hotels. These places would be filled with ‘dischargees’ from prisons and psychiatric hospitals with no other suitable resources, families or homes they could turn to. New York as I recall was indeed treating these unfortunate folks with outreach mental health, public health and social work teams struggling to help keep them stable in such grim and lonely settings, but these ‘placements’ quickly became cesspools of crime and corruption as the predatory types, the criminal wolves of society learned to prey upon these defenseless persons at the first of every month when their benefits checks would arrive. [In the days before automatic electronic deposit had taken hold].
New York City Police had to deal with this and it was a nightmare and a number of deaths and tragedies brought this practice to the corrective glare of the light of investigative focus.
Those detestable practices likely had to be employed since states, as they closed aging, falling down, decrepit state hospitals without funding adequate decent housing on a massive social scale for this displaced population.
The ironic similarity to refugee camps in the Middle East sprang easily again to my mind. Any person without stable resources, a supportive surrounding community of “friends and neighbors,” an adequate income and food supply, medical care and all the ordinary trappings of a life in a familiar community that most of us take for granted, and has only as many possessions as they can carry on their heads, or in a duffel bag or black plastic garbage bag or a ‘borrowed’ grocery store cart, qualifies as a “refugee,” in my mind. In fact, to stretch this wretched analogy further, we have our own internal large population of “Syrian refugees,” in our country though we largely do not realize it on a collective national consciousness. Except the “relief” workers do, who struggle valiantly to help care for these unfortunates against truly daunting odds.
As they say in real estate, “location, location, location,” I would add the phrase “funding, funding, funding,” to this national disgrace. This sector of our nation’s life and citizens needs new “infrastructure rebuilding” as much or more so than our fabled Interstate Highway System conceived and begun during President Eisenhower’s era.
Rather than send the reader off to the article via a hyperlink I have decided to excerpt portions of the article for the reader to read and ponder first hand:
Posted: 7:31 a.m. Thursday, May 11, 2017
Mentally ill patients often left Georgia’s state psychiatric hospitals with just a bus token and directions to a homeless shelter.
For people with disabilities, these same institutions became places of permanent confinement.
This is the system that Georgia, under pressure from the federal government, pledged seven years ago to radically overhaul. But with a court-enforced deadline fast approaching, the state increasingly seems unlikely to fulfill its promises.
Georgia has less than 14 months – until June 30, 2018 – to comply with a settlement it reached with the U.S. Department of Justice in 2010. The agreement followed an investigation that concluded the state had systematically violated the rights of people with mental illness and developmental disabilities.
But the state continues to discharge patients with mental illness to places where they are unlikely to get psychiatric treatment: extended-stay motels, for instance, and even the massive Peachtree-Pine homeless shelter in midtown Atlanta. All patients with disabilities are supposed to be moved into group homes or other community-based facilities, but at the current rate of progress, the state might not meet that requirement for another 10 years.
As officials try to comply with the agreement, they also are investigating an alarming number of deaths in community-based treatment: about 350 since 2014. Those apparently include five dozen suicides.
A court-appointed monitor credits the state with making many promised improvements, especially regarding crisis intervention and other services for people with mental illness.
Still, a grim picture emerges from the monitor’s most recent report, as well as from interviews and documents reviewed by The Atlanta Journal-Constitution.
It is “absolutely essential” that the Georgia Department of Behavioral Health and Developmental Disability “act with urgency to meet its obligations,” the monitor, Elizabeth Jones, wrote in late March in a report to U.S. District Judge Charles Pannell. “Although there has been noteworthy progress in certain discrete areas of implementation, the reform efforts require additional diligent and effective actions if compliance is to be achieved within the anticipated timeframe.”
Department officials declined to be interviewed.
In a statement, the agency did not say whether it expects to meet the deadlines next year. But the department said it is moving at “a reasonable pace” to move. “Transitions are carefully and individually planned to meet the unique needs and preferences of each individual and to provide the best opportunities for success in the community.”
The agency said it welcomed the monitor’s “reflections and recommendations.”
The Justice Department began investigating Georgia’s psychiatric hospitals in 2007 after a Journal-Constitution series, “A Hidden Shame,” exposed a pattern of poor medical care, abuse, neglect and bad management that had caused dozens of unnecessary deaths.
Transforming a historically troubled mental health system has been a slower process than perhaps anyone envisioned when state and federal authorities put together a plan. Already, a judge extended the deadline for compliance once, from 2015 to 2018.
The state has spent millions of dollars and reorganized the bureaucracy that oversees the hospitals and community treatment. It also closed two state hospitals, in Rome and Thomasville. All that’s left of Central State Hospital, the notorious facility in Milledgeville that once warehoused as many as 12,000 people, is a unit for people committed through the criminal justice system.
The state complied with hundreds of provisions from the settlement agreement with ease. But several issues have proved insoluble.
For instance, despite promising to provide “supported” housing to 9,000 people with mental illness, the state has managed to find such homes for fewer than 2,500 former hospital patients, according to the monitor’s report.
Vouchers that pay for the housing have been “a game changer for the people who have gotten the housing vouchers,” said Talley Wells, who runs Atlanta Legal Aid’s disability integration project. “But the reality is we still have a long way to go to complete the settlement. The state made a commitment to 9,000 people to provide this game-changing housing.”
In past years, the state hospitals, especially Georgia Regional Hospital/Atlanta, sent scores of newly discharged patients to locations where continued treatment seemed unlikely: homeless shelters, street corners, even an abandoned van on a street in Atlanta’s West End.
But from 2016 to 2017, according to the monitor’s report, the hospitals cut discharges to homeless shelters by half. At the same time, however, the number of patients placed in extended-stay motels quadrupled.
The patients typically leave state hospitals with appointments for additional mental-health treatment; in Atlanta, it’s usually at a clinic operated by Grady Memorial Hospital. But most patients discharged to shelters and motels never show up for their appointments, the monitor found. Some return to state hospitals again and again.
The lack of housing sometimes contributes to deaths and injuries, state records show.
In November 2014, records show, a staff member at a community-based mental health center promised a client she would complete paperwork to get him a housing voucher. Almost a month passed before the staff member followed through. By then, the client was homeless – and had killed himself.
Finding appropriate places for developmentally disabled patients has been just as difficult.
Since 2010, the state has moved more than 500 disabled patients out of state hospitals. But in the year ending June 30, 2016, officials managed to transfer just 26 patients and as many as 10 times that many remain in state hospitals. (The monitor’s report listed the number as 284, while the state said it is 204.)
The state has continually struggled to find high-quality community settings, especially for patients who have complex medical needs.
As the Journal-Constitution reported last month, many patients have ended up in privately run group homes where inadequate staffing, poor training, and incessant cost-control measures have put them at risk. Between 2014 and 2016, 53 people died in Georgia under the care of just two for-profit group home operators. At least 46 of the deaths were unexpected and, according to state reports, may have been preventable.
A state panel called the Community Mortality Review Committee examines each death. Minutes from the committee’s meetings show that at least two dozen disabled people choked to death on food from 2014 to 2016. Others died from bowel obstructions, a condition that is supposed to be closely monitored.
State officials redacted most details of individual deaths. But the committee’s minutes show that in one case in 2015, for example, the staff of a group home had not been trained on what foods would be too difficult for a particular patient to swallow. The state left the resident alone during breakfast with food she couldn’t swallow, and she choked to death.
The deaths show the need for better screening and more oversight as transfers from the state hospitals continue, advocates for people with developmental disabilities said.
“This is all about making sure people have the supports they need to lead meaningful lives in their communities,” said Alison Barkoff, one of the lawyers who represented advocates during the state and federal negotiations over the settlement agreement. “It’s not just moving people for the sake of moving people.”
Barkoff said the state should either fix problems immediately, if it can, or acknowledge it will need to extend the settlement agreement past the June 2018 deadline.
But what happens if the deadline passes without the state’s full compliance is not at all clear.
Under President Barack Obama’s administration, the Justice Department aggressively pushed the state to act. At one point, federal lawyers asked a judge to hold the state in contempt of court for failing to live up to its promises. That request led to the extension of the settlement agreement.
Advocates worry that President Donald Trump’s Justice Department may show little interest in enforcing Obama-era settlements such as the one with Georgia. While career attorneys in the department’s civil rights division remain on the job, the division’s top positions, which are political appointments, are unfilled.
With the state so far from complying with the settlement agreement, the matter may come to a head next year before a federal judge.
“I can’t imagine they will have met their obligations,” said Ruby Moore, executive director of the Georgia Advocacy Office, a federally mandated agency that promotes the rights of disabled and mentally ill people. “There is just too much to be done. They’re working hard, but I don’t think they have enough time.”
As what I feel and predict will go from a quiet common state governmental call to action to hard pressed and at times, downright stingy state legislators, Gov. Sununu of New Hampshire has gone quite public in his urgent call for the establishment of inpatient acute state hospital psychiatric beds. This might seem like not so big a deal but I expect that this will become more and more frequent as the acuity of the public deficit in the capabilities to the now overflowing needs in many states overwhelmed by the numbers of chronically mentally ill.
In an article published of all places in the New Hampshire newspaper, The Portland Press Herald, April 21,2017 entitled “New Hampshire Gov. Chris Sununu calls for more beds at psychiatric hospital,” the Governor publicly declared again but more emphatically the need for major figures in the state government agencies, especially the Dept. of Health and Human Services to mount a rapid effort with short-term corrections, which I guess means “more beds please,” and a long-term realistic plan to address the mental health crises for treatment service delivery in the state. I think that this is noteworthy because it represents a growing trend that has finally burst into the open. However reluctant many governors have been in confronting this issue, I think that more will come out of their legislative closets and start trumpeting the needs for such actions. It has already started in such states as Texas and especially Washington state where Gov. Jay Inslee has been focusing on acute state public mental health issues as much or than any other state chief executive except the Governor and the Virginia’s two year old oversight committee on mental health issues with some of the most comprehensive and innovative programs in the country except perhaps my own state of North Carolina which has worked on these issues very quietly (in spite of HB2 ‘bathroom law’ distraction.
In yet another unbelievable horrible tragedy, a chronically mentally ill man in Washington state was finally admitted after a few months of court orders by a judge, a fine of the state mental health department to the tune of $2,000per day and ceaseless and desperate advocacy for inpatient psychiatric treatment for their relative.
I must confess that in the above first paragraph, I did a little dishonest thing, an intentional literary device. I implied that it only after all those pushing and shoving well placed and well-intentioned efforts, did this man get the help he needed. No, those efforts were the unsuccessful prelude…
This middle aged man murdered his elderly father and THEN he was admitted to the state hospital. The article, “David Altman finally gets a bed at Western State Hospital,” makes for a very sad read. As I read it for the first time, the old colloquial phrase, “a train wreck in slow motion,” came to mind.
This tragedy is even worse in a way than the Gus Deeds tragedy in Virginia over two years ago. In that ‘case,’ Gus Deeds was a mentally ill psychotic young man in his early 20’s. His mental illness was known to the family and well managed as the father, a Virginia state legislator, is a Ph.D. clinical psychologist. He also saw the warning signs of spiraling psychosis and immediate need for acute inpatient psychiatric admission. Under the then peculiar obstacles in Va’s state hospital admissions procedures a bed could not be found for Gus and he was released from an emergency after four days. Within 1 or 2 days as I recall, he had tried to stab his father to death and then ended up suiciding.
Clinicians around the country years ago began warning of these kinds of tragedies in the 1990’s. I remember joining the shrill and desperate warnings in those days at various levels of my own participation in state and then in my younger days, the national organizations as we advocated for our patients. I recall realizing along with many others that our estimates and assumptions about the weight of our influence in the ‘halls of power,’ were vastly self-deluding. ‘We’ were not only not listened to, but I recall as those in power and frankly zealots in the new wave of the then growing world of mental health restructuring, viewed us as psychiatric Luddites, old fogies who were no longer ‘with the program’ so to speak. Mental health professionals were viewed as stumping to preserve their own positions of power or whatever and our warnings were not only resented but also labeled as being rather like Chicken Little shrieking “the sky is falling!” As we continued our dissent and disturbingly factual predictions of what kinds of tragedies that reductions in training programs, inpatient, and outpatient resources would produce, we began to be denigrated, ignored and accused of holding up progress. Well, truly not to gloat utilizing families’ incredibly sad tragedies to do so, I must state the obvious, “We are not Kansas anymore,” and the predictions a generation of mental health professionals repeated over and over that fell on deaf ears, have to come to occur and confirm not how smart us mental health nags and gadflies were, but that those actions were to have dire and tragic consequences and for the last decade or more we have seen them materialize in front of us.
But on an optimistic note, we have turned the corner I firmly believe. The growing number of bills in legislatures at the national and state levels are now openly addressing and discussing the issue of the failures of mental health reform. Pieces of legislation are looking at many of the correct entre’ points for cultivating solutions: increasing training funds for all types of mental health professionals, financial incentives to go into the traditionally underpaid careers with loan forgiveness programs and other responsible incentives, starting up new training programs, restoring services, and spending monies by states and the nation even (gasp) talking of ‘enhancing revenue streams,’ (read new modes, methods of taxes, horror of horrors) to make any and all of these corrective measures possible.
Corrective legislation will have to be written to facilitate the immediate and easier mobilization of emergency psychiatric admission and legal mandated involuntary psychiatric hospitalizations to help to stem these kinds of horrific tragedies and save lives. And the balance of the rights of the person so involved will have to be redrawn in a different conceptual framework so that it is not virtually impossible to hospitalize someone who is psychotic and dangerous as it still is in some venues.