Who are the Manifestly Violent Mentally Ill and Why Should We Care About the Current Law Regarding MVMI?

Research shows the mentally ill are more violent than the general population. Other factors, like substituting cocaine for licit medication, make their violent behavior highly predictable.

Studies find that a schizophrenic off meds and on cocaine will be violent in the first six months. (See the work of J. Reid Meloy, Ph.D. especially, his book Violence Risk and Threat Assessment.)

In every city, there are a set number of mentally ill who monopolize resources and pose serious risk to the public. Their violent behavior causes the public to wrongly consider all mentally ill dangerous and therefore to be avoided. I believe that if we identify and isolate the manifestly violent mentally ill (MVMI), we will free the passively ill from this stigma.

A major myth is that the MVMI just "snap." Studies show they warn family and mental health professionals well before they act. It appears that now in our culture mass shootings by the mentally ill are increasing and they are often accompanied by warnings sent to the media.

Currently, our jails are the largest treatment facilities for the MVMI

My son and two brothers are police officers. Law enforcement is our first line of defense against these offenders and our jails are the largest treatment facilities. The former executive director of the National Sheriffs' Association, Thomas Faust, has written that the three largest mental health facilities in this country are these well-known jails: Rikers Island (NYC); Los Angeles County Jail; and Cook County Jail (Chicago).

I would like every officer to see on his computer when they are approaching the house of a MVMI, that they are former patients who expressed a desire to “die by cop.”

Death threats by the mentally ill should be considered as seriously as a suicide threat.

All death threats to family and members and others by the mentally ill should be taken as seriously as threats to commit suicide. It will save lives. Mental illness is the third highest predictor of violence following previous violent history and drug use.

Currently, there is too much pressure placed upon the treating physicians.

Only patients, who are dangerous to themselves or others, are committed involuntarily. Indeed, without the word “kill” in the affidavit supporting commitment, it is most difficult to access the state hospital. Almost everyone who goes in, goes in and out again and again.

Presently, statistics show judges never overrule a doctor who directs commitment or release!

That means all the responsibility for ensuring public safety rests with doctors. The doctors’ treatment and decision to report or not to report are also protected by medical privacy. Except for notorious crimes, their reports are never seen by the media or public, even if the patient has foretold their behavior with serious violent hallucinations.

I believe new legislation is vitally important to the public safety, that new laws will save lives of police officers, that passing new statutes will reduce the stigma the mentally ill suffer and relieve psychiatrists from the sole responsibility of dealing with the MVMI.

In the future, I will have guest posts by mental health professionals, who will discuss this issue from their professional perspective. Other experts in fields related to this issue will also be providing their input (from the judiciary, law enforcement, etc.)

And, of course, I welcome your comments to this issue.

-- Judge Tom Rickhoff

Why I'm So Concerned About the Violently Mentally Ill in this Country

In 1968, while working for legal aid, I had a client who told me, "I need to kill Lyndon Johnson because he raped my daughter."

I had him removed by the civil mental health unit and reported to the Secret Service. He called the next day and said, "Do you know where I am? I am in a Mental Institution."

Today, I feel driven to help find solutions to a serious problem in our society.

Now, over 40 years later, hopefully I've gained some wisdom and perspective in the area of mental illness -- not the least of which comes from calling the Bexar County mental health docket for 60 months. (We see the mentally ill today in our Probate Court as well, usually in our guardianship proceedings.)

Perhaps my personal involvement in cases dealing with the mentally ill has given me more impetus to take action.

I feel driven now to try and contribute as best I can towards finding solutions to problems I see in how our society deals with its mentally ill citizens. Particularly so, after reading things like the July 2009 murder here in San Antonio of a 3 1/2 week old newborn baby boy by his mother, who decapitated him with a steak knife and then skinned and gutted him. The mother also reportedly ate some of the baby's toes and part of his brain.

The decapitation of a newborn by his mother here in San Antonio gained worldwide media coverage.

This local story gained international media coverage. The issue of the mother's mental illness received small mention as the gory elements of the event took most of the word count; nevertheless, we do know that Otty Sanchez had a history of mental illness, and told law enforcement that she was hearing voices: the devil made her kill her little boy.

The reality is a "Revolving Door" without a workable treatment plan.

Here's the reality: if a mentally ill individual in this county is actually taken into care involuntarily, Bexar County is good about quickly admitting an individual needing treatment. However, that admittance isn't long: currently, the process is merely a "revolving door" that quickly releases the individual back into the community without a workable treatment plan.

The failure to identify, segregate, and treat the violently mentally ill is the most tragic flaw in our system. It is the chief part of my frustration as a Judge with more than 25 years of experience serving the bench.

I am passionate about doing something to help find a solution here.

Why? Because all too often, the untreated, violently mentally ill precipitate true tragedy, in sometimes horrific circumstances. And, although only 20% of violent crime is committed by mentally ill individuals, one untreated, violent mentally ill person truly can destroy lives and even change world history (e.g., assassination attempts of Pope John Paul; President Reagan; John Lennon; Robert Kennedy; and the catalyst for World War II, the assassination of Archduke Ferdinand).

We can no longer avoid use of the word "violent" because of a fear of stigmatization.

Many advocacy groups abhor the word "violent" because it tends to stigmatize all mental illness. Still, there is a fraction of mentally ill patients who are best described that way: violent. It is my opinion that it is in their best interests -- as well as our community's -- that the violently mentally ill be identified, adequately treated, and adequately medicated.

What about the cost? Heck. Right now, one violent mentally ill patient can cost up to $1.5 million to treat over a lifetime if continuously rotated through hospitals.

Our current system of dealing with the mentally ill is not acceptable.

Our current system of laws in dealing with this reality is not acceptable. Judges have no discretion over whether to admit or to decline the release of a patient. Currently, psychiatrists control everything in this area. And while violent offenses themselves are commonly reported, the fact that these offenses are committed by the mentally ill isn't. Why not? Violent offenses by the mentally ill come under the protection of certain state and federal privacy laws.

I'll be working on many fronts - and reporting about things on this blog.

I'll be writing more -- and asking others to provide their opinions and insights -- here on this blog, on a regular basis. I'll also be working in other areas to find answers to this serious and real problem that impacts not just our community, but our nation as a whole. Periodically, I'll provide updates here regarding all that I'm doing.

I'm not alone -- Judge Yvonne Rodriguez takes a stand today.

And, I will look for -- and support -- others who share my concern, such as Judge Yvonne Rodriguez of El Paso County's Probate Court No. One (1).

Judge Rodriguez wrote an excellent article for the El Paso Times today on this issue, where she concludes by writing, "I for one am ready to take a stand."

As am I.

-- Judge Tom Rickhoff

How We Currently Deal with the Violent Mentally Ill Here in Texas - The Short Term Involuntary Commitment

Under the current law for the State of Texas, patients who are "dangerous to themselves or others" can be civilly committed. And only those patients.

The Legal Balance is Freedom versus "Dangerous to Themselves or Others"

If facts can be placed into evidence that support the individual is "dangerous to himself or others," then the law allows their rights to freedom to be curtailed as they are involuntarily placed into a facility where they can receive assistance and support. However, we are a country that values freedom, and perhaps no state is more passionate about liberty, freedom, and the independence of the individual than Texas.

Legal Limitations on Involuntary Civil Commitments in Texas

Involuntary commitment flies in the face of the law's stringent protection of freedom. As well it should. Accordingly, limitations are placed upon civil commitments.

After being committed, the law allows these acutely ill patients to depart just two weeks later. During their commitment, they will have been seen by health care professionals and treated by therapy and medication. Hopefully, there will have been some success, and the individual patient is no longer a danger for suicide or homicide, or some other violence danger. They are then released, after only a short stay in a treatment facility.

What Happens After the Civil Commitment?

And, here's the rub. It may not be enough. Too many mentally ill patients complain that the medications that help them have unbearable side effects. They become sleepy, they feel like "zombies," they feel like they are living in a bubble. The result? They stop taking the drugs. Many start to self-medicate with illegal drugs or alcohol.

And soon, with a few weeks time, that same individual is once again a serious threat to himself, or others, and we're back to square one and hoping that no one is hurt or killed before this sick person -- suffering from an illness -- can get real, substantive treatment.

-- Judge Tom Rickhoff

Three Goals for Reform Legislation Dealing with the Violently Mentally Ill

I believe there are three overriding goals for reforming the current laws dealing with the violent mentally ill in our state, and these are:

1. Reduce the stigma on the mentally ill;

2. Protect the public, particularly law enforcement; and

3. Relieve treating psychiatrists from sole responsibility for release of committees.

I will be discussing these in detail over the next few months, and welcome your comments and contributions.

-- Judge Tom Rickhoff