"I Kill For God" And Other Thoughts For The Washington State Legislature

On Friday, the alleged mass murderer Isaac Zamora, who killed six during a shooting rampage in Skagit County, Wash. last week, was arraigned. He told the judge, "I kill for God. I listen to God." Variously described as having schizophrenia (my guess as well) or bipolar disorder, Zamora also has a long history of drug use (cocaine mostly), arrests, and as a guy who almost completely evaded the mental health system (he was hospitalized a few times, but largely blew off medications, treatment and any aftercare).

On Sunday, the Seattle Times' editorial board chimed in with an editorial demanding that the state legislature hold hearings on the state's civil commitment laws and outpatient commitment. Compared to the Seattle Post-Intelligencer's deeply biased and flawed reporting on outpatient commitment last week, the editorial was low-key, but one does worry about turning this whole tragedy into a political football. Then again, a cop was killed, so this is a natural outcome.

"The Legislature has a duty, however belated, for the six deceased and their loved ones, to look at the state's mental-health system and civil-commitment laws and procedures. Zamora's record put him into the orbit of state Department of Corrections supervision. How credible and useful was the monitoring of this multiple-slaying suspect?

"Is the current threshold for involuntary treatment too high? If the standard is imminent danger, does that ignore the menace who is a persistent threat and always just beyond the reach of a satisfactory outcome for those threatened? Does failure to have treatment available speak to the strictness of the law, or inadequate options and a lack of available residential space and professional help?"

Like it or not, the Legislature is going to get this whole mess dumped in its lap, despite the fact that most of the next legislative session, which begins in January, will be taken up with an inevitable budget deficit and all the other usual complications of running a state. People want something done and the leg will be pressed to do something.

The Zamora case is probably not the best one upon which to base arguments in any direction for change. There's too much about it that's sui generis--the guy had been living in the woods for months apparently, among other things. But there are questions the leg should be asking.

First, how did this guy get his hands on a gun or guns (he's a convicted felon and had been committed once before for more than 14 days, both of which mean he couldn't legally buy a gun)? Were they laying around the family's house or did he steal them or something else? Second, when he appeared before a judge back in May, why didn't the judge order an outpatient commitment hearing (the state does have an outpatient commitment law) or some other form of mental health intervention, given Zamora's long rap sheet and documented mental health history? Why did the judge simply parole him and turn him over to the corrections department? Third, what kind of follow-up did DOC do? Did anyone there have doubts about Zamora's ability to live in the workaday world?

I'm raising questions about both the judge and DOC because it seems like a ball may have been dropped somewhere in that chain. The reality is that Zamora's rampage could've been headed off months ago with some kind of appropriate intervention.

Beyond that, legislators will hear a lot of passionate arguments from advocates on all sides of the issue about how they believe Washington State's civil commitment laws are too loose and how the state's outpatient commitment law needs to be employed more frequently. Both arguments are bogus. The state's civil commitment law requires that a person be an imminent danger to self or others in order to be committed involuntarily. It also allows a person to be committed involuntarily if they are too gravely disabled to take care of themselves, a provision of the law that is hardly ever used. Obviously, there's much debate over what "imminent" means, but the reality is that this law has worked fairly well for the decade since it was last updated with a glaring exception. It is very difficult to get someone committed in this state for more than a few days simply because there are no beds available at the two state hospitals (generally filled to bursting) and shorter-term psychiatric facilities such as Harborview are generally maxed out as well. More beds are needed, plain and simple. And I say this as someone who is no fan of long-term psychiatric hospitalization.

As for outpatient commitment laws, in the real world they are often rendered unnecessary because mental health facilities often put their patients under something called an LRA or least restrictive alternative. It's essentially a contract entered into between patient and institution, requiring the patient to undergo treatment in exchange for their release for the institution (if a patient violates the LRA, then off to court they go). My experience is that this practice is pretty effective for the most part and certainly saves an overburdened court system time and resources.

One thing the leg may want to ask about are the so-called CDMHPs or county designated mental health professionals. Under state law, these are the only people who can order a patient committed involuntarily to an institution--doctors and the police cannot. Having been involved in the mental health field as both a reporter and social worker (briefly), I can say a lot of people in the system are deeply confused about how CDMHPs define danger to self or others, as there seems to be wildly different outcomes each time a person is sent to them for an evaluation. Let me offer one personal example: Earlier this year I worked at a homeless shelter in Seattle. One day, a young woman appeared at the shelter and was admitted. Soon after, I briefly interacted with her and noted she was not capable of responding to questions and appeared to be zonked, for lack of a better term. A few hours later, she punched another client in the face. Police were called. All the workers encouraged the woman, who was buggy-eyed and removed from reality, to voluntarily go with the police to Harborview for an evaluation. She refused and the cops cuffed her and took her away. Most of us were convinced she would be held in the psych unit there. But within two hours, she was on the sidewalk in front of the shelter on a very cold night with a group of crack dealers circling her. We couldn't readmit her to the shelter since the woman had broken the rules by assaulting another client. That episode has never made sense to me and it's my understanding that she was not held at Harborview because the CDMHP who examined her disagreed with both the social workers and the police as to whether or not she was a threat to anyone. This kind of thing goes on with the CDMHPs all the time and the way they make their determinations needs to come under review. There are numerous documented instances in this state where CDMHPs have released people who were dangers to the public.

The leg will hear a whole bunch about "treatment" and how all people with serious mental illnesses need is to be forced into treatment and violence will be prevented. To be clear, when the term treatment is floated we aren't talking about anti-depressants and mood stabilizers but antipsychotics. It's ironic that legislators will be hearing about them at a time that a rolling scandal about the dangers of these drugs for people with schizophrenia (and many others) is taking place and several states are already suing Eli Lilly, AstraZeneca and Johnson & Johnson over safety issues with the drugs. Washington State is likely to be one of the states joining a multistate action against Lilly if it's not settled earlier. It's even more ironic that Lilly recently hosted a party for Washington State delegates to the Democratic National Convention.

Beyond that, advocates for antipsychotic use--even doctors--should be quizzed about how well and consistently these drugs actually work. There is a growing body of research showing that their performance is highly inconsistent (see the 2005 CATIE study among others) and that the drugs do such things as cause brain shrinkage and other side effects such as strokes, diabetes and heart attacks. If advocates are going to demand treatment, then it would be grand if they advocated for treatments that work.

What's more, the leg is likely to be lobbied by a group called the Treatment Advocacy Center and its head E. Fuller Torrey. Feel free to listen to their arguments, but ask them where the data they cite comes from and whether it's been published in peer-reviewed journals. TAC and Torrey have a long history of twisting data, using unreliable data sources and they commonly do not submit their claims to the scrutiny of academic peer review (why newspapers such as the P-I buy their claims in open to debate). Also, the leg should know that Torrey is deeply reviled within mental health circles, not just by patients but by actual researchers as well. You might even ask him why his group cites violence done by people not taking medications, but ignores violent acts committed by people who were on medications and why so many of the studies the group cites are decades old. For example, TAC has recently floated claims that 1,000 homicides a year can be tied to people with schizophrenia and bipolar disorder. But the group cites no source for its claim, one that was accepted by the P-I as legit and published in its pages.

I'm putting all of this into the public realm in hopes that, if the leg is going to take up these issues in the wake of last week's tragedy, then legislators watch out very carefully for the spin and wild overstatements that come with tragedy. If you are going to make changes to a system, make the ones that are truly needed, not the ones that advocates say are needed.